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Preface

One day in the autumn of 1958, I went for an interview to New York University School of Medicine. N.Y.U.’s major affiliated teaching facility was (and still is) Bellevue Hospital. During the course of my interview, the Dean asked me why I wanted to go to medical school. I told him:

I want to be a doctor because then I’ll have an acceptable excuse to talk and listen to unusual people for the rest of my life. I want to come to Bellevue because I think that’s where they have more unusual people than anywhere else in the world.

The Dean cleared his throat, and I jumped out of my chair. But then I saw the corners of his mouth flickering upward, and I heard him say:

You know, we get pretty weary of hearing one applicant after the other say he wants to become a doctor so that he can help suffering humanity. You are either terribly honest or terribly inventive. Either way, you’re so far out I feel you can’t help but succeed.

I thanked the Dean and went home. My letter of acceptance arrived three days later.

So, I went to Bellevue. During the next six years, as medical student, intern, and resident physician, I watched in gratified amazement as great giant hordes of peculiar individuals acted out their scenes before me. I had been right: there seemed to be something in those dingy wards and hallways that brought out the exceptional in the inhabitants, whether they were patients, relatives, or hospital employees.

When the new Bellevue Hospital, twelve years in the building, finally opened a few years ago, alumni throughout America sighed in relief and offered the opinion that life at The Vue would henceforth be very different. But I knew better. It didn’t matter that the physical structure was new, because the hospital would continue to be inhabited by the very same cast of characters who had always caused Bellevue to be a singularity, and who always will.

Introduction

An Overview of The Vue

We called it THE VUE, and without a doubt that was the most complimentary nickname Bellevue Hospital ever had. More than once I heard someone call the place Bedlam Hospital, after the infamous London madhouse. Other sobriquets were even more derogatory. In the process of interviewing an internship candidate, one of the residents referred to his place of employment as Satan’s Little Acre. And one day, as I got up to debark from a bus pulling to a stop in front of Bellevue, the driver sang out, “Foist Av’noo’n Twenty-six Street. Noo Yawk City Slaughterhouse.”

There existed many reasons for the plethora of nasty names. Throughout its very long history Bellevue has traditionally dispensed free medical care to the needy, and people generally feel that anything free is worth no more than the price. Bellevue has long been associated with medical schools; hence it became known as the place where innocent patients were butchered by students while learning their trade. Then too, The Vue possessed a well-earned reputation as an outstanding research center which, unfortunately, gave rise to the belief that if you were lucky enough to escape the blunders of its medical students, some nut in a long white coat would turn you into a guinea pig. Nor did certain of Bellevue’s component parts help its image; for any huge general hospital which also happens to contain within its walls both a major psychiatric institution and the city morgue is more likely to inspire trepidation than adulation in the minds of the local populace.

Perhaps as much as anything, Bellevue’s very appearance was responsible for its lack of charisma. Many of today’s medical centers, especially those seen on television, are soaring glass-and-concrete architectural triumphs, designed to lead people to imagine that the gods of healing truly do reside there. In contrast, Bellevue appeared to have been constructed by a man whose mother had been frightened by a Picasso drawing of a toad.

Set down on a rectangular plot bordered by the East River Drive, First Avenue, Twenty-sixth Street, and Thirtieth Street, The Vue was a dreadful mélange of squat buildings of dark red and dirty yellow brick. The various edifices were put up between 1904 and 1940, each part a seeming afterthought, connected to the others by endless mazes of hallways and subterranean tunnels. The entire complex was surrounded by a black iron fence. An uninformed visitor to New York City, on seeing the hospital, would most likely have assumed it to be a prison built especially for the detention of the most despicable and miserable sorts of criminals.

If such a visitor were sufficiently courageous to set appearances aside and walk into the hospital, he would have been even more dismayed. Entering through the main door, he’d have found himself in a large lobby, consisting of a wide walkway running past a line of information cages, whose bars reinforced the general prison-like appearance of the institution. On the other side of the walkway, and occupying most of the lobby area, he’d have seen rows of brown wooden benches. Most of the seats would have been occupied by as colorful a representation of the lower socioeconomic classes as one could possibly find anywhere on earth.

Bowery bums would have been scattered here and there, mostly sitting hunched forward, staring at the floor. Perhaps one, his head wrapped in bandages and gauze, would have been lying on his side, his knees drawn up to his chest and his mouth hanging slackly open. Nearby, but at a discreet distance, an old woman with a shawl over her stringy gray hair might have been sitting with a shopping bag between her feet, her eyes darting back and forth as though on guard against an imminent assault. Three benches away, there could have been a junkie, nodding off to sleep. Around them all, large numbers of ragged little children of all sizes and colors would have been charging back and forth, playing tag and chasing each other between the benches. Occasionally, the old woman would have become irritated and shooed some of them off. They’d have laughed at her and continued their games. The visitor would have wrinkled his nose against the stench of unwashed bodies and exhaled alcohol.

