Hospital Care at Second Avenue and East 17Th Street, New York City, 1894-1984 Henry Pinsker, M.D., David M

905

HOSPITAL CARE AT SECOND AVENUE AND EAST 17TH STREET, NEW YORK CITY, 1894-1984 HENRY PINSKER, M.D., DAVID M. NovICK, M.D., AND BEVERLY L. RICHMAN, M.D. Beth Israel Medical Center The Mount Sinai School of Medicine of the City University of New York New York, New York

B ETH Israel Medical Center's recent sale of the building that housed its Morris J. Bernstein Institute brings to an end nearly 90 years of medical care at Second Avenue and East 17th Street in New York City. During this time, three separate institutions provided care to differing patient popu- lations in the handsome building at 307 Second Avenue. New York Lying- In Hospital, Manhattan General Hospital, and the Morris J. Bernstein In- stitute each contributed to medical progress in areas that at one time received little attention from the medical community. Except for the removal of two ironwork balconies that were found to be unsafe in 1979 and removal of the glass solarium from the roof in 1981, the exterior of the building is substantially as it was when opened in 1902 (Figure 1). A historical perspective of the three hospitals follows.

NEW YORK LYING-IN HOPSITAL The New York Lying-In Hospital had its origins in the yellow fever epi- demic of 1798.1 Dr. David Hosack, a prominent practitioner in New York City, observed that many expectant mothers, widowed by the yellow fever, "were rendered wretched under the accumulated evils of grief and poverty." At that time there were no provisions for the medical care of women during pregnancy or confinement. Dr. Hosack secured subscriptions from many prominent people, and the hospital, located in a house at 2 Cedar Street, began to receive both destitute and paying patients on August 1, 1799. Expenses were greater than funds raised, however, and the hospital closed in its second year. An arrangement was made between the governors of the Lying-

Address for reprint requests: Henry Pinsker, M.D., Beth Israel Medical Center, 10 Nathan D. Perlman Place, New York, N.Y. 10003

Vol. 60, No. 9, November 1984 906 906H.H. PINSKER, AND OTHERS

jiff... we.

a -'it

Fig. 1. The New York Lying-In Hospital Building in 1902, the year of its opening. Reproduced by permission from The Architectural Record 11:94, 1902.

In Hospital and the Board of Governors of New York Hospital, then located on the west side of Broadway between Duane and Worth Streets, permit- ting the Lying-In Hospital to conduct its activity in a New York Hospital ward. Disagreement between the governing bodies about financial matters terminated the relationship in 1827. The Society of the Lying-In Hospital maintained its corporate existence without providing any service until 1855, when, still unable to afford a building, it began a program of giving money to poor women to assist with the costs of confinement at home. While there had been sentiment in the 18th and early 19th centuries that it was morally inappropriate for men to practice obstetrics, it nevertheless developed as a medical specialty during the middle of the 19th century.2 With increasing affluence, women demanded obstetrical care from physicians. In the latter part of the 19th century, medical schools offered only lectures, and medical students made their own arrangements to obtain clinical experience. At this time, midwives, many with little or no specific train-

Bull. N.Y. Acad. Med. SECOND AVENUE AND EAST 17TH STREET 907 ing, assisted at half of the births in new York City.2'3 To improve instruc- tion in obstetrics for medical students and provide better service to pregnant women, a small group of physicians, organized by Dr. James Markoe and Dr. Samuel L. Lambert, opened an independent outpatient Midwifery Dis- pensary at 312 Broome Street on the Lower East Side, patterned after the one they had known as students in Munich in 1887.1 Students staffed the new dispensary, and, by not charging for their services, effectively com- peted with the midwives. Meanwhile, investments of the essentially inactive Society of the Lying- In Hospital continued to grow. When the president of the Society was in- formed about the work of young physicians and medical students in the Broome Street Dispensary, he immediately began to provide financial support, and in 1892 assumed financial responsibility for the entire operation. Dr. Markoe had met financier-philanthropist J. Pierpont Morgan during the winter of 1891-92. On Christmas Eve, 1893, a mutual friend told Mr. Morgan that Dr. Markoe was about to perform a cesarean section on a destitute rachitic dwarf who lived in a room about 10 feet square in a tene- ment on Norfolk Street. Mr. Morgan joined others in contributing $10 for expenses. The next day Mr. Morgan gave $300 to provide for rent, food, clothing, and the service of a trained nurse. Thus began Morgan's support for The Lying-In Hospital. 4 In 1893 the Society of the New York Lying-In Hospital paid $200,000 for the mansion of Hamilton Fish at East 17th Street and Second Avenue. Fish had been governor of New York, a United States senator, and secre- tary of state during the Grant administration.5 Alterations were made during the summer of 1894, and the house, equipped as a hospital, opened on November 1, 1894 (Figure 2). The new facility, named New York Lying- In Hospital, had accommodations for 32 patients, an operating room, a deliv- ery room, and quarters for the intern staff and students.' Just a few years after beginning to provide service in the converted Hamil- ton Fish mansion, the hospital was turning away more applicants for confinement than it could accommodate. Morgan agreed to contribute $1,350,000 for construction of a new building, with the stipulation that operating funds be raised from the public. In 1899 the mansion was razed and construction of the new hospital began. The staff continued to provide home care while hospital service was suspended. Before the plans for the New York Lying-In Hospital were completed, Morgan sent Dr. Markoe to Europe to survey modern hospitals there. 4 The information obtained was given to Robert H. Robertson, the architect re-

