Ancient Greek medicineThe first known Greek medical school opened in Cnidus in 700 BC. Alcmaeon, author of the first anatomical work, worked at this school, and it was here that the practice of observing patients was established. Hippocrates established his own medical school at Cos.[1] Despite their known respect for Egyptian medicine, attempts to discern any particular influence on Greek practice at this early time have not been dramatically successful because of the lack of sources and the challenge of understanding ancient medical terminology. It is clear, however, that the Greeks imported Egyptian substances into their pharmacopoeia, and the influence becomes more pronounced after the establishment of a school of Greek medicine in Alexandria.[2]

Hippocrates and Hippocratic medicine

The Hippocratic Corpus contains the core medical texts of this school. Although once thought to have been written by Hippocrates himself, today, many scholars believe that these texts were written by a series of authors over several decades.[citation needed] Since it is impossible to determine which may have been written by Hippocrates himself, it is difficult to know which Hippocratic doctrines originated with him.

The existence of the Hippocratic Oath implies that this "Hippocratic" medicine was practiced by a group of professional physicians bound (at least among themselves) by a strict ethical code. Aspiring students normally paid a fee for training (a provision is made for exceptions) and entered into a virtual family relationship with his teacher. This training included some oral instruction and probably hands-on experience as the teacher's assistant, since the Oath assumes that the student will be interacting with patients. The Oath also places limits on what the physician may or may not do ("To please no one will I prescribe a deadly drug") and intriguingly hints at the existence of another class of professional specialists, perhaps akin to surgeons ("I will leave this operation to be performed by practitioners, specialists in this art").[3]

HumourismThe equilibrium of the four humours: black bile, yellow bile, (red) blood, and (green) phlegm

The Hippocratics, along with many other Greeks, also believed in the theory of the four humours. This theory had its roots in the belief in four elements which, Empedocles argued, made up everything in the world: earth, air, fire and water with their associated qualities of dryness, coldness, heat and wetness respectively. These, in turn, were linked to the four seasons; dry autumn, cold winter, hot summer and wet spring (it followed that you were more likely to suffer from a particular humour in the corresponding season). The humours being, for autumn, black bile, for winter, phlegm, for summer, yellow bile, and for spring, blood. Among other corollaries, this theory meant that for some diseases,

remedies to purge excess humours, such as bloodletting or vomiting, seemed advisable and generally useful as a source of use and understanding.

As to the exact relationship between the humours and illness, beliefs varied. The Hippocratics taught that one could only be in perfect health when the humours were in balance, known as crasis or eucrasia and the opposite state dyscrasia. The natural tendency towards balance, or recovery, was called pepsis or coction.

Aristotle

The ancient Greek philosopher Aristotle was the most influential scholar of the living world from antiquity. Though his early natural philosophy work was speculative, Aristotle's later biological writings demonstrate great concern for empiricism, biological causation, and the diversity of life.[4] Aristotle did not experiment, however, holding that items display their real natures in their own environments, rather than controlled artificial ones. While in physics and chemistry, this assumption has been found unhelpful, in zoology and ethology it has not, and Aristotle's work "retains real interest".[5] He made countless observations of nature, especially the habits and attributes of plants and animals in the world around him, which he devoted considerable attention to categorizing. In all, Aristotle classified 540 animal species, and dissected at least 50.

Aristotle believed that intellectual purposes, formal causes, guided all natural processes.[6]Such a teleological view gave Aristotle cause to justify his observed data as an expression of formal design; for example suggesting that Nature, giving no animal both horns and tusks, was staving off vanity, and generally giving creatures faculties only to such a degree as they are necessary. In a similar fashion, Aristotle believed that creatures were arranged in a graded scale of perfection rising from plants on up to man; : the scala naturae or Great Chain of Being.[7] .