Proceeding past the lobby and through the labyrinthine halls, the visitor to New York would have come upon one or another of the patient areas. Private rooms were a rarity at The Vue, the few that existed usually being reserved for sick doctors or nurses who chose to be treated on their home grounds. Open wards were the rule; they contained anywhere from twenty to forty beds in two or three long rows stretching the length of the room. Curtains could be pulled around the beds at the sides of the ward, but privacy was impossible to the inhabitants of the center row.

Everything in the place was in disrepair. Cobwebs and dirt hung in the corners between the high walls and the ceilings. No wall was without its region of peeling paint or plaster. The hands on the flyspecked clocks stood motionless, except for the occasional pair that zoomed through hours in seconds, giving off a buzzing noise as they did. Lighting was dim throughout, and dark shadows that moved slowly across the walk, floors, and ceilings produced an atmosphere of depression which continually affected the mood and behavior of the inhabitants.

Right from its beginning, Bellevue was Bellevue. The institution dates its origins, spiritually, if not physically, to 1736 when a six-bed infirmary was set up in the New York Publick Workhouse and House of Correction, located in the region of the present-day entrance to the Brooklyn Bridge. There, the medical and surgical needs of the inmate prisoners and indigents were attended to.

As early as 1811, New York was beginning to show signs of growing pains, so the city purchased a large farm on what was then uptown land, near the East River. A part of this region was known as Belle Vue (which it may well have been at the time), and the public hospital facility constructed on the site took its name from the location. Like the city it served, it grew like Topsy.

By 1877, one hundred years ago, The Vue had twelve hundred beds, an emergency room, ambulance services, and outpatient facilities. (These latter three attributes were all Bellevue innovations.) It even had its own medical school: after a decade during which lectures and surgical demonstrations were presented on a loosely organized basis, the Bellevue Hospital Medical College was founded in 1861. This marked the formal beginning of The Vue as a teaching institution, a modus operandi which has persisted to the present day. But not via the same vehicle. Little more than thirty years after it had begun operations, the physical plant of the Bellevue Medical School was destroyed by fire. The faculty then accepted the offer of the nearby New York University Medical College to share its facilities and, in 1898, the Bellevue people decided to merge with their benefactors rather than rebuild. Thus began the association between N.Y.U. and The Vue, which has continued without interruption for the past seventy-nine years.

During this interval, Bellevue has been the focal point of many historic medical crises and catastrophes. During the early years of the twentieth century, there were several spectacular fires in lower Manhattan. When the steamer General Slocum burned in the East River in 1904, more than a thousand of its passengers were killed and several hundred were injured. The majority of these survivors were brought to The Vue by horse-drawn ambulances. The same equine-powered conveyances also brought in the victims of the 1911 Triangle Shirtwaist Company fire and the 1912 Equitable Life Assurance Building conflagration.

The year 1918 marked the great influenza epidemic, and the lion’s share of the seriously ill New Yorkers received their inpatient care at The Vue. Since there was no effective treatment for the condition, mortality rates were astronomical: on one particular day that fall, sixty-two Bellevue inmates lost their battle with the flu bug. Included among the grim statistics were several members of the hospital’s nursing and physician staffs.

In the spring of 1947, New York City had a serious smallpox scare. The disease was brought in by a traveler from Mexico who, on his way to Maine, got as far as Gotham before collapsing. Guess where he went for help at that point. Before the problem was declared solved, two months had passed, twelve people had come down with smallpox (two of whom died), six million citizens had been vaccinated, and the city had spent more than $800,000 to prevent the generalized epidemic which otherwise would certainly have occurred.

Around the turn of the century, it became apparent that the physical facilities were grossly inadequate for the medical load, and what was left of the grass and trees from old Belle Vue began to disappear under tons of brick and mortar. New buildings were erected in 1904, 1908, 1911, 1916, and 1917. In 1926, Mayor Jimmy Walker referred to the psychiatric facilities as “a state of affairs in which I wouldn’t ask my dog to be kept.” Four years later, Beau James presided at the ground-breaking ceremonies for the new psychiatry pavilion, which was opened in 1935. Lastly, the administration building, at the front and near the middle of the complex, was completed in 1940. With that, almost every inch of space was occupied, with the exception of a parking lot in the back.

But Manhattan continued to outgrow The Vue, and by the early 1960’s, New York City’s Municipal and Hospital administrations reached the decision that the conglomeration of now old buildings could no longer be tolerated, and that an entire new Bellevue must be built. That was the end of the parking lot. Having the unmistakable evidence of wisdom of brick-and-mortar neighbors on all sides that proved the folly of wasting air space in twentieth-century New York City, the administrators and the architects resolved that Nova Bellevue would scrape the sky like all modern structures, and thereby require a minimum of ground space. A deep hole was sunk into the turf where Pontiacs and Volkswagens had once pranced, and there it remained for several years, periodically filling up with water, awaiting the resolution of multiplex municipal squabbles that delayed construction progress. But finally, in 1966, construction was resumed, and after seven more years had passed the new building was dedicated. All things take time. Especially at Bellevue.