Vol. 60, No. 9, November 1984 908 908 H. PISEPINSKER, ADOHRAND OTHERS

'. lM Fig. 2. The Hamilton Fish Mansion at the corner of Second Avenue and East 17th Street. The New York Lying-In Hospital was situated here from 1894 to 1899, at which time it was razed so that a larger facility could be built. Reproduced from Harrar, J. A.: The Story of the Lying-In Hospital ofthe City ofNew York. New York, The Society of the Lying-In Hospi- tal, 1938. Courtesy of the Medical Archives, New York Hospital-Cornell Medical Center. tained by Morgan to design the new building. Robertson had previously designed many churches, houses, mansions, railroad stations, and office buildings, including the Corn Exchange Bank Building on William Street and the 27 Park Row building.6 Despite numberous construction delays, the new facility opened its doors on January 22, 1902. The structure was described in the February 15, 1902 issue of Harper's Weekly: Unquestionably the most complete, the most modern, and the most comprehensive structure for the benefit of maternity patients yet built in this or any other country.. . But the greatest importance of the building itself, aside from its origin and its practical usefulness, is the epoch which it marks in hospital construction ... No Eu- ropean structure compares with it for they all have been studied by the doctors and architects, and the best ideas they could offer have been adopted.7 The eight-story hospital building occupied the entire block between East 17th and East 18th Streets on the west side of Second Avenue. Stuyvesant Park is directly south of the building.

Bull. N.Y. Acad. Med. SECOND AVENUE AND EAST 17TH STREET 909

The top floor contained an operating amphitheater, rooms for sterilizing equipment, laboratories, and a kitchen. Elsewhere were located a lecture room, library, museum, printing plant, extensive heating and lighting sys- tems, sleeping accommodations for male and female medical students, and nurses' quarters. In the basement were offices, examining rooms, a chapel, a mortuary, and a "stable for the electric ambulance ... [which] embodies new features, in opening from the side and being lighted from the top. Its great weight lessens jars and swaying."3 The interior design of the building was notable. The wards had 171/2 foot ceilings, quite high even in 1902, and contained eight to 20 beds. In some places, duplex suites provided staff quarters close to clinical units. Each ward had an isolation room. An overriding concern in the design was to be im- maculate. Sharp angles, seams, and joints were eliminated, and the junc- tions of the floors and ceilings with the walls were curved to permit easy cleaning. Even the upper corners of doors and windows were rounded. To prevent dust accumulation, radiators were boxed in, the window shades ran on the outside of the windows (to avoid shaking dust into the wards), and the doors had no trim or framing. The flooring, constructed from lignolith, a composition of cement and sawdust, in one unbroken surface, had a glazed appearance which radiated cleanliness. The furnishings were of glass and iron, easy to clean, although stark in appearance. Illumination was by in- direct lighting. In addition to an electric elevator, a white marble stairway circled from the entrance to the roof, where there was a glass walled solarium (Figure 3). This spacious room was a haven for recovering maternity patients who on winter days could bask in the sunlight amidst palms and plants. An outdoor promenade on the roof was used in fair weather. Also located on the roof were the photographer's quarters and 10 large exhaust fans. The facade was ornate, with wrought iron balconies and numerous bas- reliefs of infants in swaddling clothes (Figure 4). Robert L. Dickinson, M.D., writing in 1902, summarized the impact of the new building as follows: Helpless and suffering, ignorant and poor, the mother-to-be places herself under this protection. The best that skill and science and sympathy, with money, can provide, are hers. In a spotless bed she watches the tiny new arrival laid in his iron wicker crib that hangs at her bed-foot, and is watched over by a system and a perfectness of skill in every detail, which minimizes suffering and danger, and teaches invaluable lessions in cleanliness, in order and in the care of herself and her child.3 The model hospital stay was two weeks. During its early years, 59% of all hospital births in Manhattan took place in this building.

Vol. 60, No. 9, November 1984 910 H. PINSKER, AND OTHERS

Fig. 3. The hospital building at 307 Second Avenue as it appeared in the 1930s. Note the glass solarium on the roof. Courtesy of the Medical Archives, New York Hospital - Cornell Medical Center.

From 1904 to 1932, a scientific journal, The Bulletin ofthe Lying-In Hospi- tal, was published approximately twice a year. The hospital was the pioneer in the United States in seeking and finally evolving a satisfactory method of safely alleviating, over a period of hours, the suffering of childbirth: the use of morphine and scopalamine hypodermically, followed with the rectal instillation of ether and oil. A gynecological service was an integral part of the hospital, and about 100 operations a year were performed. However, only those who had formerly been maternity patients at the hospital were eligible for treatment, and the service remained small. The cohesive spirit that moved the dedicated founders from makeshift quarters on Broome Street to this splendid new building did not endure. By 1918 all who had participated in the founding of the midwifery dispensary had left. Two of them founded a new facility, the Manhattan Maternity Hospital. Continual controversy between the medical staff and the governors of the Society finally led to the resignation of Dr. Markoe. He was suc- ceeded by Dr. Asa B. Davis, who held the post of chief surgeon until his death in 1930.1

Bull. N.Y. Acad. Med. SECOND AVENUE AND EAST 17TH STREET 911

Fig. 4. Detail of infant in swaddling clothes on the exterior of the hospital building. Lee Snider, Photo Images.

