HA-GreekRomanMed
HEALTH
CARE DELIVERY SYSTEMS IN ANCIENT' GREECE AND ROME
By
Dr. Warren Kump MD
Dr. Kump (ADA,
Kansas, 1950), is a Minneapolis
radiologist who serves on the clinical faculty of the University of Minnesota. He
has been interested in medical history as a hobby, and prepared this paper as
an outgrowth of that avocation.
Medical History is
usually written by physicians or other health professionals. Consequently the
emphasis is on the evolution of scientific knowledge and theory, on the
circumstances attending various medical discoveries, or on biographical detail
relating to important practitioners of the healing arts. In this day of
consumerism and the rising influence of third parties it is appropriate to attempt
a more general perspective, one in which the sick or injured patient occupies
the center, and the physician is relegated to a supporting position as one of
society's several major health resources.
When the more
general consideration of health care is undertaken, the relative value of the
contributions made by various cultures is subject to revision. One example is
in the case of ancient Greece and Rome. Traditionally Greece has been given the
credit, and rightfully, for the development of rational or scientific medicine.
Rome adopted rational medicine along with many other intellectual and
scientific contributions of the Greek civilization, but added comparatively
little of its own to the body of medical knowledge. In the field of total
health care, however, the performance of Rome was more creditable.
A differentiated
medical profession was recognizable in Greek society as early as the siege of
Troy in the 12th century, B.C. Its practictioners, if they attempted to gain
their entire livelihood by the treatment of wounds and sickness, were dependent
upon the wealth and good will of their patients. The idea that a patient's
access to such treatment depended upon his ability to pay for it could not have
become widespread until the position of medicine had become much more secure.
It was not until the sixth century, B.C., that the Greeks considered the
importance of The medical profession great enough to warrant official notice by
a unit of government. In 526 B.C. the celebrated practitioner Democedes was appointed
public physician of Aegina. The following year he was attracted to Athens and
still later to Samos by offers of higher salaries. By the fourth century the
practice of engaging public physicians or demosieuontes
was widespread in Greece, with cities or districts contracting to pay them
out of public funds.
The
responsibilities to the community of the public physicians has long been a
matter for study. Cohn‑Haft, in the most extensive modem investigation,
has concluded that, contrary to previous impressions, the demosieuontes were not engaged to provide free medical care for the
poor, but rather to insure the availability of medical service in the community
on a dependable and stable basis. In his view the rather small salary
offered by the municipalities was considered in the nature of a bonus or
retainer, obligating a popular or highly regarded physician to practice in the
city, but not to give his services free of charge. He practiced medicine as did
any other physician, collecting his fees according to convention and the
ability of his patients to pay, and with no more obligation to treat the poor
free of charge than was felt by any other practitioner.5 Such an arrangement,
more similar to the modem attempts to attract physicians to rural communities
through scholarships, grants, and other financial inducements than to the free
care offered in charity hospitals and the military, would have been in
accordance with the early Greek conception of public welfare. In the classical
view a public expenditure should be made to promote the interests of all
citizens directly and equally, not to provide exclusive aid to any special
segment of society such as the poor. In the case of the retention of a
physician at public expense, however, the equal benefit would have seemed more
theoretical than real to those unable to afford his services.
If
public welfare programs were rudimentary, large scale private philanthropy was
also limited. This was largely because of the lack of a legal concept of the
corporation or foundation in classical times. A fund without a "legal
personality" and unable to exist in its own right independent of the
continued existence of the particular individual or body which might be
administering it at any given time had little prospect of surviving beyond the
lifetime of its original donor. The result was a discontinuous or sporadic
approach to poor relief, consisting of isolated and occasional giving and
dependent on the personal fortunes and inclinations of the wealthy. The absence
of the idea of a foundation also made it impractical for men of modest means to
join in raising funds for purposes of mutual aid.
Figure
1. Contemporary illustration of patient care in an asklepieion. The temple
snake licks the patient's afflicted shoulder as a part of the therapeutic
regimen. National Museum, Athens.
The
milieu of individualism makes the socio‑economic policy of Hippocrates
understandable. Various Hippocratic maxims advised selflessness on the part of
physicians, such as one urging doctors to take into account the resources of
the patient, and sometimes to be ready to give treatment without fee.