My tenure at The Vue essentially spanned the hole-in-the-ground years. I arrived as a first-year medical student in the fall of 1959, and left (at the insistence of my tall, bewhiskered uncle) after a year of residency, in 1965. Since first- and second-year medical students spent little time on the wards, my intense and intimate association with the place actually covered a four-year period, consisting of most of the early 1960’s, a time of great social upheaval and turmoil in American society.

As the primary municipal hospital in Manhattan, The Vue drew patients from the entire borough, although the great majority of the clientele came from lower Manhattan. This region included the Bowery and its numerous derelicts who were accustomed to patronizing The Vue to obtain medical repair of their worn-out parts (usually lungs or livers).

Many Bellevue patients came from the Lower East Side of Manhattan. The Lower East Siders consisted primarily of two groups of people. First, there were the elderly Jews, the holdovers from the massive wave of Middle and Eastern European immigrants who had come to America earlier in the twentieth century, and who had turned large areas of the Lower East Side into mini-ghettos. Their children moved on to New Jersey or Long Island, but the old people remained where they had grown up and raised their families. Each year there were fewer of them, but their numbers were still considerable. The other major Lower East Side group was made up of more recent immigrants, the Puerto Ricans. Often, whole families resettled en masse in New York, and infirm Puerto Ricans kept all the Bellevue wards busy, from pediatrics to geriatrics.

As in its earliest days, Bellevue generally catered to the less-solvent strata of society, but such was not invariably the case. Sometimes, The Vue would play host to a middle-class or even an affluent patient. This was especially likely to happen in case of emergencies, such as when a neighborhood businessman suffered a heart attack while at work, or when a suburban housewife, in the city for a day of shopping, misjudged the determination of a cab driver while crossing the street, and was brought in with tread marks on her person. And additionally, since one’s social or financial status is never a factor when one runs amuck, some fairly “fancy” people were taken to Bellevue Psychiatric Hospital for observation.

At the other end of the social spectrum, The Vue never forgot its Publick Workhouse and House of Correction origins, and a portion of the second floor was set aside as a prison ward, complete with barred doors and windows, with police on duty in addition to the usual ward attendants. Here prisoners were brought from the various New York jails whose medical or surgical problems could not be handled by the jail infirmaries.

All members of the Bellevue medical staff were affiliated with a medical school, thereby making The Vue a teaching hospital. During the early 1960’s, three schools provided The Vue with its students and staff. Bellevue was the primary teaching facility for New York University, but Columbia and Cornell both maintained very active secondary affiliations. (Their primary associations were with Presbyterian and New York Hospital, respectively.) Today only N.Y.U. is represented at The Vue. By reducing the number of medical indigents in the city, health insurance has lowered Bellevue’s patient population to the point where it can no longer support more than one medical school.

The medical personnel at Bellevue were organized along rigid hierarchical lines. Low men on the totem pole were the freshman and sophomore students. During their first two years of training, most of their time was spent in classrooms, learning the principles of basic medical science. On occasion, groups of them were brought together with experienced doctors on the Bellevue wards, to be taught the skills of physical diagnosis.

This first experience in the bowels of the Behemoth of First Avenue was usually more or less unnerving to the initiates, which was made apparent by their pale faces and nervously darting eyes.

By the third year of medical school, students were expected to have mastered the scientific material necessary to the care of patients, and to have psychologically reached the stage where it would take more than the sight of blood to make them pass out. Hence, for their last two years of study they were assigned to ward duty on the different services: medicine, surgery, obstetrics and gynecology, pediatrics, and psychiatry. In addition, there were periods of elective time that could be spent on many of the smaller services. The students took histories, performed physical examinations, and helped with their patients’ ongoing medical care under the supervision of graduate physicians.

They also did a load of scut work. “Scut” is a word reputedly derived from the Greek term for excrement, and it was used in reference to the innumerable unpleasant little tasks which were, in most private hospitals, performed by non-medical workers. At The Vue, however, these jobs slid down the chain of command to the bottom, where they settled among the medical students and interns. Performing blood counts was scut, and so was wheeling patients to and from the X-ray Department. No less scutty was having to run the length of the hospital to Central Supply when the electrocardiograph machine ran out of paper in the middle of working up a patient.

The scut jobs at The Vue were endless, and medical students spent an inordinate amount of their time wondering how it came to pass that their tuition fee involved them in more hours of doing scut than making ward rounds with attending physicians. When they protested, they were patronizingly told that scut was, after all, also an L.E. (Bellevuese for “Learning Experience”), to which the students would usually react with an expletive that meant scut.