General public and municipal support of the New York Lying-In Hospi- tal declined after the death of J. P. Morgan in 1913, leaving an increasing financial burden to few benefactors as expenses mounted. From the beginning, fund raising drives tended to be unsuccessful because the public regarded this as one of Morgan's personal charities. Mr. Morgan's son continued his father's support for the hospital, exceeding that which was called for in his father's will. Nevertheless, he was concerned that the hospital might not survive and initiated discussions with the trustees of New York Hospi- tal, who were then planning a new medical center on York Avenue between East 68th and East 72nd Streets. New York Hospital asked for $6,000,000 to absorb the Lying-In. Morgan sought help from John D. Rockefeller. Ul- timately, Rockefeller and Morgan gave two million each, and George Baker and George F. Baker, Jr. gave one million each. The agreement, signed in June 1928, made the Lying-In Hospital the maternity department of the new medical center being established in connection with Cornell University Med- ical College. Also absorbed into the new medical center was Manhattan Maternity Hospital, the facility founded by former Lying-In staff.I

Vol. 60, No. 9, November 1984 912 H. PINSKER, AND OTHERS

By the time the last patient was discharged from Lying-In Hospital on Au- gust 6, 1932, more than 5,800 physicians had been given bedside instruc- tion and experience in deliveries there. The hospital, which had occupied one ward in New York Hospital between 1801 and 1827, now occupied its own building in the New York Hospital complex.' By this time Beth Israel Hospital had completed three years in its new 400-bed building on the east side of Stuyvesant Square, having moved there from a 115-bed facility at Jefferson and Cherry Streets.

MANHATTAN GENERAL HOSPITAL During the early years of the century, enterprising physicians were able to organize small sanitaria without the extensive regulatory concern that af- fects us today. Dr. Alfred A. Richman established such a facility at 50 West 74th Street in 1925. In 1928 he leased the 20-bed Plaza Hospital at 136 East 61st Street. In 1930 he moved to 161 East 90th Street, leasing the building that had been opened in 1927 as Pan American Hospital. He reopened it as Manhattan General Hospital, a proprietary hospital with a capacity of 108 beds and 14 basinets. In 1934 the building was abruptly bought by Beth David Hospital, which had been unable to meet health department standards in its old quarters. Dr. Richman had already acquired some properties on the same block, considering the possibility of erecting a new hospital there,8 but in April 1934 signed a 22-year lease with New York Hospital for the empty building that had formerly housed the Lying-In Hospital at 307 Second Av- enue.9 Dr. Richman purchased the building in 1947 for $550,000.10 The refurbished building (Figure 5) contained several innovations, including a beauty parlor, barber shop, soda fountain, cafeteria, lending library, and arrangements for a radio in every room."I The hospital, formerly rated at 250 beds, was described as able to accommodate 300 patients under or- dinary circumstances and 400 in an emergency. With the transfer of 52 patients in July 27, 1936, Manhattan General was transformed from a small hospital to a major facility with 171 active beds for private and service patients, providing medical, surgical, and obstetrical services. The availability of a large number of underutilized beds made possible, in years to come, the creation of important new programs. An unusual departure from customary utilization of hospital space was the use of several rooms on the main floor of Manhattan General by the Works Progress Administration (WPA) Artists' Project. The WPA, which provided federal employment for many unemployed people in a wide variety of jobs

Bull. N.Y. Acad. Med. SECOND AVENUE AND EAST 17TH STREET 913

Fig. 5. Drawing of the entrance to Manhattan General Hospital which was used on the hospital stationery. during the dpression, employed artists who worked in studios and other locations throughout the city. A portion of the hospital building was used as a workshop and warehouse for the artists. Supplies were shipped here to be picked up and used in studios, or in public buildings where murals were being painted. Frames were made, canvases prepared, and pigments ground. In lieu of rent, the WPA artists did significant work to assist with the refur- bishing of the hospital. This workshop activity, begun when the hospital building was unoccupied in 1935, continued along with hospital operations into the 1940s.'102 Dr. Richman, himself an accomplished painter and sculptor, displayed his work in public areas and in the Medical Board Room.

