Bellevue

Bellevue is the iconic public hospital in New York City. When it first opened in 1818 it consisted of an almshouse, an orphanage, a lunatic asylum, a prison, and an infirmary. It developed into a world-renowned hospital, a training and research institution that has always provided the best medical care to all comers regardless of their ability to pay. Everyone from the criminally insane to indigent immigrants and the homeless; victims of infectious disease outbreaks; celebrities like Lead Belly, Stephen Foster, and O. Henry; John Lennon’s assassin; and even presidents were treated by Bellevue’s doctors and doctors-in-training, often with little or no pay. They felt well rewarded by the opportunity help the unfortunate and to learn from a wide variety of patients with a spectrum of diseases not readily encountered elsewhere. Some of them selflessly treated highly contagious patients, contracted the diseases themselves, and lost their lives.

David Oshinsky, a history professor who won a Pulitzer Prize for his book Polio: An American Story, tells Bellevue’s story in his new book Bellevue: Three Centuries of Medicine and Mayhem at America’s Most Storied Hospital. Bellevue is a microcosm; in telling its story, he also tells the story of American history and politics, of the changes in New York’s population as waves of immigrants arrived from a sequence of different countries (more than a hundred languages are currently translated at Bellevue), of medical and political controversies and scientific discoveries, of the development of ambulances and professional training for nurses, of the end of grave-robbing and the legalization of human dissection in medical education, and of the history of medicine as it groped its way from pre-scientific superstitions to modern science-based practices.

There were many mistakes along the way. Early Bellevue doctors thought disease was caused by bad air. Before there were many effective drugs, patients were routinely prescribed alcohol to ease their pain. There were indeed many instances of “mayhem” as Oshinsky’s title reflects. But science is a self-correcting endeavor, and Bellevue has consistently corrected its mistakes over the course of time.

This is an engaging story with a cast of hundreds of fascinating individuals. It’s hard to do justice to its encyclopedic material in a book review, so I will just highlight a few things that particularly stood out to me.

Germ theory: a tale of two presidents

When Garfield was shot in 1881, a Bellevue doctor probed his wounds with unwashed fingers and dirty instruments, causing a fatal infection. In 1893, Grover Cleveland’s oral cancer was secretly removed by Bellevue doctors using the best antiseptic techniques; he survived. Oshinsky vividly describes the prolonged conflicts at Bellevue between the doctors who were quick to accept the emerging evidence about germ theory and preventing infection and the more hidebound doctors who ridiculed those ideas and refused to believe in tiny organisms they couldn’t see. He tells how doctors gradually went from operating in bloodstained street clothes to using anesthesia, gloves, and sterile precautions.

Circumcision

I knew a lot about circumcision, but I never really understood how the routine practice of circumcising American babies came about. Oshinsky offers a chilling explanation. Bellevue’s Dr. Lewis Sayre, one of the founders of orthopedic surgery, performed an emergency circumcision to relieve a “constricted penis” on a 5-year-old boy who was unable to walk because of leg deformities. Within weeks, the child was walking with perfectly straight limbs. He thought circumcision might benefit other conditions, and he boasted of having used it to cure everything from club foot to epilepsy. He brought circumcision to the attention of the public. His ideas were reinforced when a doctor at Johns Hopkins found that immigrant Jews had greater longevity; fewer idiots and epileptics; and lower rates of cancer, syphilis and other diseases than non-Jews. He simplistically assumed that they were healthier because they had been circumcised. And studies of the time suggested that circumcised people masturbated less. (Really? A 1992 study found that circumcised men were more likely to report masturbation!) Anyway, we know today that masturbation is not harmful; the objections to it were moralistic and religious, not health concerns. It seems that generations of newborns were subjected to a surgical procedure because of unwarranted assumptions and false beliefs.

 Floods of patients and actual floods

Throughout its history, Bellevue has had to cope with massive influxes of patients, first with wounds from the Civil War and then with infectious disease outbreaks like cholera, typhus, yellow fever, tuberculosis, the 1918 influenza epidemic, and AIDS. In the 1918 influenza epidemic, they quickly ran out of beds and the overflow patients were forced to sleep on doors ripped from their hinges and on unsanitary piles of straw.  Often Bellevue was burdened with patients that other hospitals turned away. It has risen to every occasion. Perhaps its most heroic moment was its response to Hurricane Katrina. The floodwaters breached the new safety doors that protected the basement fuel pumps that supplied the hospital’s generators. A human bucket brigade of volunteers carried containers of fuel up the stairs, buying a brief reprieve; but soon the elevators and life-sustaining medical equipment were out of commission and the toilets were backed up. It was soon obvious that a complete evacuation was necessary. Patients were carried down multiple flights of stairs by hand or on stretchers with only the illumination of flashlights and cell phones. The criminal psychiatric unit was evacuated in groups of six, chained together at the ankles and surrounded by a police guard. Using volunteers, dedication, and ingenuity, they somehow managed to safely evacuate every patient and get them to other hospitals. Mt. Sinai accepted a dozen Chinese psychiatric patients who spoke no English. Isolation rooms had to be found for the court-detained tuberculosis cases. Some convicts were too ill to return to Riker’s Island. The staff performed nobly in unimaginable conditions, and Bellevue was closed for the first time in its history. It has since reopened.

Ebola

The first case of Ebola in America was treated in Dallas. The patient was misdiagnosed and mistreated for several days. Even after he was correctly diagnosed and admitted to the ICU, the staff was unprepared and did not take proper precautions. Two nurses contracted Ebola, but survived.

When the second American case of Ebola arrived at Bellevue, they were prepared with detailed plans and training drills. Nurses worked in pairs and were supervised by a team from the CDC. The patient survived, but at great cost. His care stressed Bellevue to its limits; so many experienced nurses were involved that ICU patients had to be moved to other hospitals. Just the expense of treating the patient’s medical waste was estimated at $100,000 a day.

Prejudice and malpractice

Bellevue’s successes were balanced by failures. Oshinsky shows how Jews, Blacks, and women were systematically denied medical training. He describes the ground-breaking medical research that took place at Bellevue, but he also describes ill-conceived clinical studies, for instance the ones that inappropriately subjected children to electroconvulsive shock therapy and dosed autistic children with LSD.

Thumbs up

Oshinsky’s book is well-written and engaging, fun to read and packed with fascinating information. It offers something for everyone, and it provides unique insights into how modern medicine evolved. Highly recommended.

from Science-Based Medicine http://ift.tt/2jEAmzJ