After four years of medical school, and having mastered the fundamentals of basic medical science and patient care, the student was permitted to put M.D. after his name, and was graduated into internship. Now the learning process began in earnest.

Although the intern was technically an employee of Bellevue Hospital (being paid a munificent $3,200 per year), he was part of the affiliated medical school teaching staff together with his more senior house officers—the residents and the staff of attending physicians. He learned from his superiors and he helped to teach the students beneath him.

Working on the wards and in the clinics all day, and taking calls through many of the nights, the intern was first on the firing line in the care of his patients. By doing what he could by himself, and by helping his seniors with more difficult tasks, his fund of knowledge and reservoir of confidence gradually increased. It is generally true that most doctors have learned more during their internship than during any other single year of their lives.

Upon completion of internship, the doctor became a resident physician. Residency consisted of a set number of years of training, during the course of which there was progressive assumption of more complex duties and greater responsibilities, all of which ultimately led to the doctor’s capacity to function independently as a specialist in a particular field. The length of time spent in residency varied with the specialty, ranging from two years in pediatrics to seven or more years for some of the surgical sub-specialties. Residents supervised the work of interns and medical students, and they, in turn, were supervised by more senior residents and by attending physicians.

For all practical purposes, the chief residents on the various specialties were the kingpins of The Vue. In consultation with their attending physicians, they made the ultimate decisions regarding patient care, performed the most difficult operations, and generally kept watch over their entire services. When an intern or a junior resident blundered, the chief resident was held accountable. When all was going well on a service, that was merely to be expected. The buck definitely stopped on the chief’s desk. After surviving that sort of a year, the graduating chiefs were ready for anything that practice had to offer.

The senior members of the teaching team were the attendings, of which there were two types. Part-time attendings were men and women in practice who wished to maintain a strong association with a medical school. Therefore they donated their time to help with the on-the-job training for the medical students and the house staff. The full-time attendings, on the other hand, were paid a salary by the school in return for which they taught at Bellevue, gave lectures to the pre-clinical students, and did research. Even at the attending physician level, the Bellevue fondness for hierarchism exerted itself: the attendings were placed at either the junior or the senior level.

At Bellevue, no service had anything good to say about any other service. According to the surgeons, the internists were a bunch of pusillanimous dudes, many of whom wore glasses, and were given to interminable arguments over picky, unimportant details of diagnosis or therapy, usually carried out while the patient was dying before their eyes. In return, the internists regarded the surgeons as mindless technicians, peculiar hybrids of butchers and tailors, who were happy only when they were up to their armpits in blood—someone else’s blood, to be specific. Obstetricians and gynecologists either hated their mothers, enjoyed seduction, or were simply incapable of understanding anything more complicated than crotch plumbing. Pediatricians were afraid of adults. Urologists were animals, barely able to speak intelligible English. Dermatologists hated the sight of blood as much as surgeons loved it. And psychiatrists, of course, were nuttier than their patients.

Fortunately, behind all the name-calling was the obvious recognized fact that the services were interdependent in terms of their own survival, let alone that of the patients. That prevented the potential antagonisms from ever going beyond the banter stage.

The Bellevue patient-care system was centered around the Admitting Office. This was something of a misnomer, since much more than the mere admitting of patients was carried out there. The A.O. was the general receiving area where those seeking medical attention presented themselves and were sorted out and disposed of according to their particular needs. Doctors assigned to the Admitting Office looked over each new patient and then decided how he or she might best be served by the Bellevue setup.

Some patients came to the Admitting Office with problems that were neither acute nor serious: for example, a head cold. They did this in the hope of obtaining treatment more quickly than it could have been gotten in the Clinic, where a supplicant frequently sat on a wooden bench for four hours or longer before a doctor called his number. These patients generally were not pleased when they were given Clinic appointments for the next day and told they weren’t sick enough to warrant care at the A.O. Their protests were heated enough to melt the gelatin capsules in the medicine cabinets.

On the other hand, problems requiring immediate attention were handled on the spot. Lacerations were sutured, boils were lanced, asthmatic attacks were terminated, and strep throats were combated with shots of penicillin to the nether zones. In most cases, follow-up was achieved via the infamous Clinic.

Not all conditions could be handled in the Admitting Office, though. Patients requiring longer-term care were admitted to the inpatient service. When there was no need for continuous close attention or intensive care, the patients were sent to routine wards. However, a patient with a severe heart attack, major hemorrhaging, or an overdose of drugs would be wheeled to the Emergency Room. This was the equivalent of today’s intensive-care unit, offering the best chance of survival to such critically ill people.