Vol. 60, No. 9, November 1984 914 H. PINSKER, AND OTHERS

Although Manhattan General, as a proprietary hospital, was operated to some extent to bring a return on its owner's investment, the hospital made continual efforts to maintain the standards of a voluntary hospital. A medical board was established and given responsibility for medical policies and standards. While still in the East 90th Street building, the hospital was accepted by the Hospital Register of the American Medical Association, and it was approved to conduct an internship. Over the years, accreditations were reinstated and revoked several times. Continuing problems included a low number of autopsies and inadequate clinical records. The later owners of the institution, a private corporation with four principal stockholders represented by Dr. Richman, continually attempted to meet the requirements, seeking reinspection many times to demonstrate compliance. From 1957 on- ward, the Hospital received full three-year accreditations from the Joint Com- mission for Accreditation of Hospitals. A remarkable number of large-scale projects were undertaken at Manhattan General Hospital. The hospital accepted large numbers of workmen's com- pensation cases at a time when many hospitals were reluctant to do so because the reimbursement rate was lower and because workmen's compen- sation cases might include more black patients than some hospitals wanted. And when most hospitals would not, Manhattan General Hospital accepted black physicians as staff members.'3 Dr. Aubrey Maynard, a black physician, writing about his career at Harlem Hospital noted, "I was accepted as an attending surgeon on the staff of the Manhattan General Hospital in 1932, at that time probably the best of the large private institutions from the standpoint of facilities, equipment, and service. 14 MGH was known as the largest proprietary hospital in the country."'0 In 1949 a unit to care for tuberculosis patients was established under Dr. James E. Edlin, who was also director of the municipal sanitorium in Otisville, N.Y. As described by the city's Commissioner of Hospitals, this was "the first time in hospital history that a private nonvoluntary hospital in New York is accepting city patients on such a scale." City reimbursement at the start was $7.50 per patient day. The tuberculosis unit. which by 1950 had 240 beds, had its own staff, four residents and its own entrance, admitting area, laboratory, kitchen, and dishwashing facility. 'S With this contract, Manhattan General Hospital became the only proprietary hospital to appear in the city's charitable institutions budget and the only general hospital to offer tuberculosis patients a full range of medical, surgical, and social services. In all New York City in 1949 only four other nongovernmental general hospitals had tuberculosis beds, the numbers being 15, 21,

Bull. N.Y. Acad. Med. SECOND AVENUE AND EAST 17TH STREET 915

26, and 112.16 Dr. Edlin described the importance of the new unit: Fear of tuberculosis has been a major factor in the isolation of this disease to distant sanatoria-fear on the part of the hospital administrator, the physicians, nurses, em- ployees and the general public. It has long been felt that once the tuberculosis case has been diagnosed the general hospital's function becomes one of facilitating disposition to a sanatorium ... Teaching has suffered by the isolation of the tuberculosis patient ... the medical profession and its co-workers have come to regard the tuberculosis patient as a menace.... The tuberculosis unit can be integrated with the hospital and all the facilities of the general hospital can be utilized. Patients with tuberculosis are not spared other diseases ... and the staff of the general hospital should be available for consultation and treatment.17 The venture was so successful that at one point it was approved for eight residencies in pulmonary disease, and a 110-bed annex was established in Brooklyn. But within the decade development of antimicrobial agents had so revolutionized the treatment of tuberculosis that large numbers of beds for prolonged care were no longer needed, and the staffs of general hospitals no longer shunned the patients. The last tuberculosis patients left the hospital on April 29, 1960, 11 years and two months after the opening of the unit. As tuberculosis declined as a public health problem, narcotic addiction grew. Prior to 1953 a patient seeking medical detoxification from heroin had to travel at his own expense to the United States Public Health Service Hospi- tal at Lexington, Kentucky.'8 In 1953 the city opened Riverside Hospital on North Brother Island in the East River, a treatment facility for 141 adolescent addicts. In 1958 Dr. Ray E. Trussell, then dean of the School of Pub- lic Health at Columbia University, directed a detailed study of Riverside Hospital at the request of the state Commissioner of health, reaching the con- clusion that the Riverside program was totally ineffective.'9 Dr. Trussell, who had become part-time director of the Mayor's Commission on Health Services, Dr. Morris Jacobs, Commissioner of Hospitals, and Henry Co- hen, Deputy City Administrator, enlisted the support of Mayor Robert F. Wagner, who accepted the premise that heroin addiction was a growing health problem and required attention. Just as municipal and voluntary hospitals had shunned tuberculosis patients, they shunned those with addictive disease. On one occasion various administrators and clinical directors of the municipal general hospitals joined to refuse the commissioner's request that 25 beds, two in each hospital, for detoxification of pregnant addicts be found among their 15 hospitals.20 In 1959, as a result of the Columbia study and a behind-the-scenes deci- sion to close Riverside Hospital when possible, the city opened a 50-bed

