The Evolution of The Modern Health Care System

Primitive humans considered diseases to be “visitations”—the whimsical acts of affronted gods or spirits. As a result, medical practice was the domain of the witch doctor and the medicine man and medicine woman. Yet even as magic became an integral part of the healing process, the cult and the art of these early practitioners were never entirely limited to the supernatural. Using their natural instincts and learning from experience, these individuals developed a primitive science based upon empirical laws. For example, through acquisition and coding of certain reliable practices, the arts of herb doctoring, bone setting, surgery, and midwifery were advanced. Just as primitive humans learned from observation that certain plants and grains were good to eat and could be cultivated, the healers and shamans observed the nature of certain illnesses and then passed on their experiences to other generations.

Evidence indicates that the primitive healer took an active, rather than simply intuitive, interest in the curative arts, acting as a surgeon and a user of tools. For instance, skulls with holes made in them by trephiners have been collected in various parts of Europe, Asia, and South America. These holes were cut out of the bone with flint instruments to gain access to the brain. Although one can only speculate the purpose of these early surgical operations, magic and religious beliefs seem to be the most likely reasons. Perhaps this procedure liberated from the skull the malicious demons that were thought to be the cause of extreme pain (as in the case of migraines) or attacks of falling to the ground (as in epilepsy). That this procedure was carried out on living patients, some of whom survived, is evident from the rounded edges on the bone surrounding the hole, which indicate that the bone had grown again after the operation. These survivors also achieved a special status of sanctity so that, after their death, pieces of their skull were used as amulets to ward off convulsive attacks. From these beginnings, the practice of medicine has become integral to all human societies and cultures.

It is interesting to note the fate of some of the most successful of these early practitioners. The Egyptians, for example, have held Imhotep, the architect of the first pyramid (3000 BC), in great esteem through the centuries, not as a pyramid builder but as a doctor. Imhotep’s name signified “he who cometh in peace” because he visited the sick to give them “peaceful sleep.” This early physician practiced his art so well that he was deified in the Egyptian culture as the god of healing.

Egyptian mythology, like primitive religion, emphasized the interrelationships between the supernatural and one’s health. For example, consider the mystic sign Rx, which still adorns all prescriptions today. It has a mythical origin: the legend of the Eye of Horus. It appears that as a child Horus lost his vision after being viciously attacked by Seth, the demon of evil. Then Isis, the mother of Horus, called for assistance to Thoth, the most important god of health, who promptly restored the eye and its powers. Because of this intervention, the Eye of Horus became the Egyptian symbol of godly protection and recovery, and its descendant, Rx, serves as the most visible link between ancient and modern medicine.

The concepts and practices of Imhotep and the medical cult he fostered were duly recorded on papyri and stored in ancient tombs. One scroll (dated c. 1500 BC), which George Elbers acquired in 1873, contains hundreds of remedies for numerous afflictions ranging from crocodile bites to constipation. A second famous papyrus (dated c. 1700 BC), discovered by Edwin Smith in 1862, is considered to be the most important and complete treatise on surgery of all antiquity. These writings outline proper diagnoses, prognoses, and treatment in a series of surgical cases. These two papyri are certainly among the outstanding writings in medical history.

As the influence of ancient Egypt spread, Imhotep was identified by the Greeks with their own god of healing: Aesculapius. According to legend, the god Apollo fathered Aesculapius during one of his many earthly visits. Apparently, Apollo was a concerned parent, and, as is the case for many modern parents, he wanted his son to be a physician. He made Chiron, the centaur, tutor Aesculapius in the ways of healing (Figure 1.1). Chiron’s student became so proficient as a healer that he soon surpassed his tutor and kept people so healthy that he began to decrease the population of Hades. Pluto, the god of the underworld, complained so violently about this course of events that Zeus killed Aesculapius with a thunderbolt and in the process promoted Aesculapius to Olympus as a god.

Inevitably, mythology has become entangled with historical facts, and it is not certain whether Aesculapius was in fact an earthly physician like Imhotep, the Egyptian. However, one thing is clear: by 1000 BC, medicine was already a highly respected profession. In Greece, the Aesculapia were temples of the healing cult and may be considered the first hospitals (Figure 1.). In modern terms, these temples were essentially sanatoriums that had strong religious overtones. In them, patients were received and psychologically prepared, through prayer and sacrifice, to appreciate the past achievements of Aesculapius and his physician priests. After the appropriate rituals, they were allowed to enjoy “temple sleep.” During

              FIGURE 1.1; A sick child brought to the Temple of Aesculapius

the night, “healers” visited their patients, administering medical advice to clients who were awake or interpreting dreams of those who had slept. In this way, patients became convinced that they would be cured by following the prescribed regimen of diet, drugs, or bloodletting. On the other hand, if they remained ill, it would be attributed to their lack of faith. With this approach, patients, not treatments, were at fault if they did not get well. This early use of the power of suggestion was effective then and is still important in medical treatment today. The notion of “healthy mind, healthy body” is still in vogue today.

