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  But it was the Bellevue Establishment where the crush of new arrivals hit hardest. In 1846, Bellevue Hospital—the city pesthouse—had admitted 3,600 patients, with 2,200 listed as Irish. A year later, the numbers surged to 6,541 patients, including 4,863 Irish. A deadly epidemic had again reached New York City, with unmistakably immigrant roots.

  It went by several names: Irish Fever, Ship Fever, and Jail Fever. But physicians called it typhus—from the Greek typhos, meaning hazy—for the dizzying state it produced. Typhus is a bacterial disease that thrives in close, filthy quarters. Spread by a body louse, it is best known for decimating Napoleon’s army during the Russian campaign of 1812, and for the millions of soldiers and civilians it killed in Europe during both world wars. Perhaps the oddest thing about typhus is how rarely it has appeared in the United States. There is no record of a serious outbreak during the American Revolution or the Civil War, despite abysmal troop conditions. Research suggests that the environment here proved inhospitable to the vector—the body louse. In truth, nobody knows.

  There had been occasional typhus outbreaks in New York City during the early 1800s, concentrated in the immigrant slums. Then came the devastating potato blight in Ireland. “The potato was the staff of life,” wrote one historian, “the staple consumed at every meal and burned for fuel.” At least a million Irish died in the years between 1846 and 1852, spurring the exodus to North America. Each day an armada of so-called famine ships departed Liverpool for Canada and the eastern port cities of the United States. Passengers spent the ocean voyage packed like cattle in quarters with little food or clean water, no spare clothing, and barely a breeze. Fires, storms, and icebergs were among the dangers, but the big killer was disease. One immigration official described conditions on board as “no better than that of a slaver or a coolie ship,” adding: “Ten deaths among one hundred passengers was nothing extraordinary; twenty percent was not unheard of; and there were cases of 400 out of 1,200 passengers being buried before the ships left port.”

  The main debarkation point was New York City, which received an average of three hundred Irish immigrants a day in the famine years, with many choosing to settle. Each passenger had been checked for obvious diseases before leaving Europe, and “foreign” ships entering New York harbor were met by a health inspector. While evidence of sickness could mean quarantining everyone on board, in most cases only the visibly ill were singled out and ferried to the New York Marine Hospital on Staten Island called the Quarantine. In 1846, this eighty-bed facility admitted 900 patients; a year later, the figure was 8,000 and climbing. Of the 730 deaths recorded there in 1848—the highest total ever—433 were from typhus.

  Staten Island seemed ideal for the Quarantine—a sparsely settled expanse of farmers and oystermen whose concerns about “dangerous foreigners” were casually brushed aside. That proved a mistake. In 1858, a mob of locals stormed the Quarantine, and burned it to the ground. Fortunately, the patients had been “removed before ignition.”

  Because the telltale signs of typhus—rash and fever—are not immediately apparent, many future victims escaped detection on board. Once off the boats, they headed for the tenements of Five Points and other slums, carrying lice in their clothing and body hair. What made typhus different from smallpox or yellow fever or even cholera was its limited geographic range. A fixture of the poorest neighborhoods, it caused little panic in the city as a whole. There were no mosquitoes, or contagious victims, or contaminated wells, to spread the danger much beyond the miserable quarters of the immigrant poor.

  Many typhus victims died where they lay, but hundreds more wound up at Bellevue Hospital. Beds were shared and “pest tents” were pitched on the lawn. A more ideal setting for typhus transmission could hardly be imagined. The patient death rate at Bellevue soon topped 40 percent, and for the staff it was even higher. So many resident physicians fell to typhus that medical students were asked to fill the void. To scroll through the fatalities in 1847–48 is akin to reading the names on a war memorial:

  Gorham Beals, M.D.…died in New York City, January 9, 1848; cause: typhus fever, contracted while on duty in the hospital.

  William Cahoon, M.D.…died in 1848: cause: typhus fever, contracted while on duty in the hospital.