He held that the level of a creature's perfection was reflected in its form, but not foreordained by that form. Yet another aspect of his biology divided souls into three groups: a vegetative soul, responsible for reproduction and growth; a sensitive soul, responsible for mobility and sensation; and a rational soul, capable of thought and reflection. He attributed only the first to plants, the first two to animals, and all three to humans. [8] Aristotle, in contrast to earlier philosophers, and like the Egyptians, placed the rational soul in the heart, rather than the brain.[9] Notable is Aristotle's division of sensation and thought, which generally went against previous philosophers, with the exception of Alcmaeon.[10]Aristotle's successor at the Lyceum, Theophrastus, wrote a series of books on botany—the History of Plants—which survived as the most important contribution of antiquity to botany, even into the Middle Ages. Many of Theophrastus' names survive into modern times, such as carpos for fruit, and pericarpion for seed vessel. Rather than focus on formal causes, as Aristotle did, Theophrastus suggested a mechanistic scheme, drawing analogies between natural and artificial processes, and relying on Aristotle's concept of the efficient cause. Theophrastus also recognized the role of sex in the reproduction of some higher plants, though this last discovery was lost in later ages.[11].The biological/teleological ideas, of Aristotle and Theophrastus as well as

their emphasis on a serious of axioms rather than on empirical observation, cannot be easily separated from their consequent impact on Western medicine.

AlexandriaFrontispiece to a 1644 version of the expanded and illustrated edition of Historia Plantarum (ca. 1200), which was originally written around 200 BC

Following Theophrastus, the Lyceum failed to produce any original work. Though interest in Aristotle's ideas survived, they were generally taken unquestioningly.[12] It is not until the age of Alexandria under the Ptolemies that advances in biology can be again found. The first medical teacher at Alexandria was Herophilus of Chalcedon, who corrected Aristotle, placing intelligence in the brain, and connected the nervous system to motion and sensation. Herophilus also distinguished between veins and arteries, noting that the latter pulse while the former do not. He did this using the experiment involving cutting certain vein and arteries in a pigs neck until the squealing stopped.[13] In the same vein, he developed a diagnostic technique which relied upon distinguishing different types of pulse.[14] He, and his contemporary, Erasistratus of Chios, researched the role of veins and nerves, mapping their courses across the body.

Erasistratus connected the increased complexity of the surface of the human brain compared to other animals to its superior intelligence. He sometimes employed experiments to further his research, at one time repeatedly weighing a caged bird, and noting its weight loss between feeding times. Following his teacher's researches into pneumatics, he claimed that the human system of blood vessels was controlled by vacuums, drawing blood across the body. In Erisistratus' physiology, air enters the body, is then drawn by the lungs into the heart, where it is transformed into vital spirit, and is then pumped by the arteries throughout the body. Some of this vital spirit reaches the brain, where it is transformed into animal spirit, which is then distributed by the nerves.[15] Herophilus and Erasistratus performed their experiments upon criminals given them by their Ptolemaic kings. They dissected these criminals alive, and "while they were still breathing they observed parts which nature had formerly concealed, and examined their position, colour, shape, size, arrangement, hardness, softness, smoothness, connection."[16]

Though a few ancient atomists such as Lucretius challenged the teleological viewpoint of Aristotelian ideas about life, teleology (and after the rise of Christianity, natural theology) would remain central to biological thought essentially until the 18th and 19th centuries. In the words of Ernst Mayr, "Nothing of any real consequence in biology after Lucretius and Galen until the Renaissance."[17] Aristotle's ideas of natural history and medicine survived, but they were generally taken unquestioningly.[18]

Influence on Rome & Christianity

Through long contact with Greek culture, and their eventual conquest of Greece, the Romans absorbed many of the Greek ideas on medicine. Early Roman reactions to Greek

medicine ranged from enthusiasm to hostility, but eventually the Romans adopted a favorable view of Hippocratic medicine.[19]

This acceptance led to the spread of Greek medical theories throughout the Roman Empire, and thus a large portion of the West. Following the collapse of the Empire, however, official Catholic support for Galen's teachings made these the only politically acceptable ideas on medicine until the Renaissance. This support was a major reason for the huge impact of his teachings, despite their sometimes questionable value. For example, the theory of bloodletting was popular into the 19th century, despite its total inefficacy and the extreme riskiness: many people, including possibly George Washington, died from its failure. Medicine was very important to the Greek culture because they had such high priority was placed upon such healthy lifestyles.