Vol. 60, No. 9, November 1984 916 H. PINSKER, AND OTHERS detoxification research unit at Metropolitan Hospital under direction of Dr. Alfred M. Freedman's Department of Psychiatry of New York Medical Col- lege. Since this was not sufficient to meet the still growing need, the city approached Dr. Richman, who in December 1960 accepted a contract to make 90 beds in Manhattan General Hospital available for detoxification treatment of addictions On January 23, 1961 a 35-bed unit for detoxification of male heroin addicts was opened at Manhattan General Hospital under the direction of Dr. Harold L. Trigg, whose association with the hospital began when he worked as a consultant on the tuberculosis service. Dr. Marie Nyswander was ap- pointed psychiatric consultant to the detoxification service. Heroin detoxification patients, like tuberculosis patients in earlier years, were admitted through a side entrance and segregated from other patients to avoid upset- ting them or their families. Methadone, a long-acting synthetic narcotic, was used for detoxification. Initially, patients with histories of epilepsy, active tuberculosis, or recent myocardial infarction were excluded, but these re- strictions were later dropped. In addition to detoxification and psychiatric intervention when appropriate, social work counseling, occupational ther- apy, recreation, and vocational guidance were offered.22 The Narcotic Detoxification Unit, as it was then called, increased to 60 beds in 1961, and later expanded again to become the only facility providing detoxification for female addicts.23 The Detoxification Unit eventually exceeded 300 beds. Elsewhere at this time, as a result of city-state negotia- tion, 150 "research beds" for adolescent patients were opened in state hospitals, Riverside Hospital was closed, and some municipal hospitals had established small detoxification units. '9

MORRIS J. BERNSTEIN INSTITUTE OF BETH ISRAEL MEDICAL CENTER As hospital care became increasingly subject to regulatory scrutiny and control, proprietary hospitals became targets of critical appraisal. Dr. Trussell, then Commissioner of Hospitals, had begun a program of affilia- tion contracts under which voluntary hospitals assumed responsibility for professional staffing of municipal hospitals. For example, Beth Israel Hospital had a contract to operate ambulatory services at Gouverneur Hospital, a small municipal hospital on the Lower East Side. Dr. Trussell was influential in persuading Mr. Charles H. Silver, president of Beth Israel Hospital, former president of the Board of Education, and at that time special assistant to the mayor, that Beth Israel should purchase the 455-bed Manhattan General

Bull. N.Y. Acad. Med. SECOND AVENUE AND EAST 17TH STREET 917

Hospital, which was increasingly pressured by rising costs and ever more exacting regulations.20 Concurrent with the announcement of the purchase on September 1, 1964, the city provided Beth Israel an unprecedented 10- year contract for service to addicts in what was to be known as the Man- hattan General Division.24 On September 25, 1966 the facility was dedicated to Morris J. Bernstein, a philanthropist who donated one million dollars (Fig- ure 6). A committee chaired by the Medical Center's Dr. Sidney Leibowitz evalu- ated the quality of care in the detoxification unit. It found that much of the medical care was the responsibility of elderly general practitioners and "moonlighting" psychiatry residents. A final recommendation was "despite the obstacles inherent in this detoxification project, the objective for medical care to be rendered must be set at the highest level .. despite realistic recognition that most of the admitted addicts are not ill in the traditional sense .... '"25 Dr. Leibowitz's committee attached greatest urgency to identifying the addicts' medical illnesses so that they could receive optimum treatment. Upon its urgent and farsighted recommendation, a medical unit was established to treat the serious medical complications of addiction such as acute and chronic liver disease, tuberculosis, gastrointestinal hemorrhage, pancreati- tis, pneumonia, subcutaneous ulcerations, infective endocarditis, and chronic renal disease.26-30 The medical unit at Morris J. Bernstein Institute is now used for the training of house officers from Beth Israel and medical students from Mount Sinai School of Medicine, with which Beth Israel is affiliated. Medical responsibility for patients on the drug detoxification service is maintained by a small number of internists supervising a large staff of physician's assistants. During the 1970s the city's addict population changed markedly. At the beginning of the decade, the drug addiction service focused primarily on heroin addiction. In 1972 the Medical Center established, with support from city and state, a comprehensive alcoholism treatment program comprised of an outpatient clinic, a halfway house, and, within the Bernstein Institute, a 50-bed detoxification unit. Increasingly, multiple addiction became the clinical problem. Procedures were developed to treat patients who had been using combinations of narcotics, sedatives (including alcohol), stimulants, and hal- lucinogens. Many clinical research projects were undertaken, some in con- junction with Rockefeller University with which Beth Israel is affiliated.3 At its maximum capacity the Institute admitted more than 9,000 addicted patients annually, and with 387 beds it was the largest nongovernmental

Vol. 60, No. 9, November 1984 918 H. PINSKER, AND OTHERS

Fig. 6. Entrance to the Morris J. Bernstein Institute in 1982. Note numerous faces of infants and additional representations of infants in swaddling clothes. Lee Snider, Photo Images.

hospital in the world for voluntary treatment of narcotic addiction. Detoxification services have often been criticized because relapse is com- mon in addictive disorders and detoxification does not alter underlying problems.32 In many instances, however, detoxification treatment prevents progress from substance abuse to addiction. Dr. Robert G. Newman, general director of Beth Israel Medical Center, pointed out that the benefits of detoxification treatment include attention to coincident health problems, referral to relevant social agencies, and reduction of the addict's need to procure money with which to buy narcotics.33 The concept of methadone maintenance as treatment for narcotic addiction was developed at Rockefeller University by Drs. Vincent P. Dole and Marie E. Nyswander. In 1964 they began to study the pharmacology of various narcotic agents in chronic heroin addicts, hoping to find an alternative treatment method to generally unsuccessful psychological approaches. A year's work with six patients established that a single oral dose of metha-