The performance of this human sorting function was often more then a little tough on the doctor’s nervous system. No one wanted to give a Clinic appointment to a patient who would carry the appointment slip only as far as the front steps of the hospital, and then proceed to drop dead. On the other hand, every admission had to be considered with the utmost care. When a patient was admitted, an intern or a resident had to work up the individual, and that usually meant many hours of labor, involving a history, a physical examination, and laboratory scut. That was fine if the patient were truly sick, but God help the Admitting Office doctor who caused one of his buddies to be up all night with a crock. (A crock is a non-sick patient, a hypochondriac, a malingerer, or an hysteric. Most doctors are very unfond of them.) The A.O. physician often felt that whatever course of action he took, someone was going to bitch at him. Unfortunately, this perception was usually accurate.

Perhaps the best way to sum up Bellevue is to say that it was a crisis-oriented place. Most of the patients who came there for care were truly good and sick. Then, as now, poor people did not have much truck with preventive medicine, thereby usually giving the illness a generous head start before they dragged themselves in for care.

And where did these disease-ravaged persons go for help when the inevitable could be put off no longer? To an institution chronically short of critical equipment, nurses, and aides, whose physical facilities seemed to sag in response to the weight they were forced to bear, where interns less than a year out of medical school and often with no sleep the night before tried to cope with, understand, and adjust to a constant struggle of life-and-death proportions.

No wonder Bellevue was the setting for innumerable astonishing episodes of peculiar, eccentric, and downright zany behavior. Patients and staff alike were subjected to pressures capable of taxing minds beyond the limits of tolerance; and to survive in that unusual environment sometimes required behavior which, viewed dispassionately, would have to be classified as something other than normal. Try to keep this in mind if the view from The Vue seems a little distorted in spots.

Don’t Go Away Mad

Once, when I told a young woman that I was working at Bellevue Hospital, she burst out with, “Oh, that must be just fascinating. That’s where they send all the real nuts.” I assumed that she was referring to the patients in the Bellevue Psychiatric Pavilion, but I did worry a bit. In any case, my new acquaintance rapidly followed up her emphatic declaration with a request that I tell her “all about it.”

That, in fact, would have been a major project. The Bellevue psychiatry building, constructed in 1935, was already long outmoded by the time I went to work there. Its seven floors of wards were divided into facilities designed to provide care for inmates according to their degree of impairment. The most seriously disturbed patients were confined on the top floor; below them were the moderately ill. The remainder of the building was given over to the care of patients with less critical mental disorders and to outpatients. Parts of two of the floors were set aside as psychomedicine wards, for mental patients who also suffered from serious bodily illnesses.

The physical characteristics of the psych building did very little to enhance the moods of inmates suffering from depression. Any patient who was not depressed on admission, and was capable of relating to his environment, didn’t take long to experience a whopping dejection of spirits. Windows were few in number, and those that did exist were covered with bars. The hallways were long, dark, and dirty. Wards were overcrowded, understaffed, filthy, and malodorous. The beds were crammed into every available alcove, one right next to the other. Patients were either sprawled on the beds or sat on wooden chairs, usually clutching their belongings in paper bags, to guard against the otherwise inevitable theft. Too often, they simply stared into space; there was nothing else to do.

The wards for the most serious patients were genuine chambers of horrors. Shrieks, screams, and groans reverberated down the corridors in a never-ending cacophony. Here and there a patient stood motionless, perhaps with a stream of urine running down his leg to form a puddle at his feet. Others lay uncommunicative, apparently unaware of the feeding tubes which were keeping them alive.

The worst patients, those reduced to either animal or vegetable status by deficiency or aberration of mentality, passed the time by mutilating themselves or others at every opportunity, or by assuming a rigid fetus-like posture for weeks or months on end. Therapeutic psychiatry being as primitive as it was, all we could do for these people was to keep them fed, relatively clean, quiet, and as far from harm’s way as possible. Had they been dogs or horses, we’d have shot them without a second thought. But they were human beings, so we gave them tranquilizers.

My first exposure to psychiatry at The Vue came during my second year of medical school. We had a series of weekly lecture-demonstrations at which the professors would describe the manifestations of the different psychiatric diseases, and would then interview illustrative cases before us. It looked very easy.

The doctor sat in a chair opposite the patient, a picture of calm assurance, asking question after question, and appearing not in the least disturbed when the patient gave a seemingly inappropriate answer. When that happened, the professor usually picked up on something the patient had said and quickly changed the direction of his inquiry, but he was never at a loss for something to say. He maintained, at all time, an attitude that bespoke thorough command of the situation; he was totally unflappable. I thought that psych was going to be a breeze.

When the third year came around, I was assigned to spend six weeks on the psychiatry service. I was in a group of eight medical students assigned to Dr. Samuel Rothstein. Dr. Rothstein was a large, handsome man in his mid-forties whose eyes exuded kindness and understanding. On the first morning, he took us to the ward, selected a patient, and began to talk with him. The patient was a hopeless schizophrenic and, in response to Dr. Rothstein’s quiet but firm probing, told us all about the astonishing collection of disembodied voices and peculiar creatures which lived within the distorted confines of his mind. The performance sent shivers along the vertebral columns of the uninitiated, but there seemed to be no reason for trepidation or anxiety. It still looked very easy.