Medicine in ancient RomeAncient Roman medicine combined various techniques using different tools and rituals. Ancient Roman Medicine is split among a number of specializations such as intemistic, opthalmological and urological. Romans believed in supernatural causes for many diseases and in some supernatural cures (see bottom of article). The Romans favoured the prevention of diseases over the cures of them; unlike in Greek Society where Public Health was a personal matter, Public Health was encouraged by the Government at the time; they built bath houses and aqeuducts to pipe water to the cities. Many of the larger cities, such as Rome, boasted an advanced sewage system, the likes of which would not be seen in the Western world again until the late 17th and 18th centuries (see Cloaca Maxima).

They also did not fully understand that germs were related to diseases. Roman surgeons carried a tool kit which contained forceps, scalpels, catheters and arrow extractors. The tools had various uses and were boiled in hot water before each use. In surgery, surgeons used painkillers such as opium and scopolamine for treatments and acetum (the acid in vinegar) was used to wash wounds. Romans didn't believe in the supernatural as much as the Greeks; the Greeks used temples and religious belief to try and cure someone, yet the Romans developed specific hospitals which enabled the patients to be fully rested and relaxed so they could completely recover. By staying in the hospitals, the doctors (which now had different levels of qualification) were able to observe the illness rather than rely on the supernatural to cure him/her.

Galen

Galen was a famous doctor who encouraged his students to dissect animal corpses to find out more about the human body (the dissection of human corpses was frowned upon at the time and would continue to be until the Renaissance & subsequent fall of power in the Church). Galen discovered, among other things, that blood ran through the arteries and veins in your body and that the human skeleton had a specific form, which greatly influenced doctors from the Christian and Arabic religions because the theory "fitted in"

with their belief that only God could create such a complex structure. Galen was also said to have believed in one God (Monotheism), the Christian Church argued that it could have been their God and the Islamic Religion did similar, both organisations were able to adopt him and his ideas. Many of Galen's theories were wrong however, such as his ideas on the human anatomy, particuarly the structure of the jaw and the shape of the human bone structure (anatomy); because he was not able to dissect human subjects, Galen believed that the bone structure of an ape would be similar to ours. Galen's theories, backed by the power of the Church, would remain unchallenged until the Renaissance, when advancements in machinery, the Reformation of the Church and other factors would lead to many being dispproved.

Medicinal instruments

Medical tools used in ancient Rome:

Scalpels : These instruments were strictly used to make incisions, whether it be deep or long cuts. Scalpels were mostly made from bronze or steel.

Bone hooks: These instruments were long and thin and were mostly used for maneuvering tissue. The Greeks also used this tool. The hooks came in two varieties: sharp and blunt. Sharp hooks were used to remove tissue from wounds and blunt hooks were used for dissections.

Bone drills: Picture a wine cork screw, this is what a bone drill looked like. Bone drills were used to remove diseased bone tissue from the skull or to remove any foreign object(s). Similar tools had been used by Prehistoric Man to remove evil spirits.

Vaginal speculum: This is one of the rarest surviving Roman medical instruments. These tools were large and were often recommended for diagnosing vaginal and uterine disorders.

Spatula: This instrument was used to mix and apply various ointments to patients.

Probe: This instrument was used to carefully examine a wound before treatment.

Surgical saw: This instrument was used to cut through bones in amputations and surgeries.

Forceps: Used as modern pincers are used today. Its main purpose was to remove splinters and other small unwanted fragments in the tissue

Catheter: Used to cause urination. It would was likely far more uncomfortable than modern catheters due to the fact that Roman catheters were made of some sort of metal such as bronze.

Medicinal herbs

Some Ancient Roman herbs used in medicine were:

Fennel: It was thought to have calming properties

Elecampane: Used to help with digestion

Sage: Although it had little medicinal value, they had great religious value.

Garlic: Beneficial for health, particuarly of the heart

Fenugreek: Used in the treatment of pneumonia

Mustard

Rosemary

Silphium: Used for a wide variety of ailments and conditions--especially for birth control.

Asclepieions in Roman Medicine

When the Roman Army conquered Greece they adopted many of their medicinal beliefs and ideas. The cult of Asclepios had spread across much of Greece and numerous temples (asclepieions) had been built in his name. These Asclepieions (or Asklepieions) were places of healing. They contained baths, gardens and other facilities designed to improve people's health. People who were being treated in the Asclepieions would sleep in front of a statue of the Greek God in the hope that he would heal them in their sleep. Though several accounts have been recovered, detailing the progress in health made by people admitted to the Asclepieions, it is unlikely that they were based on fact; they may simply have been used as propoganda.