Inscriptional evidence makes it clear that some physicians were indeed ready
to regard remuneration as of secondary importance. Free service by doctors acting
in a private capacity, however, was optional and not required by any moral or
legal code. Plato's Republic includes
evidence of separate standards of medical care for poor and rich, for example
the carpenter who was expected to recover or die with minimal medical care and
loss of time from work, while the rich man could continue to live, supported by
his wealth and through protracted medical attention.
The
individualist position was not embraced unanimously, however, as evidenced by
Socrates' belief that a man, whether rich or poor, should not be encouraged to
live if unable to contribute to his own welfare and that of the state. Other
egalitarian sentiments, although not encountered very frequently, are
manifested occasionally among the official actions of the Greek citystates.
An example is the direct payment of two obols a day to the crippled and
disabled of Athens whose property assessment was less than three hundred
drachmae. This allowance, originally limited to injured war veterans but soon
extended to all the physically handicapped, represents a rare example of the
application of a "means test" in classical times.
There existed in
Greek society besides the medical profession yet another health resource in the
presence of temple medicine. While Apollo and the goddess Athena were renowned
healers, the most important institution in the field of faith healing was the
Cult of Asklepios. Its influence by the fourth century, B.C., was widespread,
offering the people an attractive alternative to the rational or natural
approach to health care. Matters of relative effectiveness aside, and there
was probably not a great deal to choose between the natural and supernatural
systems, the Cult was more appealing to the poor than was the medical
profession. The pbysicians who practiced among the poor were not the most
skilled and highly educated, but rather those who could not hope to attain a
following among the rich. The open‑air stands in the city streets from
which they dispensed their first‑aid and counsel were no match for the
pastoral surroundings and the richly ornamented edifices of the
Asklepieia. Neither were their simple
ministrations of healing as the solumn ceremonies to be observed at the temples
of, healing. The allegiance of the masses therefore went mainly to the
Asklepieia.
The temples made
provisions for the many ailing visitors who were unable to pay. There were inns
or hostels nearby for the accommodation of the sick and their friends or
relatives; these were open to rich and poor alike. Asklepios himself was a
compassionate god and socially aware, widely known to be satisfied with small
offerings. A cock was the most common sacrificial gift of the poor, while the
rich were expected to give generously.
In fact the temple practice of putting whatever was necessary at the
disposal of those supplicants who were unable to pay amounted to a considerable
subsidy of the poor, since the masses tended to patronize the Asklepieia while
the more wealthy and sophisticated consulted physicians.
Thus with public
physicians who did not necessarily treat the poor, Hippocratic physicians who
charged according to opportunity and conscience, and Asklepieia with sliding
scales of suggested donations the Greeks had developed not only an early model
of the non‑system, but a pluralistic non‑system at that.
Ptolemy's Greek
enclave in Egypt, on the other hand, with its tightly organized totalitarian
state, represented another extreme of social planning. Here was developed the
iatrikon, a tax levied on the Greek settlers which entitled all of them to free
medical care. The treatment was provided by physicians who were in the royal
service, receiving their income from the king and giving their services as
directed. Undoubtedly the state medical service was under the strong influence
and quality control of the prestigious medical faculty of Alexandria, itself
under royal patronage and regulation. Of special interest here is the fact
that, in a prophetic protofascist spirit (Ptolemy was once a general in the
armies of Alexander the Great), neither the tax nor the free medical service
was applied to the far larger indigenous population, which made do with second‑class
citizenship or no citizenship at all.
Despite a
reputation fox having a word for every need, the Greeks were remiss in
developing a jargon apphcable to community health care. The Romans at first
were little better; although they did come up with the S.A.C. (stationes
arcarioruni Caesarianorum), the official name of Rome's welfare offices. In the
early days of the Republic, however, the Romans showed little promise in the
field of medical bureaucracy. Their spciety lacked even a formal medical
profession. Instead they relied on a system of popular or folk medicine,
treating themselves and their families according to tradition and under the
direction of the head of the family. The paterfamilias
presided over a small collection of household remedies which were
administered in timehonored ways, a particular combination and ritual for each
affliction. Many households had their own specifics: Cato's cure‑all was
cabbage. The central theme of this fiercely private medicine was a strict
consumer control that opposed the development of medical professionalism and
refused, as Pliny records, "to give payment to profiteers to
preserve their lives."