After Dr. Rothstein had dismissed the patient, he answered our questions. Then he told us he thought we were ready to try a psychiatric interview on our own. He handed each of us apiece of paper. Mine bore the name Robert Jackson. Dr. Rothstein told us that after we had interviewed and examined our patients, he’d discuss their problems with us. Buoyed by eagerness and enthusiasm, I went off in search of Mr. Jackson.

The ward nurse told me that Mr. Jackson usually hung out “over there.” She pointed to the end of a long corridor. I thanked her and strutted away, chin high.

As I made my way along the corridor, I began to notice the figures alongside me. They were men of all ages, sizes, and shapes; all in the same general state of disrepair. Some were sitting or lying motionless; others rocked to and fro; and still others paced. A middle-aged man, wearing a hospital bathrobe and badly in need of a shave, came forward and clutched at my spotless white coat. As he did, I pulled away by reflex.

Suddenly I realized I was all by myself, and that I was not only going to have to interview one of these patients, but also perform a physical examination. All my confidence emulsified and floated out the nearest window, between the bars. My pace slowed perceptibly, and I almost tripped over an old man who was stretched out across the hallway.

I had no sooner recovered myself than he grabbed my pants leg and wouldn’t let go. After I had pulled away, I went on past another fellow who was masturbating onto the immobile, staring schizophrenic next to him; and then I passed a codger who was holding his little paper bag of personal belongings in his left hand, while he used his right hand to direct his stream of urine against the wall. By the time I reached the end of the hallway, I was shaking. I saw a young man sitting there, staring out the window. In a voice about two octaves higher than my usual, I asked, “Mr. Jackson?”

Mr. Jackson turned very slowly, and then took about thirty seconds to glare at me. He was about twenty-five years old, and he had long, straight black hair, and the most angry, hating, hostile eyes I have ever seen. Going up another octave, I explained that I was Dr. Karp, and that I had come to interview him.

Silently he motioned me to sit down in the chair next to him. I thanked him, sat down, and gave my folder of papers a professional shuffle.

My mind was racing. I thought, My God, what happens if I ask this guy a wrong question and he gets pissed off at me? He’ll kill me and drink my blood and leave me lying here and they’ll never find me; they’ll think I’m just another catatonic patient.

Finally I forced myself to be calm. I’m being silly, I thought. He won’t hurt me. And I won’t ask any wrong questions. I drew a couple of deep breaths and then noticed that all this time Mr. Jackson was staring at me with hostility in his eye and a sardonic little smile at the corners of his mouth.

I knew I had to start talking, and I drew in another breath. No hesitancy now, Karp. Show him who’s boss.

“Well, Mr. Jackson,” I said. “Why don’t you tell my why you’re here in the hospital?”

Mr. Jackson ran the fingers of his right hand through his hair. Then he looked up slowly and glared into my eyes.

“Well, Doc,” he drawled, in a subtly mocking tone, “it’s like this. The reason I’m here is that I think all the paranoids in the world are out to get me.”

In the end, I managed to survive my interview with Mr. Jackson, but it took a bit of prodding by Dr. Rothstein to get me to see my second assigned patient. Fortunately, that encounter was considerably less traumatic, and after interviewing and examining a few more patients, I even managed to regain a part of my original confidence. One issue, though, continued to haunt me and make me uneasy: the claim by the patients that they had been railroaded to Bellevue. It seemed that every patient I interviewed, who was in any way capable of conversation, sooner or later informed me that he or she was at that moment talking to me only because an enemy had arranged for the patient to be involuntarily committed. The sole variation on the theme was in the nature of the enemy.

By far the most frequent committer of the innocent was the F.B.I. It seemed, however, that the Feds persecuted only the most blatantly psychotic inmates, and it was pretty easy to disregard such a complaint when the patient followed it up by pointing his finger at an uninhabited corner to show me the G-man who was still tailing him day and night. Less clear-cut were the situations involving supposed commitments because of the complaint of a spouse or another relative. Sometimes the hospital records bore out the basic truth of the complaint, sometimes not. In either event, as a group, the patients making this claim did not seem as strange as the F.B.I. bunch, and I experienced a good bit of difficulty in trying to sort out justified anger from paranoia.

What do you think when an enraged, but seemingly coherent man tells you that the cops dragged him off to The Vue because his wife claimed he had attacked her with a knife, but that in reality he had done no such thing. To make the situation thoroughly incomprehensible, a patient of this sort sometimes also said that his wife had been trying to get rid of him for some time, and that the first thing he was going to do upon his release was kill her. Such a guy was definitely more than a little dangerous, yes. But crazy? I could never tell. Every now and then, one of the less violently inclined “referrals” would eventually get out and promptly hire a lawyer in an attempt to squeeze a little monetary compensation out of the city.