Insula Tiberina

Insula Tiberina was a temple to the god of healing Aesculapius, or the Greek god Asklepios, and a hospital. It was built on a small isle in the Tiber River and has been a center of medicine well into the middle ages. It was built when a plague fell upon Rome in 295BC. Normal treatments, herbs and appeals to their Gods did not work against it. In desperation the Romans built the temple, dedicated to the Greek god of healing, Asklepios and the plague soon went away.

Antonine Plague

The Antonine Plague, 165-180 C.E., also known as the Plague of Galen, was an ancient pandemic, either of smallpox or measles brought back to the Roman Empire by troops returning from campaigns in the Near East. The epidemic claimed the lives of two Roman emperors — Lucius Verus, who died in 169, and his co-regent who ruled until 180, Marcus Aurelius Antoninus, whose family name, Antoninus, was given to the epidemic. The disease broke out again nine years later, according to the Roman historian Dio Cassius, and caused up to 2,000 deaths a day at Rome, one quarter of those infected. Total deaths have been estimated at five million.

In 166, during the epidemic, the Greek physician and writer Galen traveled from Rome to his home in Asia Minor. He returned to Rome in 168 when summoned by the two Augusti. Galen's observations and description of the epidemic, found in the treatise "Methodus Medendi", is brief. He mentions fever, diarrhea, and inflammation of the pharynx, as well as a skin eruption, sometimes dry and sometimes pustular, appearing on the ninth day of the illness. The information provided by Galen does not clearly define the nature of the disease, but scholars have generally preferred to diagnose it as smallpox.

The epidemic had drastic social and political effects throughout the Roman Empire. Imperial forces moved east under the command of Emperor Verus when the forces of Vologases IV of Parthia attacked Armenia. The Romans' defense of the eastern territories was hampered when large numbers of troops succumbed to the disease. According to the 4th century Spanish writer, Paulus Orosius, many towns and villages in the Italian peninsula and the European provinces lost all their inhabitants. As the disease swept north to the Rhine, it also infected Germanic and Gallic peoples outside the Empire’s borders. For a number of years, these northern groups had pressed south in search of more lands to sustain their growing populations. With their ranks thinned by the epidemic, Roman armies were now unable to push the tribes back. From 167 until his death, Emperor Marcus Aurelius personally commanded legions near the Danube, trying with only partial success to control the advance of Germanic peoples across the river. A major offensive against the Marcomanni was postponed until 169 because of a shortage of Imperial troops.

During the Germanic campaign, Marcus Aurelius also wrote his philosophical work, "Meditations". Passage IX.2 states that even the pestilence around him is less deadly than falsehood, evil behavior, and lack of true understanding. As he lay dying from the disease, Marcus uttered the words "Weep not for me; think rather of the pestilence and the deaths of so many others."

Plague of Cyprian

In 251 to 266, at the height of a second outbreak of disease, known as the Plague of Cyprian (the bishop of Carthage), 5,000 people a day were said to be dying in Rome. Cyprian's biographer, Pontius the deacon, wrote of the plague at Carthage:

"Afterwards there broke out a dreadful plague, and excessive destruction of a hateful disease invaded every house in succession of the trembling populace,

carrying off day by day with abrupt attack numberless people, every one from his own house. All were shuddering, fleeing, shunning the contagion, impiously exposing their own friends, as if with the exclusion of the person who was sure to die of the plague, one could exclude death itself also. There lay about the meanwhile, over the whole city, no longer bodies, but the carcases of many, and, by the contemplation of a lot which in their turn would be theirs, demanded the pity of the passers-by for themselves. No one regarded anything besides his cruel gains. No one trembled at the remembrance of a similar event. No one did to another what he himself wished to experience" [1].