  John Fraime, Jr., M.D.…died in New York City in 1847; cause: typhus fever, contracted while on duty in the hospital.

  Elihu Hedges, student of medicine, died in 1848; cause: typhus fever, contracted while on duty in the hospital.

  Henry Porter, M.D.…died in 1847; cause: typhus fever, contracted while on duty in the hospital.

  David Seligman, student of medicine….died in 1848; cause: typhus fever, contracted while on duty in the hospital.

  Augustus Van Buren, M.D.…died in 1847; cause: typhus fever, contracted while on duty in the hospital.

  Sidney B. Worth, student of medicine….died in 1848; cause: typhus fever, contracted while on duty in the hospital.

  The typhus outbreak of 1847–48, known at Bellevue as the “Great Epidemic,” would be recalled with bitterness and pride. The house officers and medical students who died there were well-connected young men seeking clinical experience before entering private practice. They had remained at their posts through the worst of it, some rising from their deathbeds to train others to carry on. But hard feelings lingered: typhus, after all, was a reminder of what Bellevue had always been, and seemed destined to remain—a dumping ground for those deemed too ill to be anywhere else.

  What could be worse than admitting hopeless patients and then being blamed for having such a high mortality rate? “At least two-fifths of those who die at our hospital [come] in a dying state,” a Bellevue doctor fumed. “During the past year, three have died at the very door…ten more within two or three hours after admission, and forty within the first week.” The doctor then singled out the worst offender. “Very many are sent from New York Hospital, where they have been…pronounced incurable and dismissed for us to take charge during the remainder of their lives.”

  There was truth to this. New York Hospital had a long history of dumping its sickest patients, a pattern that would continue well into the twentieth century. In this instance, however, it did treat some victims from the “famine ships” because of growing public pressure. Interestingly, just 10 percent of its typhus patients would die there, and only one of its doctors contracted the disease. He returned to duty three months later.

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  Typhus would not soon disappear. Each year that passed without a doctor’s death at Bellevue seemed cause for genuine relief. “It is a subject worthy of congratulation,” read the hospital’s annual report in 1852, “that we can [speak] without the melancholy necessity of paying an obituary tribute to…members of the House Staff who have fallen victim to the typhus fever.” But it returned with a vengeance a decade later, killing “nine of twenty-two employees” who contracted it, and “six of fifteen physicians.” Conventional wisdom still blamed the disease on foul vapors from decomposed matter, which led a young visiting physician named Alonzo Clark to pose a logical question: If typhus arose from harmful miasmas—whether inside a coffin ship, a tenement, or a hospital ward—shouldn’t its treatment be linked to commonsense remedies such as less crowding, cleaner surroundings, and purer air? Bellevue might not be able to match New York Hospital in these matters, but surely it could do better.

  Clark ordered his own typhus ward to be whitewashed, the windows flung open, and the doors removed from their hinges. He also replaced the heroic therapies of bleeding and purging with gentler measures designed to spur a “natural recovery.” His aim, aside from dissipating the bad air, was to quietly stimulate the body rather than harshly deplete it. Like David Hosack, Clark employed alcohol as his main elixir, though in larger amounts. As legend has it, every typhus patient under Clark’s supervision recovered. From this point forward, the treatment for typhus at Bellevue would include oceans of spirits—“the brandy bottle replacing the lancet”—along with bone-chillin
g blasts of East River air.

  The Great Epidemic proved a watershed event. It was one thing for a hospital to lose paupers to disease; quite another when the victims included much of the medical staff. “A thorough change in the mode of governing the establishment was needed,” a physician recalled, “and it came at a time when the epidemic occurrences of typhus fever raised the existing evils…to a culminating height.”