One of the most celebrated of these “healing” temples was on the island of Cos, the birthplace of Hippocrates, who as a youth became acquainted with the curative arts through his father, also a physician. Hippocrates was not so much an innovative physician as a collector of all the remedies and techniques that existed up to that time. Since he viewed the physician as a scientist instead of a priest, Hippocrates also injected an essential ingredient into medicine: its scientific spirit. For him, diagnostic observation and clinical treatment began to replace superstition. Instead of blaming disease on the gods, Hippocrates taught that disease was a natural process, one that developed in logical steps, and that symptoms were reactions of the body to disease. The body itself, he emphasized, possessed its own means of recovery, and the function of the physician was to aid these natural forces. Hippocrates treated each patient as an original case to be studied and documented. His shrewd descriptions of diseases are models for physicians even today. Hippocrates and the school of Cos trained many individuals, who then migrated to the corners of the Mediterranean world to practice medicine and spread the philosophies of their preceptor. The work of Hippocrates and the school and tradition that stem from him constitute the first real break from magic and mysticism and the foundation of the rational art of medicine. However, as a practitioner, Hippocrates represented the spirit, not the science, of medicine, embodying the good physician: the friend of the patient and the humane expert.

As the Roman Empire reached its zenith and its influence expanded across half the world, it became heir to the great cultures it absorbed, including their medical advances. Although the Romans themselves did little to advance clinical medicine (the treatment of the individual patient), they did make outstanding contributions to public health. For example, they had a well-organized army medical service, which not only accompanied the legions on their various campaigns to provide “first aid” on the battlefield but also established “base hospitals” for convalescents at strategic points throughout the empire. The construction of sewer systems and aqueducts were truly remarkable Roman accomplishments that provided their empire with the medical and social advantages of sanitary living. Insistence on clean drinking water and unadulterated foods affected the control and prevention of epidemics and, however primitive, made urban existence possible. Unfortunately, without adequate scientific knowledge about diseases, all the preoccupation of the Romans with public health could not avert the periodic medical disasters, particularly the plague, that mercilessly befell its citizens.

Initially, the Roman masters looked upon Greek physicians and their art with disfavour. However, as the years passed, the favourable impression these disciples of Hippocrates made upon the people became widespread. As a reward for their service to the peoples of the Empire, Julius Caesar (46 BC) granted Roman citizenship to all Greek practitioners of medicine in his empire. Their new status became so secure that when Rome suffered from famine that same year, these Greek practitioners were the only foreigners not expelled from the city. On the contrary, they were even offered bonuses to stay!

Ironically, Galen, who is considered the greatest physician in the history of Rome, was himself a Greek. Honoured by the emperor for curing his “imperial fever,” Galen became the medical celebrity of Rome. He was arrogant and a braggart and, unlike Hippocrates, reported only successful cases. Nevertheless, he was a remarkable physician. For Galen, diagnosis became a fine art; in addition to taking care of his own patients, he responded to requests for medical advice from the far reaches of the empire. He was so industrious that he wrote more than 300 books of anatomical observations, which included selected case histories, the drugs he prescribed, and his boasts. His version of human anatomy, however, was misleading because he objected to human dissection and drew his human analogies solely from the studies of animals. However, because he so dominated the medical scene and was later endorsed by the Roman Catholic Church, Galen actually inhibited medical inquiry. His medical views and writings became both the “bible” and “the law” for the pontiffs and pundits of the ensuing Dark Ages.

With the collapse of the Roman Empire, the Church became the repository of knowledge, particularly of all scholarship that had drifted through the centuries into the Mediterranean. This body of information, including medical knowledge, was literally scattered through the monasteries and dispersed among the many orders of the Church.