As Jews paid with their lives during the 14th century's Black Death, so in Carthage the "Decian persecution" unleashed at the onset of the plague sought out Christian scapegoats. Fifty years later, the North African convert to Christianity Arnobius defended his new religion from pagan allegations:

"that a plague was brought upon the earth after the Christian religion came into the world, and after it revealed the mysteries of hidden truth? But pestilences, say my opponents, and droughts, wars, famines, locusts, mice, and hailstones, and other hurtful things, by which the property of men is assailed, the gods bring upon us, incensed as they are by your wrong-doings and by your transgressions." (Adversus gentes 1.3)

Cyprian drew moralizing analogies in his sermons to the Christian community and drew a word picture of the plague's symptoms in his essay De mortalitate ("On Mortality"):

"This trial, that now the bowels, relaxed into a constant flux, discharge the bodily strength; that a fire originated in the marrow ferments into wounds of the fauces; that the intestines are shaken with a continual vomiting; that the eyes are on fire with the injected blood; that in some cases the feet or some parts of the limbs are taken off by the contagion of diseased putrefaction; that from the weakness arising by the maiming and loss of the body, either the gait is enfeebled, or the hearing is obstructed, or the sight darkened;--is profitable as a proof of faith. What a grandeur of spirit it is to struggle with all the powers of an unshaken mind against so many onsets of devastation and death! what sublimity, to stand erect amid the desolation of the human race, and not to lie prostrate with those who have no hope in God; but rather to rejoice, and to embrace the benefit of the occasion; that in thus bravely showing forth our faith, and by suffering endured, going forward to Christ by the narrow way that Christ trod, we may receive the reward of His life and faith according to His own judgment!" [2]

Historian William McNeill asserts that the Antonine Plague and the Plague of Cyprian were outbreaks of two different diseases, one of smallpox and one of measles, although not necessarily in that order. The severe devastation to the European population from the two plagues may indicate that people had no previous exposure - or immunity - to either disease.

In fiction

An account of the plague's effect on the provincial community of Carnuntum in 170 is in the Harry Turtledove novel Household Gods.

Byzantine medicine

Byzantine Culture

Art

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Science

Byzantine medicine is the medicine practiced in the Byzantine Empire from about 400 AD to 1453 AD. It drew largely on Ancient Greek and Roman knowledge. However, Medicine was also one of the few sciences in which the Byzantines improved on their Greco-Roman predecessors. As a result, Byzantine Medicine had a significant influence on Islamic medicine and the Western rebirth of Medicine during the Renaissance.

Byzantine physicians often compiled and standardized medical knowledge into textbooks. These books tended to be elaborately decorated with many fine illustrations, highlighting the particular ailment. The Medical Compendium in Seven Books, written by the leading physician Paul of Aegina, is of particular importance. The compendium was written in the late seventh century and remained in use as a standard textbook for 800 years.

Late antiquity witnessed a revolution in the medical scene and many sources mention hospitals in passing (although their own history in the Military sense can be drawn back to Imperial Rome and beyond). Constantinople doubtless was the center of such activities in the Middle Ages, owing to its geographical position, wealth and accumulated knowledge.

Background

Arguably the first Byzantine Physician was the author of the Vienna Dioscurides manuscript, created for the daughter of Emperor Olybrius around 515. Like most Byzantine physicians, he drew his material from ancient authorities such as Galen and Hippocrates, though this is not to say that Byzantine Physicians did not make corrections to the 'fathers of Medicine' or make original contributions. Oribasius, perhaps the greatest Byzantine compiler of medical knowledge, frequently made revisions noting where older methods had been incorrect. Several of his works, along with many other Byzantine physicians, were translated into Latin, and eventually, during the Enlightenment and Age of Reason, into English and French.

Another Byzantine treatise, that of the thirteenth century Nicholas Myrepsos, remained the principal pharmaceutical code of the Parisian medical faculty until 1651, while the Byzantine tract of Demetrios Pepagomenos (thirteenth century) on gout was translated and published in Latin by the great post-Byzantine humanist, Marcus Musurus, in Venice in 1517. Ergo it could be argued that previous misrepresentations about Byzantium being simply a 'carrier' of Ancient Medical knowledge to the Renaissance are completely factually wrong. It is already known for example that a late twelfth century Latin physician at Salerno (Roger of Salerno), was influenced by the treatises of the Byzantine doctors Aetius and Alexander of Tralles as well as Paul of Aegina.