The practical Romans first
approached the problem of community health in a characteristic way, utilizing
one of their leading technological resources, civil engineering, in conformity
with the classical philanthropic ideal of equal and direct benefit to all. The
long range program was a series of public works projects to provide for an
adequate supply of healthful water and a system of drainage. The results of the
program are well known. The first of the aqueducts was built in 312 B.C.; by 96
A.D., there were ten aqueducts capable of supplying the city with 250,000,000
gallons of water daily. About half of this torrent flowed through the immense
system of public baths. The remainder was enough to provide an average of more
than 100 gallons per capita daily for a population of one million. The same provision for a plentiful supply
of pure water was made in the other cities of the empire, with good examples
remaining to this day in Turkey, Spain, and France.
The problem of the
disposal of human wastes was mingled with that of the drainage of ground water,
as both were recognized as threats to public health. The Roman author Varro
anticipated the germ theory of disease in a tentative way: "in the
neighborhood of swamps . . . there are bred certain minute creatures which
cannot be seen by the eyes, which float through the air and enter the body
through the mouth and the nose and there cause serious diseases." Although
the existence of these "minute creatures" was mere speculation, we do
know that as early as the sixth century, B.C., the Roman Forum was drained by
the Cloaca maxima, receiving the wastes from public urinals and water closets
flushed by running water. The Cloaca maxima, as the aqueducts, was copied
widely throughout the Roman Empire.
The achievement in
public hygiene accomplished through engineering clearly exceeded in importance
any contribution which could have been made by the medicine of the day. In
well planned and well executed bursts of technological creativity the Romans
provided general and more or less permanent solutions to some of the most basic
of public health problems. However as a community they managed a less
imaginative response to the need for individual care of the sick: they imported
the Greek dichotomy of temple medicine and Hippocratic medical science.
Figure
2. Interior of the Basilica of St. Bartholomew on the Tiber Island at Rome.
According to Allbutt the columns are relics of the asklepieion built earlier on
the same site, once the city's principal center of temple medicine.
The first major
Greek import in the health field was the Cult of Asklepios. An epidemic
ravaging Rome in 295 B.C., seemed to require more effective measures than were
available at home, so the Romans called upon the greatest of the Greek gods of
healing, whose fame was by then widespread. According to tradition a deputation
of Romans applied for help at Epidauros and induced some of the temple
personnel to return with them to Rome. As the homeward‑bound ship
proceeded up the Tiber toward the city, an Asklepian snake swam ashore on the
Tiber Island, providing a miraculous and supernatural selection of the site for
the transplanted healing temple. A less romantic, though more credible version
of the location on the Isola Tiberina rests with the Roman official suspicion
of foreign gods which probably dictated the site outside the city proper for
caution's sake.
The island, cut
into the shape of a ship 300 yards in length, 80 yards in beam, and complete
with mast, prow, and stem, resembled a huge vessel at anchor in the river. Near
the "stern" was erected the main temple dedicated to the Great One,
whose name was now latinized to Aesculapius. The site of the temple is
presently occupied by the Basilica of St. Bartholomew, and fourteen of the
church's columns survive from the original Aesculapian structure. Beside the
main temple there were smaller satellite temples, shelters for the sick, and
medicinal baths.
The Roman epidemic subsided,
and Aesculapius shared in the credit. The popularity of the cult was assured as
accounts of miraculous cures, once only vague tales circulated by travelers,
were now recounted first hand. The influence of Aesculapius increased steadily
until the end of the second century, A.D.; hundreds of temples were built and
dedicated to him, and his popularity was comparable to that of any of the other
transplanted Greek gods. In general the rites of the Roman Cult of Aesculapius
were borrowed from the Greek ritual, with an occasional cultural modification
such as the practice of praying with the head covered in the Roman fashion.
Devotion to the god came from all classes of Roman society from the lowliest
dwellers of the crowded apartment houses to the wealthy land owners and public
officials.
The importation of
Greek temple healing to Rome was eventually followed by that of its parallel
natural counterpart, "rational" or theoretical medicine. The first
Greek physician known to practice in Rome was Archagathos of Sparta, who
arrived in 219 B.C. Archagathos, like many of the Greek physicians who came
soon afterward, was probably a marginal practitioner who saw in the expanding
western city an opportunity for greater success and acclaim than were likely to
be his among his more talented colleagues at home. He was granted the right of
free citizenship and was provided with an office at public expense. In spite of
the generous welcome, however, his practice did not go well. His cruelty in
cutting and searing his patients earned for him the nickname "The
Butcher," and he was eventually expelled from Rome."
