Allen D. Spiegel

Babylonian Medicine, Managed Care and Codex Hammurabi, Circa 1700 B.C.

At the dawn of civilization, about 4,000 years ago, a massive pillar of stone and written clay tablets already prescribed the concepts of managed care for the practice of medicine. Codex Hammurabi established a sliding fee schedule for services, promoted outcome measurements, which if not met, resulted in harsh penalties, required medical records to document diseases and therapies, included prescription benefits, fully explained patients rights, and marketing and advertising publicized the edicts of the King. Even though the managed care was authoritarian, there were legal actions to insure justice and equity particular to each soda! class in the kingdom. Tempered by time, the managed care mandates of Codex Hammurabi can still be considered the genesis of the current concepts of managed care.

America's First Medical Malpractice Crisis, 1835–1865

Prior to the early 1800s, medical malpractice was almost unknown in the United States. However, a large number of malpractice law suits inundated the courts between 1835 and 1865. About 70 to 90 percent of the litigation involved fractures and dislocations with imperfect results or deformities such as shortened or crooked limbs. Lawyers alleged that the physicians did not provide due proper care, skill and diligence despite the fact that the better surgeons tried to save limbs rather than follow the common practice of amputation, especially for compound fractures. While a number of texts dealt with medical jurisprudence, it was not until 1860 that a text on the subject intensively delved into the issue of medical malpractice. Coincidentally, the attitudes and behaviors of patients, lawyers, physicians and judges during the first medical malpractice crisis were surprisingly similar to those currently held.

Abraham Lincoln and the insanity plea

A confederate civilian physician shot and killed a white Union officer who was drilling Negro troops in Norfolk, Virginia. With no question as to guilt, President Abraham Lincoln decided to have a medical expert conduct a professional sanity/insanity examination. Documentation indicates that legal and political factors may have influenced Lincolns decision. As a lawyer, Lincoln prosecuted a case where the insanity plea was used as a defense. Two influential Cabinet members, William H. Seward and Edwin M. Stanton, also had legal experience involving the insanity plea. Politically, Lincoln faced serious issues such as the draft riots, the military necessity to recruit slaves into the army, the impact of Union Negro soldiers upon the border states, the morale and discipline of the army and the upcoming presidential election. Upon Sewards recommendation, Lincoln chose a physician who had a reputation for finding the accused sane and who did so in this case. As the southern physician was hanged, Lincolns means achieved the desired legal and political ends.A confederate civilian physician shot and killed a white Union officer who was drilling Negro troops in Norfolk, Virginia. With no question as to guilt, President Abraham Lincoln decided to have a medical expert conduct a professional sanity/insanity examination. Documentation indicates that legal and political factors may have influenced Lincolns decision. As a lawyer, Lincoln prosecuted a case where the insanity plea was used as a defense. Two influential Cabinet members, William H. Seward and Edwin M. Stanton, also had legal experience involving the insanity plea. Politically, Lincoln faced serious issues such as the draft riots, the military necessity to recruit slaves into the army, the impact of Union Negro soldiers upon the border states, the morale and discipline of the army and the upcoming presidential election. Upon Sewards recommendation, Lincoln chose a physician who had a reputation for finding the accused sane and who did so in this case. As the southern physician was hanged, Lincolns means achieved the desired legal and political ends.

Chloroform-induced insanity defence confounds lawyer Lincoln.

During an 1857 trial, the defence claimed that the accused should be absolved of wilful murder because an overdose of chloroform during surgery induced insanity. In a rare appearance as a prosecutor, Abraham Lincoln tried the case for the State of Illinois. Expert medical witnesses testified about the side effects of chloroform and chloroform-induced insanity. Significantly, Lincoln was not knowledgeable about medical jurisprudence and overlooked potential sources of evidence and expert witnesses. Defence lawyers presented an impressive array of physicians to testify about insanity, about chloroform and about the results of an overdosage during anaesthesia. Considering the state of scientific knowledge at the time, the trial was notable.

The role of gender, phrenology, discrimination and nervous prostration in Clara Barton's career

Clara Barton was 39 years old before she became involved in Civil War humanitarian activities. Prior to that time, three factors shaped her personality and her future: phrenology gave her philosophical principles to live by, especially “Know Thyself”; sex discrimination on her first two jobs steeled her for living in a male dominated Victorian era; and psychohygienic therapy for her long term nervous prostration, changed her behavioral approach to illness and to life. With these three influences in hand. Barton went on to gain world-wide adulation. During the Civil War, she was revered as the American Florence Nightingale, although she was not really a nurse. At age 55, Barton first embarked on the lengthy struggle to found the American Red Cross. She was president of the Red Cross for 23 years and rendered aid and comfort at a host of national and international calamities. She died at age 90 in her Glen Echo, Maryland home on April 12, 1912.Clara Barton was 39 years old before she became involved in Civil War humanitarian activities. Prior to that time, three factors shaped her personality and her future: phrenology gave her philosophical principles to live by, especially “Know Thyself”; sex discrimination on her first two jobs steeled her for living in a male dominated Victorian era; and psychohygienic therapy for her long term nervous prostration, changed her behavioral approach to illness and to life. With these three influences in hand. Barton went on to gain world-wide adulation. During the Civil War, she was revered as the American Florence Nightingale, although she was not really a nurse. At age 55, Barton first embarked on the lengthy struggle to found the American Red Cross. She was president of the Red Cross for 23 years and rendered aid and comfort at a host of national and international calamities. She died at age 90 in her Glen Echo, Maryland home on April 12, 1912.