Bull. N.Y. Acad. Med. SECOND AVENUE AND EAST 17TH STREET 919 done each 24 hours enabled addicts to function without sedation or with- drawal symptoms.34,35 They also found that if the maintenance dose of methadone was sufficiently high, it blocked the euphoric effects of concomi- tant intravenous heroin.36 Early critics of this work contended that the patients might have recovered from their addiction because of the comfortable atmosphere and concerned staff rather than from the pharmacologic effect of treatment. It was necessary to conduct trials on a larger group of addicted patients in a general hospital setting. Dr. Dole approached Commissioner Trussell with his patients' treatment summaries and a request for some beds. With the support of New York City Mayor Robert F. Wagner, Trussell arranged with Beth Israel in 1965 to assign six beds for a methadone maintenance induction unit, apart from the detoxification service. The positive results obtained at Rockefeller University were duplicated at the Manhattan General Division. 19'37 It was then deemed necessary by the Commissioners of Hospitals, Health, and Men- tal Health that a large scale trial be implemented. In June 1965 Beth Israel Hospital received a $1,380,000 contract from the Interdepartmental Health Council of New York City to expand its methadone research. The funds also provided for an independent evaluation of methadone maintenance treatment by the Columbia University School of Pub- lic Health and Administrative Medicine.38 The initial large scale trials of methadone maintenance were conducted at and from Bernstein Institute between 1965 and 1968. In the first years of work with methadone, an initial six-week inpatient stay was followed by indefinite outpatient treatment. As the Beth Israel Methadone Maintenance program expanded rapidly, inpatient induction was eliminated and clinics were established throughout the city. By 1970 2,000 patients attended Beth Israel's clinics, many of which employed successful methadone maintenance patients as counselors. At the beginning of 1982, more than 7,000 patients were in treatment through Beth Israel's network of outpatient methadone clinics in various locations in Man- hattan, Brooklyn, Queens, and Staten Island. Although objections have been raised on moral, psychological, or other grounds, methadone treatment has had an impact greater than any other treatment approach in reducing crimi- nality and facilitating social rehabilitation.39 The availability of space in the Bernstein Institute building, coupled with Beth Israel's interest in research on the treatment of addictions, led to the establishment of an abstinence model residential community. From 1967 to 1971 one of the clinical units was turned over to Phoenix House. Patients

Vol. 60, No. 9, November 1984 920 H. PINSKER, AND OTHERS who had completed detoxification and whose applications to Phoenix House were accepted were discharged from the hospital, then admitted to Phoenix House, which was clinically and administratively independent. The single nonaddiction service operated by Beth Israel in the Bernstein Institute building was a psychiatric inpatient service, typical of general hospital psychiatric units developed throughout the country after 1945. This unit, which replaced the last general medical and surgical beds in the building, opened in 1967 to provide diagnosis and short term treatment for both voluntary and involuntary inpatients. In 1980 the general psychiatric service was moved to new quarters in the main Beth Israel Hospital building, and the old facility became the country's first psychiatric service exclusively for substance abusers with other mental disorders. The original trustees' plan to cre- ate an institute from treatment and study of addictive and mental disorders was never implemented, for the clinical services in the Bernstein Institute building have functioned as unrelated components of the Departments of Medicine and Psychiatry. Patient care in the 1902 building is coming to an end, and the services are to be moved to the building located immediately south of Beth Israel Hospital that housed the new York Infirmary. New York Infirmary vacated its 16th Street premises in 1981 when it merged with Beekman Downtown Hospital and consolidated its services in lower Manhattan. It is worth not- ing that between 1951 and 1953, while the New York Infirmary building was under construction, the activities of the Infirmary were carried out at Manhattan General Hospital-their physicians were given Manhattan General staff appointments, their nurses were hired, and their patients charged In- firmary rates.'2 For Beth Israel Medical Center the high cost of maintaining the 80 year old building and of complying with the continually more stringent safety standards of regulatory agencies makes the move to the modern building on the next block seem attractive, although it requires extensive renovation. The possibility of connecting the two buildings by a tunnel under East 16th Street will offer clinical as well as financial benefit because the presence of busy Second Avenue between buildings of the Medical Center has interfered with efficient movement of patients and staff. Along with many former commer- cial or institutional buildings in lower Manhattan, the one time New York Lying-In Hospital will be transformed into an apartment building. Each of the programs that distinguished this elegant hospital building was outside the mainstream of medicine when begun, but part of the mainstream now. It is difficult for us today to imagine that a century ago childbirth was

Bull. N.Y. Acad. Med. SECOND AVENUE AND EAST 17TH STREET 921 so far from the mainstream of medicine that dedicated individuals had to form specialized societies to teach it or that when childbirth entered the hospital it involved a protracted stay and care by specialized staff. With the elimi- nation of extended convalescence after childbirth, need for specialized hospitals vanished. Tuberculosis moved into the main body of medicine after the development of antimicrobial agents, also eliminating the need for special hospitals. Short- ened hospital stays and reduced fear of the patients made it possible to move psychiatry from remote long stay institutions to small units within general hospitals. The feasibility of treating alcoholics in general hospitals has been widely recognized for only about 10 years. At this point only drug abusers are seen as candidates for a separate building, and preferably one that is part of someone else's hospital. But, as substance abuse has spread throughout the community, patients with substance abuse disorders receive treatment in almost all hospitals, often with approaches to treatment that were developed in specialized hospitals. In the current climate of economy, excess hospital bed capacity is seen as a burden for the community. In an earlier time, the oversupply of beds at Manhattan General Hospital made possible the rapid development of several important and innovative therapeutic programs. As the community no longer can afford hospitals with 171/2 foot ceilings or solariums, it can no longer afford a hospital that has the excess beds available to respond quickly to serve unmet needs.