Besides the bad
impression made by the earliest Greek practitioners there was another more
culturally related reason why the Romans were reluctant to accept theoretical
medicine. They were above all a practical people, disinterested in
abstractions, distrustful of lofty intellectual processes, and impressed only
by useful results. Hellenistic medicine made its greatest inroads in the upper
strata of Roman society; the best and most highly educated of the Greek
physicians found acceptance among the rich and the powerful, among
intellectuals and emperors. Their role, however, was more akin to consultant or
confidant than to authoritarian practitioner. They discussed theories of
disease and health and suggested possibilities for treatment, but the Roman
patient or his family made the final decisions about therapy.
Among Rome's poor
and ignorant Greek medicine fared even worse. Only the physicians of lesser
repute served the masses, and they lacked true skill and learning. The poor
often resorted to another class of healers, the pharmocopolae, or drug sellers. Until the middle of the second
century these were free of any kind of supervision or regulation, and were
usually fraudulent. Evidence of general dissatisfaction with all these
practitioners is so abundant that there is small wonder that reliance on
traditional folk remedies and the Cult of Aesculapius persisted for centuries.
In discussions of
the availability of physicians' services in Rome reference is often made to the
well publicized and obviously well organized "house of the surgeon"
unearthed at Pompeii. The building would seem to be a suitable model for a
modern clinic, and its presence at Pompeii suggests that doctors' offices must
have existed and functioned in ancient Rome much as they do in modern society.
But it would be a mistake to consider Pompeii as representative, for it was a
resort town. As a haven for the rich it was probably no more representative of
Roman society than are Carmel or Miami Beach of ours. Most Romans lived in
apartment buildings; because of the population density the streets were narrow
and the apartment buildings dark, poorly ventilated and tall, averaging five or
six stories. The ground floors were used for shops and taverns or as home for
the wealthy. The masses lived upstairs in descending order of social station,
the poorest reaching their humble attic rooms by ladders. In the days of the
Empire a sturdy and numerous middle class still survived in the provinces and
in rural areas, but in urban Rome their ranks grew ever thinner until there
were few left between the plutocracy of the court and masses too poor to exist
without the doles of the emperor and the charity of the rich.
In the second
century, A.D., more than half a million persons, possibly half the population
of the city, lived on public charity, and this figure does not include the
slaves, who were not eligible. Permanent offices of public assistance (stationes arcariorum Caesarianorum) were
set up in the halls of Trajans. market, and from the second century on public
distributions of food or money were made from them.
The provision of
physicians' services for the poor was not the serious problem one might
suppose; in the minds of the poor such services were superfluous and not even
necessarily desirable. They had their folk medicine, which was free, and in the
case of more serious ailments there was ready access to the shrines of
Aesculapius. Shrines dotted the empire and were available to citizens
everywhere. The temple on the Tiber Island was the most popular at Rome, widely
used and trusted by the ordinary people. Sick and worn‑out slaves were
brought there, sometimes to spare their masters the trouble of caring for them.
The Emperor Claudius freed such slaves and decreed that if they recovered, they
should not be returned to the control of their masters. The Island of
Aesculapius thus became a place of refuge for the sick poor.
The emperors,
because they had a higher opinion of physicians than did the masses,
occasionally took measures to increase their availability. Doctors were provided
with an indirect subsidy through the offer of immunity from taxes, first by
Vespasian and then on a larger scale by Hadrian. This may have been intended to
place a moral obligation in favor of those unable to afford a physician's fee.
It was not until the fourth century, A.D., however, that Valentinian I
appointed archiatri for each of the fourteen regiones of Rome with the
admonition, "honesty to attend to the poor rather than basely to serve the
rich." While the Emperor had never heard the term "third party,"
he was obviously aware of the concept.
In Greece and early
Rome there was little provision for individual health care beyond the services
of the physician. Nursing and other supportive care were usually undertaken in
the home by members of the patient's family. In the case of those without home
or family, arrangements had to be individualized, if possible, and according to
no particular system.
