How Did Hospitals Emerge

We think of hospitals as being a foundation to modern healthcare systems; however, the emergence of hospitals is not only ancient but it also evolved through a complex history. Hospitals were seen as a way to address healthcare in increasingly urban spaces in the ancient world. In the Medieval and Modern periods, new practices emerged that allowed them to be integrated within educational, government, and private institutions.

The Rise of Early Hospitals

Early hospitals may have had their origins from temple institutions in ancient Egypt and Mesopotamia. In both these cultures, temples and priests, who also performed healing duties, may have used part of the temple compounds as areas for patients to be healed for a variety of diseases and sicknesses. Early surgical practice is also recorded, mostly likely by the 3rd millennium BCE and became more common by the 2nd millennium BCE. In both Egypt and Mesopotamia, doctors likely performed surgery dealing with c-section and removal of boils. More complicated surgery may have been practiced; however, the limitation of not having anesthesia and infection would have made surgery at times very dangerous. What these early hospitals, or institutions, indicate is that as cities and urban areas emerged, it was clear that large populations also made it easy for sickness to spread. Hospitals and healing of common diseases, infections and even surgery became a major necessity at the dawn of urbanism. Similar to ancient Egypt and Mesopotamia, ancient Greece also had gods devoted to healing. The god Asclepius and his cult may have functioned similarly to healing gods and practices in Egypt and Mesopotamia, where the temples could have been used as areas for people to come and receive a form of healthcare, including medicine and surgery in cases.

Among early healthcare facilities, the Achaemenid Persians in the late 6th century and 5th centuries BCE may have established something comparable to a teaching hospital in Egypt and other places. In the Roman period, structures known as valetudinaria , which were likely secular facilities devoted to health care of soldiers, gladiators, and even potentially others. In the Christian period, by the late 4th century CE, there were edicts to now build dedicated hospitals. This was largely motivated by Christian interests in healing in relation to religious practices and following New Testament teaching on healing. The hospital in Constantinople and Caesarea in Turkey are among the first known. Little is known about these structures but they likely indicate a type of healthcare facility for the masses.

Perhaps the first true teaching hospital known to us, the Academy of Gondishapu, was established by the Sassanid Persians by the 5th century CE. Groups of medical scholars, who also came from the Byzantine Empire as Christian refugees because they were Nestorian Christians, banned by the emperor in Constantinople, came to Gundeshapur in Southwest Iran. They helped found an academy that had devoted medical facilities not only for healing and practice of surgery but the academy began to be developed and dedicated to education. It is here that concepts of anatomy were developed and scholarships akin to medical science developed in conjunction with dedicated medical facilities. By the 6th and 7th centuries CE, the institution likely became the most important medical center in the world. The academy attracted physicians from much of the ancient world, including from India and China. Medical students now were required to work closely with their educators and became apprenticed in the practice while working in the hospital.

The Rise of Medieval Hospitals

With the Muslim conquest, the city and academy in Gondishapur fell into eventual disrepair; however, the knowledge and training were increasingly transferred to Baghdad, as that city became the new center for medical education and development of hospitals. There, knowledge was not only integrated with Sassanid medicine and development of hospitals, but Indian medicine, such as Ayurveda, were incorporated. Lecture rooms, pharmacies and libraries were incorporated in instructions. Hospitals were soon founded in the 7-10th centuries throughout the Middle East, including in Cairo and Damascus. While hospitals became affiliated with Islamic teaching and instruction, Christians and Jews were active in medical work and in developing hospitals. Doctors and medical students began to make rounds and examine patients closely after treatment. At this time, the concept of medical records for patients was developed, where doctors would record patient information and results of treatments as they visited patients. Surgery was practiced in theaters where medical students would observe and medical books were also written about surgical practice and anatomy (Figure 1). The development of the pharmacy, first established by Middle East doctors as a separate science, evolved in the 9th century CE as a department that was also affiliated with hospitals and medical departments. What this development recognized is the importance of pharmacology as a separate science requiring both herbal and chemical knowledge .

Figure 1. Example drawing of the nervous system made by Middle East medical practitioners.

In Europe, hospitals were even less secular and affiliated with religious institutions, particularly the Catholic church. Monks and priests would often work these institutions. In fact, the relationship of hospitals and the Catholic church, in particular, has continued to this day. However, what created more secular hospitals was the Protestant Reformation. In this case, hospitals that were once supported by the Catholic Church lost their support. In England, the loss of support for hospitals led many citizens to often demand that the government begin to take control of these institutions. This began the process of government-supported and eventually private hospitals. Soon, care began to be different between Catholic and more Protestant affiliated hospitals. The Protestant hospitals gradually became more secular in the approach to medicine and health care, where the beginnings of nursing as a separate branch of health care in hospitals began to develop by the late 16th and 17th centuries

Transformation to Modern Institutions

By the 18th century, secular hospitals were now found in many parts of Protestant Europe. This further led to the idea that hospitals should be separate from church institutions and doctors were no longer required to also have religious and medical training. During this time in the Age of Enlightenment, the concept of departments or wards within hospitals developed. Patients began to be differentiated between those with acute or less severe symptoms. Private hospitals or those funded by independently wealthy individuals as charities began to appear in major cities such as London. Particularly in the 18th and 19th centuries, as health care was not always easily accessible to the poor, many wealthy individuals began to take responsibility of building hospitals. This, in effect, was replacing the Church as the former patron of hospitals in places where Catholicism had been removed. It was during the 18th century that Europe had begun adopting something already practiced in the Middle East for centuries, which was making hospitals teaching institutions and allowing them to become places of innovation as well as care. However, practical anatomy was still rarely taught in medical colleges that were developing, even though this had already been in practice in the Middle East for some time

During the 19th century, hospital care was now expanding rapidly and Protestant denominations, similar to the Catholic Church before, had begun sponsoring and supporting hospitals. Although forms of nursing had been around for centuries, it was generally less formal and often not professional in its utilization in hospitals. It was during the Crimean War Florence Nightingale wrote her influential book Notes on Nursing that helped develop nursing into a profession. She utilized money raised to establish a training school at St. Thomas' Hospital in London, making that hospital to formally train nurses. Throughout the 1860s, nursing training programs were improved and professionalized, with nursing being offered as professional training in new and older hospitals. During subsequent wars in the 1870-1880s, field hospitals staffed by professionally trained nurses had dramatically improved the chances for soldiers being saved from battlefield injuries.

Figure 2. By the 17-18th centuries in Europe, hospitals became more secular in nature and charities and governments began sponsoring them.

Conclusion

Today, many types of hospitals are found, which can be funded by government, private donors, or religious institutions. All of these bases of support had their origin from ancient, Medieval, and early modern developments. Specializing has, if anything, increased, where even more specialized departments are found. This has increased the levels of training and specialization that doctors are able to learn and focus on. Teaching and hospitals were first closely linked during the Sassanian and Islamic periods. The teaching of anatomy, clinical practice, and theoretical training were already aspects taught in these earlier institutions and that practice developed in Europe much later but it has now become the foundation of modern medical schools.