ADDENDUM The fluidity of small hospitals in the first half of this century is further illustrated by an account of the several institutions that have utilized the buildings mentioned. The East 90th Street building that was available for use by Manhattan General in 1930 was vacant because Pan American Hospital had moved out. The Pan American Medical association was founded in 1925.40 Dr. William Sharpe had become concerned that physicians in this country were ignorant of diseases seen primarily in Latin America, which became a problem due to increased travel between this country and Latin America. He observed that when he visited Latin American countries he was well received, but that there was no reciprocal arrangement for Latin American physicians here, nor a place for visiting professors to present papers. Dr. Sharpe and his colleagues established a Latin-American department at Poly- clinic Hospital, feeling that the clinical facilities of a modern hospital should

Vol. 60, No. 9, November 1984 922 H. PINSKER, AND OTHERS be available to the rapidly growing Latin American population of more than 300,000 in the New York City area. The success of this venture was such that by 1927 the trustees of Polyclinic became fearful that the character of the hospital would be changed froiriAnglo-Saxon to Latin, so the Pan Ameri- can group was asked to seek other quarters. Mr. James Barber, industrialist and chairman of the board of the old Broad Street Hospital, had invested one million dollars in the construction of a model 100-bed hospital on East 90th Street. When completed in 1927 Mr. Barber offered control of the hospital to the Pan American Medical Associ- ation. The hospital was successful from its opening in the fall of 1927. On Thanksgiving Day, 1928, Mr. Barber said that he would donate the hospital to the Association. Ten days later he died, with no arrangements yet made to accomplish this donation. Since his heirs did not wish to pursue his plan, and the Pan American Medical Association could not raise enough money to buy the building, in the spring of 1929 it was forced to vacate. The group was then given medical control of Broad Street Hospital by Mr. Henry L. Doherty, chairman of the board. From 1929 to 1938 Doherty sup- ported the venture. When he died, the hospital quickly went into bankruptcy. The physicians themselves were able to raise enough money to continue operation. They became trustees, and created Downtown Hospital and Pan Ameri- can Clinic. In 1940 Mr. Henry Lockhart, president of New York Ship building Company, was taken to Downtown Hospital following an accident. Pleased with the care he received, he then enlisted support for the hospital. In 1945 Downtown Hospital merged with the one other hospital in lower Manhattan, Beekman Hospital, and built a new building. In 1947 there was discussion of a merger of Manhattan General Hospital and the Pan Ameri- can Medical Society. A marker of the interrelationships is the memorial plaque in what is now the Medical Records Library to Edward Kellog, M.D., president of the Pan American Medical Society and president of the Medi- cal Board of Manhattan General Hospital. This merger never ensued, however. New York Infirmary merged with Beekman-Downtown Hospital in 1980. Originally New York Infirmary for Women and Children, it had been founded in 1854 by Drs. Elizabeth and Emily Blackwell. In its early years it was the only hospital staffed entirely by women physicians. Manhattan General Hospital was forced to leave East 90th Street when the building was purchased in 1934 by Beth David Hospital. Beth David evolved from The Yorkville Dispensary and Hospital. This institution, initially on East 82nd Street, later operated from 1307 Lexington Avenue, providing an "out-door service for the treatment of women and children."

Bull. N.Y. Acad. Med. SECOND AVENUE AND EAST 17TH STREET 923

This was care in the home, similar to the activity of the Lying-In Hospital for many years. In 1895 Yorkville changed its name to Metropolitan Hospital and Dispensary for Women. As Beth David Hospital, it moved into the East 90th Street building in 1937, remained until 1956 when it purchased a building vacated by the Hospital for Special Surgery (formerly the hospital for the Ruptured and Crippled) at 321 East 42nd Street. Beth David ceased operations in 1959, and its building was demolished to make way for the new Ford Foundation headquarters.

ACKNOWLEDGMENTS We gratefully acknowledge the assistance of: Ave Maria Burris La Corte, Sidney Bassen, M.D., Sherrie Butler, Fay R. Cooper, Saralie Faivelson, Arlene Freedman, Grace Kraskin, Sidney Leibowitz, M.D., David Margolis, Alfred A. Richman, M.D., Edward L. Richman, Charles A. Togut, Harold L. Trigg, M.D., and Ray E. Trussell, M.D.