The growth of
slavery in the Roman Empire overtaxed the non‑system of supportive care,
and eventually necessitated an institutional approach. In the case of the
enormous households of the wealthy where slaves might number in the hundreds or
even in the thousands, medical and nursing care became a need of such magnitude
as to require specialized facilities and personnel. The buildings outfitted for
such use were the valetudinaria, and references to them, especially after the
first century,
A.D., are numerous. They existed both in the
city and on the large country estates. Columella, in his treatise on
agriculture about 60 A.D., pointed out the need for providing valetudinaria for
slaves as places where they could rest and recuperate when ill. He suggested
that at slack times the buildings be well aired and cleansed, so that
everything should be well arranged, decorated, and wholesome for the patients.
He further urged that particular attention be given to the quality of the
provisions and cookery.
The personnel of
the larger valetudinaria undoubtedly included slaves assigned to cooking,
cleaning, and assisting the sick. If the household was an especially large or
wealthy one there might be a Greek philosopher physician attached to it who
would provide consultation to the valetudinarium. Otherwise the only skilled
care was provided by a medicus, who
was the counterpart of the street physician or drug seller, a man of uncertain
education or training and ranked socially as a tradesman. In many instances he
might be himself a slave, and in any case the final authority in medical
matters as well as in all others was the head of the household.
As a private
household infirmary the valetudinariurn was not reserved for slaves alone, but
was utilized by all classes. Seneca himself refers in one of his writings to
"lying in a valetudinarium." In addition to the immediate family of
the master the valetudinariurn might also provide care and comfort to friends
and clients of the family, but scarcely in any instance where no such personal
relationship existed. Galen makes mention of general hospitals in the
provinces, especially the Greek provinces, under public control and with
doctors officially appointed to them. Such hospitals, if they were truly
public institutions, must have been few or shortlived, since there is so little
evidence, either literary or archeological, for their existence. There is
abundant evidence, however, for the fact that the Romans did develop a well
organized system of hospitals for the military.
In the days of the
Republic there was little medical care of any kind for sick or wounded
soldiers, and what crude care existed was practiced by them on one another. A
seriously wounded soldier was left to fend for himself or, if particularly fortunate,
might be left in a friendly town to the ministrations of well‑intentioned
townspeople . As long as the military campaigns were conducted within the
Italian peninsula it was often possible to return the sick and injured to their
homes for treatment and recuperation.
In the later days
of the Republic the Hellenistic influence infiltrated the army, and Greek
physicians began to accompany the ranking officers in the field. Their
functions seem to have been limited to medical care of officers only and to consultation
in matters involving the health of the troops. Among the common soldiers there
developed a category of those judged by their fellow legionaries to be
experienced and especially adept at wound‑dressing: the medici. A medicus held a position of respect among his fellows, but he was
first a soldier in his duties; his quasi‑medical function was secondary.
His medical knowledge, such as it was, had been obtained through observation
and trial and error or gained through contact with senior medici, his knowledge of anatomy was learned from the wounds of the
soldiers. He wore the same uniform as did his "patients," shared
their chain of command, and enjoyed little privilege by virtue of his
special skill.
The function and
deployment of the army changed markedly during the early years of the Empire
with the recognition by Augustus that there must be an eventual limit to the
extension of Roman authority. The concept of a frontier where the area of
undisputed Roman control came in contact with barbarian lands called for a
system of forts, supply bases, and communications. The complex of fortified
defensive boundaries, known as the limes
(pl. limites), moved with changing Roman fortunes, but henceforth until the
fall of the Empire required the permanent stationing of troops far from home.
Most of the Roman frontiers were located at
the edges of deserts or seas where natural barriers meant that few troops were
needed for adequate defense. The notable exception was the northern limes,
which followed roughly the course of the Rhine and Danube Rivers. Control of
the river frontier did not require a force spread evenly along the banks, but
rather concentrations of troops at the main crossing points. Hence there were
established major forts at Vindonissa, (Windisch), Argentorate (Strasbourg),
and Mogontiagurn (Mainz) on the Upper Rhine, Bonna (Bonn), Colonia Agrippina
(Cologne), Novaesiurn (Neuss), Vetera (Xanten), and Noviomagus (Nijmegen) on
the Lower Rhine, and at Vindobona (Vienna), Carnuntum, and numerous other
locations along the Danube. With the invasion of Britain during the reign of
Claudius the northwest extension of the limes
brought a need for still more fortifications culminating in Hadrian's Wall.
The establishment
of these more or less permanent military installations so far from Rome meant
that soldiers no longer returned to their homes at the ends of military
campaigns and that the services for which they had once returned to Rome had
now to be provided along the limes. The
distances also meant that sick or wounded soldiers could no longer be sent home
for treatment, and the need for a more effective army medical service was
apparent, including facilities for the complete care of the temporarily
disabled.