Dr. John Frederick May and the Identification of John Wilkes Booth's Body

Shortly after President Abraham Lincolns assassin was killed on April 26, 1865, a formal inquest was held to positively identify the body. Dr. John Frederick May, a leading surgeon in the District of Columbia, was summoned to examine the remains. Two years earlier, Dr. May had removed a fibroid tumor from the back of the assassins neck and an identifiable large ugly scar resulted when the wound inadvertently opened and healed by granulation. Based upon the recognition of the scar made by his scalpel, Dr. May made a positive identification.

Bernard J. Cigrand, DDS: Father of Flag Day and Renaissance Man

Dr. Bernard J. Cigrand is acknowledged as the “Father of Flag Day.” He relentlessly continued his activities for more than sixty years to have June 14 designated for the national observance of the birth of the American flag. That finally occurred in 1948, seventeen years after his death, when President Harry S. Truman signed a Congressional Act into law. However, the law designated a voluntary observance but did not create a legal national holiday. In addition to his fervent passion for Flag Day, Cigrand undertook a variety of other initiatives He was a practicing dentist, the dean of a dental school, an investigative journalist, an expert on heraldry and seals, a lecturer and an author of books. Despite all his achievements, Cigrand is more widely known in the European country from where his parents emigrated to the United States in 1852 - Luxembourg, than in the United States.

Concerns About Infectious Hepatitis and Delacorte's Welfare Island Fountain

In 1969, philanthropist George T. Delacorte donated a spectacular water fountain to New York City on the southern tip of Welfare Island. Architects designed the fountains jet geyser to pump a plume of water from the East River more than 400 feet into the air. Public health experts feared that the water from the heavily polluted East River could be a possible source for the spread of infectious hepatitis. Water droplets could be airborne by the prevailing winds to land on the densely populated east side of Manhattan. Upon the insistence of the New York City Department of Health, the fountains water intake source was chlorinated. This action was initiated before the discovery of the hepatitis A virus (HAV) in 1973. A miscellany of continuing problems plagued the fountain for about two decades, causing the donor to label the fountain “Delacortes Folly.” Eventually, Delacorte gave up. In the late 1980s, the fountain ceased spouting and was finally dismantled.

Mary Edwards Walker, M.D.: a feminist physician a century ahead of her time.

In her teens, Mary Edwards Walker already wore the “bloomer” outfit and began to campaign for reforming the “unhygienic” clothing of women. Assertively, she attended medical school and earned her M.D. degree. Due to prejudice, her practice did not flourish and she moved to Washington to offer her medical services to the Union as the Civil War began. Rebuffed by the male medical bureaucrats, she volunteered her services anyway. Eventually, she was awarded the Congressional Medal of Honor, the only woman to ever gain such distinction. After the war, Walker became a journalist, an author of two sensational books, a political lobbyist, a suffrage campaigner, a professional and public lecturer, an ardent dress reformer, a peace activist, a Utopianist and a womens rights advocate. Light-years ahead of her times, Dr. Walker was an intelligent, independent, irrepressible and indefatigable proponent for a host of worthy causes.In her teens, Mary Edwards Walker already wore the “bloomer” outfit and began to campaign for reforming the “unhygienic” clothing of women. Assertively, she attended medical school and earned her M.D. degree. Due to prejudice, her practice did not flourish and she moved to Washington to offer her medical services to the Union as the Civil War began. Rebuffed by the male medical bureaucrats, she volunteered her services anyway. Eventually, she was awarded the Congressional Medal of Honor, the only woman to ever gain such distinction. After the war, Walker became a journalist, an author of two sensational books, a political lobbyist, a suffrage campaigner, a professional and public lecturer, an ardent dress reformer, a peace activist, a Utopianist and a womens rights advocate. Light-years ahead of her times, Dr. Walker was an intelligent, independent, irrepressible and indefatigable proponent for a host of worthy causes.

Issues and opportunities in the regulation of home health care

Recent federal legislation established a Certificate of Need (CON) process by which health care providers must receive state approval before building or renovating a facility, or adding a new service. Certainly, strict regulation of cost and quality of home health care is needed, but it is asserted that CON is an ineffective way of organizing the delivery of services and limiting costs, and furthermore, that CON is biased in favor of institutionally-based providers and maintenance of the status quo. The authors feel that vested interests have a history of trying to use earlier state CON regulations to control their turf, limit competition, and consequently stifle innovation. Home health care should be incorporated into national health planning goals and integrated into state and regional health plans. Such planning must precede CON regulations and should not be confused with it. Alternatives to CON can achieve quality service and moderate costs and include licensing of personnel, standards for provider accreditation, and utilization review. Planning for these alternatives should begin now to avoid fragmented expansion of home health care. Evidence suggests a comprehensive use of home health care as a cost-effective alternative for many levels of care given in hospitals and nursing homes.