REFERENCES 1. Harrar, J. A.: The Story ofthe Lying-In 12. Margolis, D.: Personal communication. Hospital of the City of New York. New 13. Richman, E. L.: Personal communi- York, The Society of the Lying-In cation. Hospital, 1938. 14. Maynard, A.: Surgeons to the Poor: The 2. Speert, H: Obstetrics and Gynecology in Harlem Hospital Story. New York, America. Chicago, American College of Appleton-Century-Crofts, 1978. Obstetricians and Gynecologists, 1980. 15. The New York Times, June 16, 1949 3. Dickinson, R. L.: The new Lying-In (32:2). Hospital in New York. Am. Monthly 16. TB Sanitarium Conference of Metropoli- Rev. Rev. 25:443-47, 1902. tan New York: Tuberculosis: New York 4. Satterlee, H. L: J. Pierpont Morgan: An Tuberculosis and Health Association Intimate Portrait. New York, Macmil- (1943-1949) Tuberculosis Reference lan, 1939. Statistical Yearbook. New York, Depart- 5. The National Cyclopaedia of American ment of Health, 1949, Table 40. Biography. New York, White, 1902, pp. 17. Edlin, J. S., Bassin, S., and Richman, 15-17. A. A.: The tuberculosis patient in the 6. Schuyler, M.: The works of R. H. general hospital. Dis. Chest 20:551-56, Robertson. Architect. Rec. 6:179-219, 1951. 1896. 18. Sapira, J. D., Ball, J. C., and Penn, H.: 7. Harper's Weekly 38:195, 198-99, 1902. Causes of death among institutionalized 8. The New York Times, October 14, 1934 narcotic addicts. J. Chronic Dis, 22:733- (1:7). 42, 1970. 9. The New York Times, April 7, 1935 19. Trussell, R. E.: Treatment of narcotic (1:7). addicts in New York City. Int. J. Addict. 10. Richman, A. A.: Personal communi- 5:347-57, 1970. cation. 20. Trussell, R. E.: Personal communi- 11. The New York Times, July 27, 1936 cation. (13:8). 21. The New York Times, December 19,

Vol. 60, No. 9, November 1984 924 H. PINSKER, AND OTHERS

1960 (29:8). 31. Novick, D. M., Kreek, M. J. Fanizza, 22. Trigg, H. L.: Personal communication. A., et al.: Methadone disposition in pa- 23. Fortunato, M., LaVine, R., Feldstein, tients with chronic liver disease. Clin. S., and Richman, E. L.: Predicting type Pharmacol. Ther. 30:353-62, 1981. of discharge from a narcotic detoxifica- 32. Trussell, R. E. and Gollance, H.: tion service. Int. J. Addict. 1:124-30, Methadone maintenance treatment is suc- 1966. cessful for heroin addicts. Hosp. Man. 24. The New York Times, August 21, 1964 110:56-62, 1970. (31:8). 33. Newman, R. G.: Detoxification Treat- 25. Leibowitz, S.: Report of Special Com- ment of Narcotic Addicts. In: Dupont mittee of Medical Board to Study the R. L.: Handbook on Drug Abuse. Rock- Narcotic Detoxification Unit ofMorris J. ville, MD, Nat. Inst. Drug Abuse, 1979. Bernstein Institute (Originally Manhattan 34. Dole, V. P.: Heroin addiction - an epi- General Division) ofBeth Israel Medical demic disease. Harvey Lect. 67:199-211, Center. 1967. Unpublished. 1973. 26. White, A. G.: Medical disorders in drug 35. Dole, V. P. and Nyswander, M. E.: addicts - 200 consecutive admissions. Heroin addiction-a metabolic disease. J. A. M. A. 223:1469-71, 1973. Arch. Intern. Med. 120:19-24, 1967. 27. Novick, D. M., Gelb, A. M., Stenger, 36. Dole, V. P., Nyswander, M. E., and R. J., et al.: Hepatitis B serologic studies Kreek, M. J.: Narcotic blockade. Arch. in narcotic users with chronic liver dis- Intern. Med. 118:304-09, 1966. ease. Am. J. Gastroenterol. 75:111-15, 37. Dole, V. P. and Nyswander, M. E.: Re- 1981. habilitation of heroin addicts after block- 28. Curtis, J., Richman, B. L., and Fein- ade with methadone. N. Y. State J. Med. stein. M. A. Infective endocarditis in 66:2011-17, 1966. drug addicts. South. Med. J. 67:4-9, 38. Gearing, F. R.: Evaluation of Metha- 1974. done Maintenance Treatment Program. 29. Enlow, R. W., Novick, D., Yancovitz, In: Methadone Maintenance, Einstein, S., and Winchester, R. J.: Elevated S., editor. New York. Dekker, 1971, numbers of Ia+ and T8 + (suppresor) T pp. 171-97. cells in parenteral substance abusers with 39. Dole, V. P., Nyswander, M. E., and further increases during severe bacterial Warner, A.: Successful treatment of 750 infections. Clin. Res. 30:365A, 1982. criminal addicts. J. A. M. A. 206:2708- 30. Novick, D. M., Yancovitz, S. R., and 11, 1968. Weinberg, P. G.: Amyloidosis in paren- 40. Sharpe, W: Brain Surgeon. New York, teral drug abusers. Mt. Sinai J. Med. Viking. 1952. 46:163-67, 1979.

Bull. N.Y. Acad. Med.