The last great Byzantine Physician was Actuarius, who lived in the early 14th Century in Constantinople. His works on Urine laid much of the foundation for later study in that field. However, from the latter 12th Century to the end in 1453, there is very little outpouring in medical knowledge, largely due to the turmoil the Empire was facing on both fronts, following its resurrection after the Latin Empire and the dwindling population of Constantinople due to plague and war. Nevertheless, Byzantine medicine is extremely important both in terms of new discoveries made in that period (at a time when Western Europe was in turmoil), the careful protecting of Ancient Greek and Roman knowledge through compendiums as well as the revision of it and finally, the effect it had in transferring knowledge to both Renaissance Italy and Arabia.

Hospitals

A gallery of birds from the Vienna Dioscurides Byzantine manuscript.

An important contribution of Byzantium is arguably the fact that it was the first Empire in which dedicated medical establishments - usually set up by individual Churches or the State, which parallel modern Hospitals in many way, flourished. Although similar establishments existed in Ancient Greece and Rome, they differed in that they were usually either institutions for Military use, or places were citizens went to die in a more peaceful way. Medical Institutions of this sort were common in Imperial Cities such as Constantinople and later Thessaloniki.

The first hospital was built by Basil of Caesarea in the late fourth century, and although these Institutions flourished, it was only throughout the 8th and 9th Centuries that they began to appear in Provincial Towns as well as Cities, (although Justinian's subsidization of private physicians to work publicly for six months of the year can be seen as the real breakthrough point). Byzantine Medicine was entirely based around Hospitals or walk-in dispensaries which formed part of the Hospital complex, there was a dedicated hierarchy including the Chief Physician (archiatroi), professional nurses (hypourgoi) and the orderlies (hyperetai).

Doctors themselves were well trained and most likely attended the University of Constantinople as Medicine had become a truly scholarly subject by the period of Byzantium (despite the prominence of the great physicians of antiquity, its status as a Science was greatly improved through its application in formal education (particularly in the University of Constantinople). This rigidity through professionalism (similar to the professionalism exhibited in the Byzantine Civil Service) bears many hallmarks of today's modern Hospitals, and comparisons are nearly always made by modern Scholars studying this particular field. Thus, we know that in the twelfth century, Constantinople had two well organized hospitals staffed by medical specialists (including women doctors), with special wards for various types of diseases and systematic methods of treatment.

Medical community of ancient RomeMedical community as used in this article refers to medical institutions and services offered to populations under the jurisdiction of the late Roman Republic and the Roman Empire.

Background

Medical services of the late Roman Republic and early Roman Empire were mainly imports from the civilization of Ancient Greece, at first through Greek-influenced Etruscan society and Greek colonies placed directly in Italy, and then through Greeks enslaved during the Roman conquest of Greece, Greeks invited to Rome, or Greek knowledge imparted to Roman citizens visiting or being educated in Greece. A perusal of the names of Roman physicians will show that the majority are wholly or partly Greek and that many of the physicians were of servile origin.[1]

The servility stigma came from the accident of a more medically advanced society being conquered by a lesser. One of the cultural ironies of these circumstances is that free men sometimes found themselves in service to the enslaved professional or dignitary, or the power of the state was entrusted to foreigners who had been conquered in battle and were technically slaves. In Greek society, physicians tended to be regarded as noble. Asclepius in the Iliad is noble.

Importation from Greece

Public medicine

Tiber Island today, downstream side.

A signal event in the Roman medical community was the construction of the first Aesculapium in the city of Rome, on Tiber Island[2]. In 293 BCE some officials consulted the Sibylline Books concerning measures to be taken against the plague and were advised to bring Aesculapius from Epidaurus to Rome. The sacred serpent from Epidaurus was conferred ritually on the new temple, or, in some accounts, the serpent escaped from the ship and swam to the island. Baths have been found there as well as votive offerings (donaria) in the shape of specific organs.

In classical times the center covered the entire island and included a long-term recovery center. The emperor Claudius[3] had a law passed granting freedom to slaves who had been sent to the institution for cure but were abandoned there. This law probably facilitated state disposition of the patients and recovery of the beds they occupied. The details are not available.

Tiber Island today, upstream side.