No such patient caused me more confusion—and embarrassment—than Solomon Washington. Mr. Washington was one of the patients assigned to me during my third-year clerkship. He had been admitted late the previous night, and when I sat down to interview him, had not yet run the gamut of the residents. He was still quite willing to talk to a doctor. In fact, he was eager.

He was a huge black man, weighing well in excess of two hundred pounds, and stood six-four in his paper Bellevue slippers. His bearing was of extreme, perhaps excessive, dignity, which at times approached the Amos n’ Andy burlesque style. But despite the physical resemblance and the similarity of mannerisms, Mr. Washington was no Andrew H. Brown. By his own account (which was very readily offered) he was a 1950 graduate of the University of Pennsylvania, with a major in economics.

“With that kind of background, what are you doing living on the Bowery?” I asked him.

“Please don’t be so crass as to think that every resident of a Bowery flophouse is an ignorant, uneducated hobo,” he answered. “The common denominator of Bowery existence is nothing more than lack of money. There are those of us who simply are down on their luck, you might say.”

“I didn’t think jobs were so hard to come by for economists,” I said, my voice a bit snottier than was called for.

“Oh, true, very true indeed, my dear young fellow,” said Mr. Washington with all the haughtiness at his command. “You are quite right, if you’re talking about white economists. But I’d like to see you in my skin for a little while, trying to get a job. Perhaps then you’d understand better. No, the unfortunate truth is that Negroes just aren’t faring terribly well at the moment in the economics job markets.”

“Let’s go on,” I said hastily. “Why don’t you tell me how you happened to end up at Bellevue.” I smiled in what I hoped was an ingratiating manner.

“I’ll be most happy to, if you’d like,” he said. “Though I must say, it is a rather painful subject—literally painful, I might add.” He rubbed a black-and-blue area under his left eye, as though for emphasis.

“I’d appreciate it,” I said. “It’ll help me understand your case better.”

Mr. Washington shook his hand rapidly back and forth. “No problem at all,” he said. “It’s quite straightforward, really. Last night, at about three o’clock, I was standing on the corner of Third Avenue and Fourteenth Street when some young men—some young white men, to be specific—accosted me and asked whether I had a match. It happened that I didn’t. You see, I don’t smoke, and so don’t usually have matches on my person. I told them I was sorry, whereupon they became rather abusive. They started to call me names, and—”

Mr. Washington rolled his eyes expressively. “Well, Doctor,” he said. “They began with nigger, as perhaps you might have expected, and they…well, shall we say, they accused me of behavior that would have made Oedipus feel uncomfortable.”

I fought to keep my face properly straight. I nodded soberly, and gave a professional um-hum. “What did you do?” I asked.

“Oh yes, Dr. Karp. Certainly. As I was about to say, Dr. Karp, I’m not trained as a prize fighter. I’m not aggressive and I do all I can to avoid violence. I tried to walk away. But they didn’t permit me to do that. They followed me, calling me those terrible names, and then one of them shoved me into the wall of a building while another one punched me in the stomach. At that point I decided that I had been forced to take a stand, so I hit the second fellow, the one who had punched me. When I did that, all of the miserable hoodlums jumped on me and started to beat me up. I fought back as well as I could, but I was definitely getting the worse of the affair when two policemen came by and broke up the fight. I couldn’t have been more grateful, of course, and was about to thank my benefactors when one of the young men said, ‘That nigger bum tried to get a quarter off us, and when we wouldn’t give it to ’im he pulled a razor on us.’ Before I could utter a single word of the truth in my defense, one of the policemen hit me with his billy club and knocked me unconscious. The next thing I knew, I was a guest in your establishment.”

I talked to Mr. Washington for a while longer and could uncover no mental aberrations. There were no signs of psychosis: he did not seem to suffer from delusions or hallucinations. He was oriented as to time and place, knew who the President was, could count backward from one hundred by sevens, and could correctly explain the meanings of different proverbs. The longer we spoke, the more convinced I became that because Mr. Washington was black and penniless, he had indeed been railroaded to The Vue. I began to feel angry. Finally, I could think of no further questions to ask him, so I thanked him and explained that I was going to present his case to the doctor in charge.

Mr. Washington stood up and extended his hand, which I gripped. “Thank you very much, Dr. Karp,” he said. “I do trust that you will attempt to effect my prompt release from this unjustified confinement.”

I assured him emphatically that I was firmly in his corner, proceeded directly to the chart rack, pulled out his chart, and read the police report from the cops who had brought him in. It said that he had been drunk and abusive, but made no mention of his set-to-with the gang of white youths. I ground my teeth loudly. Did they have to add falsification by omission to injustice?