Figure 3. Model reconstruction of the Roman military
valetudinarium (hospital) at Vetera on the lower Rhine. The floor plan and
central courtyard are authentic. The raised section of roof and windows over
the circulation corridor is assumed to have been necessary for lighting and
ventilation. Rheinisches Landesmuseum, Bonn.
Figure 4. Plan of the
Roman military hospital at Vindonissa (modern Windisch, Switzerland). The four‑membered
circulation corridor flanked by rows of paired wards is typical of all. This
particular hospital featured a one‑room building in the center of the
courtyard, possibly a medical treatment room.
Most of the
military valetudinaria were built in the first century, A.D., when the system
of frontier fortifications was being developed. The major valetudinaria were
located in the legionary fortresses, so named because they were designed to
accommodate an entire legion or division, numbering usually 6,500‑7,000
men. Most of them appear to have had a
capacity of 300‑400 patients or about 5 per cent of the camp's
population, a ratio similar to that of modem military base hospitals.
The earliest
military valetudinaria were constructed of wood, but by the end of the century
they had been replaced by durable stone structures, more fire‑resistant
and affording better protection against the colder winters of Central Europe.
Typically they were built near the center of the camp, often on its main
street, and near the main baths. The most characteristic architectural feature
was a quadrangular plan arranged around a central rectangular court. The wards
were arranged on either side of a main circulation corridor which extended
continuously through all four sides ‑of the building. The external
dimensions of most were in the range of 150‑200 feet by 250‑300
feet. The plan must have been workable, since it was utilized repeatedly over a
period of well more than a century with only minor variations.
One other
characteristic feature of the valetudinaria, found almost as consistently as
the basic quadrangular plan, was the arrangement of paired small wards (Fig.
5). The wards usually measured about 12 x 15 feet and accommodated five to
eight patients each. Typically two such wards shared a small anteroom by which
they communicated with the circulation corridor. The indirect access from
corridor to wards provided not only quiet and privacy, but freedom from drafts.
A third room, intermediate in size between the anteroom and the wards.
communicated with the anteroom and lay between the two wards. The function of
this room has been the subject of some conjecture. Jetter10 states that it was
used by the personnel of the valetudinarium as a sort of nursing station;
Webster identifies it as a latrine; Simonett believed it to be a storeroom for
the patients' belongings. Whatever the function of the intermediate room, The
Romans seemed to have been pleased with the basic arrangement. for they
repeated it in legionary hospitals from Austria and Switzerland to the
Rhineiand and Scotland.
It is safe to
assume that medical care in the military valetudinaria proceeded at a low
level. Galen, critical of Roman military medicine, once described being
summoned to the scene of a battle to give proper medical treatment
where, in his opinion, little such treatment existed. He noted caustically that
many doctors "talk" medicine without proving their skill. Galen's comment doubtless could also have
been applied to a large segment of the civilian profession of his day.
In summation there
can be no doubt that the first important steps toward the development of
scientific medicine were taken by the early Greeks and merely followed by the
Romans. What is less appreciated is the contribution to total health care and
maintenance made by the Romans. Their technological approaches to the provision
of healthful water supplies and sanitation and their development of the world's
first hospital system were probably more important contributions to the
solution of the health problems of their increasingly complex society than was
the medical progress made by the Greeks. The appointment and official support
of public physicians, the archiatri, for the express purpose of proving free
medical care to the poor represented social progress, considering the ambiguous
position of the Greek demosieuontes.
Figure 5. Basic paired ward arrangement common to all the Roman army's hospitals. The
tortuous entry through the small anteroom must have been difficult in the case
of litter patients.
If there was no public clamor for better
health facilities and a more equitable distribution, it was because the quality
of the care available had stimulated little demand. As long as the masses
preferred supernatural medicine to the natural the competition for physicians'
services was negligible. In a day when supportive care in the home was
approximately as good as that available in the best valetudinaria there was a
limited need for the specialized institutions.
The latter success of rational medicine in displacing the cults, in
eventually assuming the leadership of the community health effort, and, most
important in the past century, in gaining the confidence of the public
produced, through rising expectations, shortages, and high costs, a crisis in
health care distribution of which the ancients would never have dreamed.
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