The teachings of the early Roman Catholic Church and the belief in divine mercy made inquiry into the causes of death unnecessary and even undesirable. Members of the Church regarded curing patients by rational methods as sinful interference with the will of God. The employment of drugs signified a lack of faith by the doctor and patient, and scientific medicine fell into disrepute. Therefore, for almost a thousand years, medical research stagnated. It was not until the Renaissance in the 1500s that any significant progress in the science of medicine occurred. Hippocrates had once taught that illness was not a punishment sent by the gods but a phenomenon of nature. Now, under the Church and a new God, the older views of the supernatural origins of disease were renewed and promulgated. Since disease implied demonic possession, monks and priests would treat the sick through prayer, the laying on of hands, exorcism, penances, and exhibition of holy relics—practices officially sanctioned by the Church.

Although deficient in medical knowledge, the Dark Ages were not entirely lacking in charity toward the sick poor. Christian physicians often treated the rich and poor alike, and the Church assumed responsibility for the sick. Furthermore, the evolution of the modern hospital actually began with the advent of Christianity and is considered one of the major contributions of monastic medicine. With the rise in 335 AD of Constantine I, the first of the Roman emperors to embrace Christianity, all pagan temples of healing were closed, and hospitals were established in every cathedral city. (The word hospital comes from the Latin hospes, meaning “host” or “guest.” The same root has provided hotel and hostel.) These first hospitals were simply houses where weary travellers and the sick could find food, lodging, and nursing care. The Church ran these hospitals, and the attending monks and nuns practiced the art of healing.

As the Christian ethic of faith, humanitarianism, and charity spread throughout Europe and then to the Middle East during the Crusades, so did its “hospital system.” However, trained “physicians” still practiced their trade primarily in the homes of their patients, and only the weary travellers, the destitute, and those considered hopeless cases found their way to hospitals. Conditions in these early hospitals varied widely. Although a few were well financed and well managed and treated their patients humanely, most were essentially custodial institutions to keep troublesome and infectious people away from the general public. In these establishments, crowding, filth, and high mortality among both patients and attendants were commonplace. Thus, the hospital was viewed as an institution to be feared and shunned.

The Renaissance and Reformation in the fifteenth and sixteenth centuries loosened the Church’s stronghold on both the hospital and the conduct of medical practice. During the Renaissance, “true learning,” the desire to pursue the true secrets of nature including medical knowledge, was again stimulated. The study of human anatomy was advanced, and the seeds for further studies were planted by the artists Michelangelo, Raphael Durer, and, of course, the genius Leonardo da Vinci. They viewed the human body as it really was, not simply as a text passage from Galen. The painters of the Renaissance depicted people in sickness and pain, sketched in great detail and, in the process, demonstrated amazing insight into the workings of the heart, lungs, brain, and muscle structure. They also attempted to portray the individual and to discover emotional as well as physical qualities. In this stimulating era, physicians began to approach their patients and the pursuit of medical knowledge in similar fashion. New medical schools, similar to the most famous of such institutions at Salerno, Bologna, Montpelier, Padua, and Oxford, emerged. These medical training centres once again embraced the Hippocratic doctrine that the patient was human, disease was a natural process, and common sense therapies were appropriate in assisting the body to conquer its disease.

During the Renaissance, fundamentals received closer examination, and the age of measurement began. In 1592, when Galileo visited Padua, Italy, he lectured on mathematics to a large audience of medical students. His famous theories and inventions (the thermoscope and the pendulum, in addition to the telescopic lens) were expounded upon and demonstrated. Using these devices, one of his students, Sanctorius, made comparative studies of the human temperature and pulse. A future graduate of Padua, William Harvey, later applied Galileo’s laws of motion and mechanics to the problem of blood circulation. This ability to measure the amount of blood moving through the arteries helped to determine the function of the heart.

Galileo encouraged the use of experimentation and exact measurement as scientific tools that could provide physicians with an effective check against reckless speculation. Quantification meant theories would be verified before being accepted. Individuals involved in medical research incorporated these new methods into their activities. Body temperature and pulse rate became measures that could be related to other symptoms to assist the physician in diagnosing specific illnesses or diseases. Concurrently, the development of the microscope amplified human vision, and an unknown world came into focus. Unfortunately, new scientific devices had little impact upon the average physician, who continued to blood-let and to disperse noxious ointments. Only in the universities did scientific groups band together to pool their instruments and their various talents.