Leaving a cloud of smoke to mark my spot, I sought out Dr. Rothstein and poured out the story in a torrent. Dr. Rothstein stood there quietly throughout my performance. When I finished, he asked, “What did the admitting resident have to say about him?”

I gulped. My righteous indignation had prevented me from looking past the police report. Together we went back to the chart rack and read the resident’s write-up. It was concise and to the point. It said that Mr. Washington had reeked of the demon rum and that he hadn’t been making much sense when he spoke. The resident’s diagnosis was: acute alcoholic psychosis.

“That psych Admitting Office is a snakepit,” I said hastily. “Maybe the resident read the police report but didn’t have enough time to actually spend talking to Mr. Washington.”

“That’s possible,” Dr. Rothstein said. “But I don’t think it’s very likely.”

Neither did the rational part of my mind, but that entity had already been submerged in my emotions. “You come and talk to him,” I urged. “You’ll see he’s no more crazy than we are.”

Dr. Rothstein smiled and followed me to Mr. Washington. He listened as the patient told his story again, and then we walked away together.

“I think he ought to stay for observation for another day or two,” said Dr. Rothstein. He held up his hand to stop my howl of protest before it could start. “Tell you what,” he continued. “I’d like you to check up on him periodically during the day. Then tonight, before you go home, leave your phone number and tell them to call you if there’s any…change in his condition. Okay? Just be a little patient; I think you may learn something from this case.”

Mr. Washington appeared to be fine all day, but when I stopped to say good-night to him, he seemed agitated. His hands shook as he tried to eat his dinner, and he couldn’t seem to sit still in his chair. I asked what was wrong.

“If you were confined in a place like this,” said Mr. Washington, in a bass whine, “I assure you, you’d feel nervous too.”

I tried to reassure him, and told him to hold out till morning, at which time I’d again attempt to have him released.

At a quarter to one in the morning, my phone rang. The ward clerk told me to come right over, that Mr. Washington’s condition had definitely changed.

My first reaction upon arriving at the ward was mixed disbelief and anger. Mr. Washington was strapped into a restraint bed, and he was struggling so fiercely that the whole apparatus was bouncing about on the floor. He was screaming unintelligible words and sentence fragments, and his finely measured speech had vanished. His vocabulary and dialect had become pure Bowery.

I leaned over him. “Mr. Washington, Mr. Washington,” I shouted. “What’s the matter? What have they done to you?”

His eyes rolled uncontrollably. “Oooooh, no!” he wailed. “No, no, no, no, no! Ge’em oudda here, ge’em away.” He brushed clumsily at the air in front of his face. Streams of sweat rolled off his forehead in every direction.

A nurse walked up beside me. “First time you see a good case of the DT’s?” she asked. “That’s the delirium tremens, when they sees things an’ hears things an’ shakes all over.” She shook her head and chuckled. “I just dunno. These ol’ alkies, long as they keep drinkin’ they’re okay, but then they come in here an’ go a day without no booze, they all get the DT’s.” She jabbed a needle into Mr. Washington’s rump, emptied the syringeful of tranquilizer, and crooned, “Doncha worry now, honey, this’s gonna make all them snakes ‘n’ elephants go ’way, hear?”

My ears began to burn. I could have killed Mr. Washington for hoodwinking me, and I would not have suffered a pang of remorse. Nor were my feelings mitigated the next morning when Dr. Rothstein asked me to tell the group about my patient, and then, with an arch smile, he asked me whether I had learned anything from the case.

Bellevue abounded in contrasts. Two years later, as an intern on the psychomedicine ward, I took care of Mr. Washington’s opposite number. His name was Harold Bullock, and he even looked like Mr. Washington. Bullock was brought in one evening as a florid DTer, screaming and hallucinating, having been picked up on a midtown street. He was uncontrollable on admission, and it took four of us to get him into restraints. Only when we had sedated him was I able to examine him. I could find nothing of significance aside from his disorientation and a fever of 101°. There was no infectious explanation for the latter, and so I chalked it up to the joint effect of alcohol and agitation, and proceeded to treat him for his DT’s.

On rounds the next day, Mr. Bullock was no better, but that wasn’t unusual: attacks of DT’s can last for days. However, his temperature was now 102.6°, and our resident, Dr. Ronnie Edelson, frowned as he took note of that. “Where’s the fever coming from?” he asked me sharply.

I shrugged. “I guess it’s just the DT’s,” I answered. “His chest is clear; there’s no urinary tract infection; no abscesses on him; liver’s not enlarged. It must be a metabolic fever.”

Ronnie looked back at Mr. Bullock, and pulled thoughtfully at his chin. Then he leaned over, put his hand under the patient’s head, and lifted. Mr. Bullock’s entire body rose off the bed.

Contents

Preface

Introduction

An Overview of The Vue

1

Don’t Go Away Mad