Evolution of Health Care: Delving into the Past

“I will neither give a deadly drug to anybody who asked for it, nor will I make a suggestion to this effect… I will not use the knife, not even on sufferers from stone, but will withdraw in favor of such men who are engaged in this work.” - Hippocratic Oath

Article By Urvi Roy

Many may consider these thoughts to be somewhat facetious. With modern day technology and sciences, the use of medicinal drugs and surgical instruments among healthcare workers are rampant more than ever. Some may recognize that the aforementioned potent ideals date back to the Hippocratic Oath of 5th century Greece. Since this widely recognized, “binding covenant” was first written, all modern medical universities have administered its use despite social and technological debates regarding its relevance to society. It seems to be more of an upheld standard of practice rather than an obligation.

Time has altered both conditions and questions regarding physician treatments of man-made diseases, pharmacological drug development in labs, patient confidentiality regarding other providers or government healthcare and insurance organizations, Pagan vs. Religious principles and practices. It has also brought light to the past’s relevance in regards to previously unnecessary or un-heard of concepts and developments: physician assisted deaths, abortions and in vitro practices, patient group experiments, data-driven personalizaton and value-based care, reimbursement payment models, and the inevitable range of healthcare specializations that have risen just over the past decade.

“Not using the knife”, in Hippocrates’s words, would seem almost facetious with the advanced surgical practices that are being applied today. To truly appreciate the field of healthcare, as well as the modern liberties that many physicians and patients receive, we must travel back to the ancients. Our understanding of her practices of our forefathers can not be ignored due to the technological enhancements that occurred at the time. The first leg transplant by Saint Cosmas and Damian, in the 14th century, is depicted in a painting showcasing a miracle. So, let's begin by starting at what historians believe to be the beginning of the evolution of modern healthcare.

Ancient Wisdom

We are all too familiar with the practices of the Ancient Egyptians, which included the first diagnoses, prognoses, bloodletting, mummification, and trepanation (considered to be one of the first rudimentary surgical practices, with the first true “rhinoplasty” to have been performed by an Indian plastic surgeon, that drilled holes in skulls in order to decrease head pressure thought to be caused by migraines), use of herbs and juices, and spiritual rituals performed by priests. However, what may not be known is that true logical reasoning behind human ailments, in contrast to religious beliefs, was first championed by Hippocrates, “The Father of Medicine”, and later Galen by treatises such as “On the Nature of Man” or “On the Temperaments”.

The two promoted the Theory of the Humors, later known as Humorism, which include phlegm, blood, yellow bile, and black bile as well as the combination and dominance of cold, warm, wet, and dry qualities. Treatments were curated based on dietary changes due to the idea that an imbalance, dyscrasia, occurred among these humors through malabsorption and led to disease. Galen later proposed that these “Humors” were innate and furthered the idea that each of the humors factored into specific psychological and bodily changes, called melancholic, sanguine, choleric, and phlegmatic, that affected behaviors and reaction to disease.

It is said to be recorded that the opium poppy (seed latex containing the analgesic opiates and produces synthetic opioids from morphine) was observed by the Ancient Sumerians as “Hul Gil” or “the Joy Plant” and prescribed as analgesic juice by Hippocrates. The Greeks and the Romans were one of the most organized and advanced civilizations when it came to healthcare, as the Greeks were the first to use aqueducts for proper sanitization (although, evidence of bathing and sewage systems were first present in the Indus Valley civilizations) and the Roman physicians were the first to develop the concept of a clinician chamber and invent scalpels, needles, and forceps.

The Endarkenment with a Silver Lining

The height of the Middle, or Dark Ages, resulted in a loss of this Golden Age of science and technology, due to a sharp turn towards fear of death, the devil, and sin. The predominance of the Catholic Church led to the idea of purgatory and so bishops or priests were the ones who performed medical practices. Religion, dating back to the Romans, had prevented dissections, which were performed as early as the Egyptians in Alexandria, the Greeks (Herophilius), and animal vasectomies (Galen). Although pestilence, such as the Bubonic plague, Syphilis, Diphtheria, Tuberculosis, and Smallpox, diffused over trade routes through vectors based on human to human transmission stemming from unsanitary conditions and tight urban living conditions, the prevalence of Barber surgeons creating the first group of licensed workers aside from physicians at the time.

Barber surgeons were army surgeons that performed bloodletting, alternative medicinal cupping therapy, enemas, amputations, and rudimentary dentistry, in addition to hair maintenance during peacetime. Blood was commonly targeted as a source of infection. Interestingly Rhazes, a Persian doctor, deciphered that the infectious Smallpox transmitted through blood. In addition, until the Industrial Revolution, the presiding thought regarding ailments would be Galen’s Miasma theory, which propelled the inaccurate idea that “night air was the root cause for mass epidemics”.

Fortunately, this era’s semblance of darkness did see brighter times when it came to the Islamic Caliphates. The Arabs made leaps in pharmacology, anatomy, physiology, and surgery due to scholars and philosophers, such as Maimonides, that discussed the key to proper balance in a healthy lifestyle. However, their greatest contribution were the hospices and urban institutions that built the framework for modern hospitals today. They were maintained by the profits made from property donations, called waqfs, by the wealthy or that of the government (these institutions were generally free except for payments made to specific, private physicians). An incredible aspect to Medieval Ilamic healthcare was that sometimes patients would be able to receive payments from their physicians due to excess waqfs. These hospitals, called Bimaristans, were treated in a secular fashion in order to provide aid to all religions and ages, military and the common man, and both genders.

Although, the wealthier class were treated at home and royalty by court physicians. Physicians and other staff had living accommodations in these hospitals and included surgeons, bone-settlers, and specialists such as oculists. Hospitals, along with hospice or leprosariums for the disabled and blind, spread from the first in Baghdad to ones in Cairo, Tunisia, and eventually Islamic Spain. Syro-Egyptian hospitals acted as blueprints for modern hospitals with wards and iwans, or halls, for general ailments, women, rheumatic pain and aches, common cold, and the mentally challenged. It is even documented that these hospitals assigned physician rounds, orderlies and attendants, pharmacologists, medical apprentices, a state administrator, and a chief of staff.

Renaissance and the Advent of Discovery

Though these Ancient healthcare systems were well-equipped facilities, the procedures were not productive due to the lack of technology and scientific research at the time. The Post-Endarkenment, or the Renaissance, pummeled healthcare onto an entirely different playing field with the use of the scientific method. The invention of the printing press by Gutenberg helped diffuse knowledge about scientific works such as an anatomy book by Andreas Verslius and “An Anatomical Study of the Motion of the Heart and of the Blood in Animals'', published by William Harvey. Novel thoughts in the form of epistemologies, such as Rationalism, Skepticism, and Empiricism, as well as Humanism challenged the traditional ways of Scholasticism, which had cast a shadow over the sciences and the need for improvements in the practices for the ill and convalescent. The first practices of intravenous transfusion of medication and blood transfusions among canines were performed and dissections were finally permitted on executed criminal cadavers (the first authentic human transmission did not take place until it was performed by a British obstetrician in 1818). One of the greatest milestones of the Enlightenment was the invention of the microscope by Zacharias Janssen, which was later modified into various modern models by Anton Van Leeuwenhoek. The microscope paved the pathway of the discovery of microorganisms (later germs) and the study of human, animal, and plant specimen tissues and cells.

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