In England, the medical profession found in Henry VIII a forceful and sympathetic patron. He assisted the doctors in their fight against malpractice and supported the establishment of the College of Physicians, the oldest purely medical institution in Europe. When he suppressed the monastery system in the early sixteenth century, church hospitals were taken over by the cities in which they were located. Consequently, a network of private, non-profit, voluntary hospitals came into being. Doctors and medical students replaced the nursing sisters and monk physicians. Consequently, the professional nursing class became almost non-existent in these public institutions. Only among the religious orders did “nursing” remain intact, further compounding the poor lot of patients confined within the walls of the public hospitals. These conditions were to continue until Florence Nightingale appeared on the scene years later.

Still another dramatic event was to occur. The demands made upon England’s hospitals, especially the urban hospitals, became overwhelming as the population of these urban centers continued to expand. It was impossible for the facilities to accommodate the needs of so many. Therefore, during the seventeenth century two of the major urban hospitals in London—St. Bartholomew’s and St. Thomas—initiated a policy of admitting and attending to only those patients who could possibly be cured. The incurables were left to meet their destiny in other institutions such as asylums, prisons, or almshouses.

Humanitarian and democratic movements occupied centre stage primarily in France and the American colonies during the eighteenth century. The notion of equal rights finally began, and as urbanization spread, American society concerned itself with the welfare of many of its members. Medical men broadened the scope of their services to include the “unfortunates” of society and helped to ease their suffering by advocating the power of reason and spearheading prison reform, child care, and the hospital movement. Ironically, as the hospital began to take up an active, curative role in medical care in the eighteenth century, the death rate among its patients did not decline but continued to be excessive. In 1788, for example, the death rate among the patients at the Hotel Dru in Paris, thought to be founded in the seventh century and the oldest hospital in existence today, was nearly 25 percent. These hospitals were lethal not only to patients but also to the attendants working in them, whose own death rate hovered between 6 and 12 percent per year.

Essentially the hospital remained a place to avoid. Under these circumstances, it is not surprising that the first American colonists postponed or delayed building hospitals. For example, the first hospital in America, the Pennsylvania Hospital, was not built until 1751, and the city of Boston took over two hundred years to erect its first hospital, the Massachusetts General, which opened its doors to the public in 1821.

A major advancement in the history of modern medicine came in the mid-nineteenth century with the development of the now well-known Germ Theory. Germ Theory simply states that infectious disease is caused by microorganisms living within the body. A popular example of early Germ Theory demonstration is that of John Snow and the Broad Street pump handle. When Cholera reached epidemic levels in the overcrowded Industrial Era streets of London, local physician John Snow was able to stop the spread of the disease with a street map. Snow plotted the cases of Cholera in the city, and he discovered an epicentre at a local water pump. By removing the handle, and thus access to the infected water supply, Snow illustrated Germ Theory and saved thousands of lives at the same time. French chemist Louis Pasteur is credited with developing the foundations of Germ Theory throughout the mid-nineteenth century.

Not until the nineteenth century could hospitals claim to benefit any significant number of patients. This era of progress was due primarily to the improved nursing practices fostered by Florence Nightingale (Figure 1.2) on her return to England from the Crimean War. She demonstrated that hospital deaths were caused more frequently by hospital conditions than by disease. During the latter part of the nineteenth century, she was at the height of her influence, and few new hospitals were built anywhere in the world without her advice. During the first half of the nineteenth century, Nightingale forced medical attention to focus once more on the care of the patient. Enthusiastically and philosophically, she expressed her views on nursing: “Nursing is putting us in the best possible condition for nature to restore and preserve health. … The art is that of nursing the sick. Please mark, not nursing sickness.”

Although these efforts were significant, hospitals remained, until the twentieth century, institutions for the sick poor. In the 1870s, for example, when the plans for the projected Johns Hopkins Hospital were reviewed, it was considered quite appropriate to allocate 324 charity and 24 pay beds. Not only did the hospital population before the turn of the century represent a narrow portion of the socioeconomic spectrum, but it also represented only a limited number of the types of diseases prevalent in the overall population. In 1873, for example, roughly half of America’s hospitals did not admit contagious diseases, and many others would not admit incurables. Furthermore, in this period, surgery admissions in general hospitals constituted only 5 percent, with trauma (injuries incurred by traumatic experience) making up a good portion of these cases.

                      FIGURE 1.2 A portrait of Florence Nightingale.

American hospitals a century ago were rather simple in that their organization required no special provisions for research or technology and demanded only cooking and washing facilities. In addition, since the attending and consulting physicians were normally unsalaried, and the nursing costs were quite modest, the great bulk of the hospital’s normal operating expenses were for food, drugs, and utilities. Not until the twentieth century did “modern medicine” come of age in the United States. As we shall see, technology played a significant role in its evolution.