Andrew Solomon’s most recent book is “Far and Away: Reporting From the Brink of Change: Seven Continents, Twenty-Five Years.”
In “Bellevue: Three Centuries of Medicine and Mayhem at America’s Most Storied Hospital,” David Oshinsky has written a meticulous, if somewhat too narrowly focused, history that lays out the progress of medicine in the United States as well as the contextual history within which it has unfolded.
Bellevue was one of the first public hospitals in North America. From its first incarnation as a small infirmary in the 1660s up to its role in the AIDS crisis and beyond, it has been central to the invention of the American hospital as we know it. Oshinsky’s narrative reveals how hospitals, once a public service only for desperate people unable to pay a doctor to visit them at home, became the central locus of modern health care.
Bellevue contained an almshouse in its early days, and one of its buildings more recently served as a homeless shelter; no one, sick or otherwise, has ever been too destitute for its charity. Oshinsky delineates the squalor in which impoverished immigrants have lived in New York and the pestilence associated with their misery. He writes of the hospital’s function in times of plague: yellow fever, cholera, puerperal fever, tuberculosis, swine flu, AIDS, even Ebola. Unlike many parallel institutions, Bellevue has never turned away incurable patients, offering them whatever mitigating treatment was possible, often risking doctors’ lives in the process.
Oshinsky’s book also chronicles the gradual professionalization of medicine, describing the 18th-century grave robbers who enabled early medical students to learn anatomy and how those amateurish operations evolved into the highly competitive, technologically sophisticated medical schools of today. The author traces the invention of the modern American civilian ambulance following the use of medical evacuation vehicles during the Civil War. He describes the infancy of anesthesia in the mid-19th century. He takes us through the gunfire to which Presidents Abraham Lincoln and James Garfield succumbed. He reflects on the debates about germ theory, quoting the once-prevalent medical wisdom that the removal of a bullet should always be done with the “thumb and fore-finger,” usually unwashed, a prejudice that endured even after the advent of sterile procedures.
He reports on how Florence Nightingale’s visionary practice of nursing in the Crimean War provided a model for the nursing school at Bellevue, where only women who were “moral” and “cultivated” were allowed to assist; he also recounts the hospital’s flirtation with training male nurses, which was quashed by scandal amid rumors of homosexuality. He reviews the popularization of circumcision, led by a Bellevue physician. He depicts the emergence of a “chest service” in the 1920s that affiliated cardiology and pulmonology.
Oshinsky writes with particular vigor of Bellevue’s refusal to subscribe to popular prejudices, noting that the hospital welcomed Jewish doctors as well as Christian ones, female doctors as well as male ones, and African American staff as well as Caucasian. Implicitly, he tells the story of a nation riven with bigotry, where the social advancement of stigmatized groups was contingent on their irrefutable courage, brilliance and ingenuity. He is particularly impassioned about the achievements of early female doctors.
In the public imagination, Bellevue is synonymous with psychiatry, but its psychiatric facility did not achieve real prominence until the late 19th century, though the hospital had long included a small wing for the insane. In the 1840s, the issue of mixing the mentally ill with the physically ill began to attract troubling notice. “The invalid, the aged, the infirm, the vagrant, and half lunatic [are] now confined together, and are allowed the most unrestrained intercourse,” a grand jury reported, calling such arrangements an affront to “every Christian.” Journalist Nellie Bly, in a famous 1887 undercover assignment, exposed the appalling conditions in which the mentally ill were being held for supposed treatment. Funding for and attention to their care soon increased by vast multiples.
Doctors at Bellevue have since championed some of what came to be seen as best practices and some of what came to be seen as the worst. Locked wards for the criminally insane engendered their own legal system, allowing people to be tried before a clinically trained judge in a hospital courtroom. Oshinsky narrates Lauretta Bender’s alarming midcentury experiments using electroconvulsive therapy for children with a broad range of diagnoses, some of whom seem to have been helped and many of whom were certainly traumatized.
All in all, Oshinsky portrays “a place where bold, creative, if sometimes bizarre and Frankenstein-like, experimentation prevailed.” The gist of the book is that caring for impoverished populations, criminals, the insane and AIDS victims has always been steeply challenging work that all too often goes unacknowledged. It makes you feel better about humanity to learn about people who have chosen this noble work over the centuries; indeed, Oshinsky’s greatest strength may be his capacity for admiration. But seldom do we really get to know these people; they appear in vignettes — largely professional ones — until the AIDS chapter, where he expands more liberally on the personalities involved.
If you are already interested in the history of Bellevue, this is the book for you; if you are not thus invested, you may not feel compelled to stick out some of the tough sledding. Oshinsky has done a great deal of homework, and his researcher’s pride in detail leads him to provide a weight of gratuitous information — long sequences about how one building was designed, another built, yet another planned but never built, and who in which office of the city government favored or opposed a particular project. We get a rather too-thorough roster of hospital administrators. “Bellevue” is curiously lacking in emotional punch, expressing an almost hagiographic veneration for the very real accomplishments of the hospital, its doctors and its programs, but without deeply moving the reader. You find much to respect about medical progress, but your heart does not swell with the advancements. The prose can be academic even when the content has the potential to be electrifying.
Oshinsky also has an irritating habit of overstating the case. He is given to assertions such as “The stakes for American medicine could hardly have been higher,” or “A political tragedy of epic proportion struck the United States, bringing esoteric terms like Germ Theory and antisepsis into the national dialogue in an unimaginable way,” or “These two men didn’t simply revolutionize the field of forensics science, they were the field.”
The history of Bellevue is not the story of American medicine. It is a story within the bigger context of American medicine, and Oshinsky does a less-than-adequate job of universalizing from his material. Despite frequent digressions into social history or the larger medical narrative, the book remains more descriptive than insightful; the author seldom looks up from the story he is telling.
Though Oshinsky paints the dire medical circumstances poor people face and contrasts them with the experiences of those with means, we hear little of the long-running public debate about whether health care is a right or a luxury. Though he comments on the hard-pressed staff at an underfunded and crumbling facility, he doesn’t pursue the social factors that have enabled such decay. He brings up private hospitals, but he never really unpacks the class privilege that has engendered our tiered system of care. Aside from brief allusions to physicians who immigrated or trained abroad, he makes no parallels between the development of public health care in the United States and its more liberal growth in Europe.
Without this context, his narrative of Bellevue feels admirable but limited, a lively rendition of a hospital’s history but not a book relevant, as it might have been, to the ongoing crisis in American health care.
By David Oshinsky
Doubleday. 387 pp. $30