  What followed was thorough, indeed. Under intense fire, city officials in 1852 turned over the administration of Bellevue Hospital to a ten-member Board of Governors dominated by physicians and social reformers. Day-to-day operations would now be handled by a professional warden, whose duties ranged from policing the wards to taking “personal charge of all wines and spirituous liquors required for hospital purposes.” Patient care would be supervised by four distinguished “consulting” physicians and surgeons, with a dozen “attending physicians and surgeons” a rung below. All would visit Bellevue on a regular basis, “granting their services gratuitously.” The job descriptions seemed distinctly unappealing—great responsibility with no apparent compensation. In fact, these positions would be deeply coveted by the city’s medical elite as a sign of professional status and Christian duty. And each man could bring “three of his students gratis to see the practice of the house”—an accommodation for lucrative tutoring on the side.

  At the bottom of the ladder were five recent medical school graduates who would live at Bellevue and earn a nominal $130 for a six-month term. Known as the house staff, they were to visit the wards each morning and evening accompanied by five current medical students who performed routine procedures like “bleeding, cupping, leeching, and dressing wounds” (a sign that the old ways of heroic medicine had not been fully abandoned). On paper, at least, the house staff would be chosen by competitive examination. “All are received upon common footing; all are [tested] by the same committee….They must stand on their merits alone, incited by the hope of entering Bellevue Hospital.”

  Most revealing were the new guidelines regarding patient selection. “No person shall be admitted whose case is judged to be incurable,” read a key sentence in the new Rules and Regulations for the Government of Bellevue, “nor shall any who [are] judged insane or who shall have the smallpox or measles, or any malignant or contagious fever, to be received.” Such patients would be sent to the new East River facilities on Blackwell’s Island, freeing Bellevue from its notorious almshouse–pesthouse past.

  Here, at last, were the outlines of dramatic change. General and acute care would become top priorities. Chronic and contagious cases would no longer clog the wards, except in extraordinary circumstances. Those suspected of insanity would be examined first at Bellevue—but then either released or shipped to Blackwell’s Island for incarceration. One thing that wouldn’t change, however, was the credo of the institution. Bellevue would accept “only patients who were unable to pay for their board and maintenance”—those, in short, with nowhere else to turn.

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  “Who shall take care of our sick?” This vital question, posed by anxious Catholic Church leaders in New York, had become an increasingly popular refrain. The mass exodus from Europe had overwhelmed the city’s meager health services, leaving immigrant communities, for the most part, to fend for themselves. One might use the dispensary system for minor ailments, or a charity birthing clinic if a bed were available. There were separate spaces now for lunatics and epidemic victims—but not much more. New York City claimed but two general hospitals in 1850, and neither held much appeal for the immigrant poor. One was seen as too judgmental and aloof; the other too chaotic and grim. And neither was acceptable to the Roman Catholic Church.

  The reason was clear enough. Hospitals in this era had a Protestant, evangelical bent. They were considered places of redemption—ideal for wooing vulnerable patients back to Christ. “Many are brought in wholly ignorant of the first truths of the Gospel, arrested in a life of sin,” a nurse explained. “[But] the fear of dying overwhelms them, and they are thankful and willing to listen to words of instruction and prayer.”

  While New York Hospital was less appealing to the city’s Catholic clergy, Bellevue posed the greater spiritual threat. For one thing, it kept a Protestant chaplain on the payroll at city expense. He “leaves no room unvisited,” the warden noted, delivering Bibles to the patients and leading them in prayer. For another, Bellevue treated far more Catholics and stood several miles from the downtown immigrant strongholds, isolating patients from family and friends. For church leaders, the real worry at Bellevue wasn’t the high mortality rate, but the conversion of fearful Catholics into Protestants. Bellevue, said one suspicious Jesuit, was like “a royal hunting ground.”

  No one took this threat more seriously than John Hughes, America’s first Roman Catholic archbishop. A native of Ireland, known as “Dagger John” for affixing a “stiletto-like cross” to his signature, Hughes was determined to protect his growing immigrant flock. Headquartered in Manhattan, he would become the model for future “brick and board” prelates, constructing an impressive defense line of churches, convents, schools, and cemeteries throughout his diocese. The situation at Bellevue particularly galled him, because Catholic priests weren’t welcome there unless specifically requested by a patient—a humbling affront.

  In 1849, the Sisters of Charity opened a thirty-bed hospital in a rented house on East 13th Street, led by the archbishop’s biological sister, Ellen Hughes. The order was “just about the finest thing the immigrant Church had for the sake of public relations,” wrote Dagger John’s biographer. Founded by Elizabeth Seaton, it had courageously treated the poor during the great New York cholera epidemic of 1832, when most religious leaders were seen running for their lives. The new hospital, named St. Vincent’s for the canonized seventeenth-century French priest, was intended for “the Catholic indigent sick.” Conditions were spare: the original building lacked gaslight, indoor toilets, and running water. Those with means were charged $3 a week for “board, washing, nursing, and medical attendance.” Those with no money were declared charity cases. The Sisters slept on the floor of the front parlor, next to the mortuary on the porch.

  The beds, however, were always full. In 1855, the Sisters moved to larger quarters on West Ninth Street and Seventh Avenue, with an eye toward further expansion. Money was raised the Catholic way—through block parties, raffles, and the trusty collection box. Lot by lot, dollar by dollar, the Sisters methodically bought the land they needed. “Building in New York,” wrote their frugal treasurer, “is very expensive.”

  The city’s first Catholic hospital, St. Vincent’s was unique in other ways. While serving an Irish immigrant clientele not unlike Bellevue’s, it relied on private funding to survive. Among its lasting (if premature) innovations was a small space, set apart from the charity wards, that offered “well-furnished private apartments” for those requiring “special accommodations.” Who might these people be? A New York City guidebook, published in 1872, provided some examples: “To clergymen or other persons stopping at hotels or to strangers of means, overtaken suddenly with disease, these rooms offer peculiar advantages, combining the comfort of a home with the advice and treatment of the Hospital.”

  St. Vincent’s had little trouble recruiting a medical staff. As one of only three general hospitals in Manhattan, it provided a vital outlet for doctors looking to hone their clinical skills. But what kept St. Vincent’s afloat in its difficult early years was the devotion of its nuns. Even the most rabid bigots showed a grudging respect for the Sisters of Charity. They “serve for life with no expense to the Institution save board,” marveled an anti-Catholic journalist. “[Their] self-imposed penury…life-long toil and sleepless vigilance [to] the Mother Church, notwithstanding all their errors of faith and practice, present a sublime anomaly in the history of the world, and are eminently worthy of imitation.”

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  And imitation, it turned out, is precisely what occurred. The mid-ni
neteenth century saw a dramatic surge in voluntary hospitals throughout New York City. The example of St. Vincent’s spread to other ethnic groups, including German Americans who comprised New York’s second-largest foreign-born community. Always a presence in the American colonies, Germans had come in waves to the United States in the 1840s and 1850s to escape political and economic turmoil at home. More than a million Germans entered the country in these decades, most through New York City, with the great bulk moving on to the farms and cities of the Midwest and Great Plains. Still, about one in ten settled where they landed, making New York the third-largest German-speaking city in the world, behind only Vienna and Berlin.

  Many of these newcomers lived in Kleindeutschland, or Little Germany, a Lower East Side enclave seen, through native eyes, as the German equivalent of Five Points. In truth, Kleindeutschland was more diverse, with Protestants, Catholics, and Jews, Bavarians, Prussians, and Saxons living side by side. And, while every bit as cramped as other immigrant neighborhoods, it wasn’t quite as poor. Many Germans had been forced from the land, like the Irish, but those who settled in New York came with skills better suited for an expanding urban economy. According to the New York State Census of 1855, Irish immigrants constituted a majority of the city’s laborers, teamsters, dockworkers, and domestic servants. For Germans, by contrast, it was bakers, tailors, cabinetmakers, and grocers.