It was not the first time a temple had been constructed at Rome to ward off plague. The consul, Gnaeus Julius Mento, one of two for the year 431 BCE, dedicated a temple to Apollo medicus (“the healer”).[4]. There was also a temple to salus (“health”) on the Mons Salutaris, a spur of the Quirinal. There is no record that these earlier temples possessed the medical facilities associated with an Aesculapium; in that case, the later decision to bring them in presupposes a new understanding that scientific measures could be taken against plague. The memorable description of plague at Athens during the Peloponnesian War (430 BCE) by Thucydides does not mention any measures at all to relieve those stricken with it. The dying were allowed to accumulate at the wells, which they contaminated, and the deceased to pile up there. At Rome, Cicero[5] criticized the worship of evil powers, such as Febris (“Fever”), Dea Mefitis (“Malaria”), Dea Angerona (“Sore Throat”) and Dea Scabies (“Rash”).

The medical art in early Rome was the responsibility of the pater familias, or patriarch. The last known public advocate of this point of view were the railings of Marcus Cato against Greek physicians and his insistence on passing on home remedies to his son.

The importation of the Aesculapium established medicine in the public domain. There is no record of fees being collected for a stay at one of them, at Rome or elsewhere. The expense of an Aesculapium must have been defrayed in the same way as all temple expenses: individuals vowed to perform certain actions or contribute a certain amount if

certain events happened, some of which were healings. Such a system amounts to gradated contributions by income, as the contributor could only vow what he could provide. The building of a temple and its facilities on the other hand was the responsibility of the magistrates. The funds came from the state treasury or from taxes.

The practice of medicine

Medical values

The Romans valued a state of valetudo, salus or sanitas. They began their correspondence with the salutation si vales valeo, “if you are well, I am” and ended it with salve, “be healthy.” The Indo-European roots are *wal-, “be strong”, and *sol-, “whole”.

They understood generally that conditions of strength and wholeness were to some degree perpetuated by right living. The Hippocratic oath obliges doctors to live rightly (setting an example). The first cause thought of when people got sick was that they did not live rightly. Vegetius’ brief section on the health of a Roman legion states only that a legion can avoid disease by staying out of malarial swamps, working out regularly and living a healthy life.

Despite their best efforts people from time to time did become aeger, “sick”. They languished, had nausea (words of Roman extraction) or “fell” (incidere) in morbum. They were vexed and dolorous. At that point they were in need of the medica res, the men skilled in the ars medicus, who would curare morbum, “have a care for the disease”, who went by the name of medicus or medens. The root is *med-, “measure”. The medicus prescribed medicina or regimina as measures against the disease.[7]

The physician

The next step was to secure the cura of a medicus. If the patient was too sick to move one sent for a clinicus, who went to the clinum or couch of the patient. Of higher status were the chirurgii (which became the English word surgeon), from Greek cheir (hand) and ourgon (work). In addition were the eye doctor, ocularius, the ear doctor, auricularius, and the doctor of snakebites, the marsus.

Fees

That the poor paid a minimal fee for the visit of a medicus is indicated by a wisecrack in Plautus:[8] "It was less than a nummus."[9] Many anecdotes exist of doctors negotiating fees with wealthy patients and refusing to prescribe a remedy if agreement was not reached. Pliny says[10]

”I will not accuse the medical art of the avarice even of its professors, the rapacious bargains made with their patients while their fate is trembling in the balance, …”

The fees charged were on a sliding scale according to assets. The physicians of the rich were themselves rich. For example, Antonius Musa treated Augustus’ nervous symptoms with cold baths and drugs. He was not only set free but he became Augustus’ physician. He received a salary of 300,000 sesterces.[11] There is no evidence that he was other than a private physician; that is, he was not working for the Roman government.

Legal responsibility

Doctors were generally exempt from prosecution for their mistakes. Some writers complain of legal murder. However, holding the powerful up to exorbitant fees ran the risk of retaliation. Pliny reports [12] that the emperor Claudius fined a physician, Alcon, 180 million sesterces and exiled him to Gaul, but that on his return he made the money back in just a few years. Pliny does not say why the physician was exiled, but the blow against the man was struck on his pocketbook. He could make no such income in Gaul.

This immunity applied only to mistakes made in the treatment of free men. By chance a law existed at Rome, the Lex Aquilia[13], passed about 286 BCE, which allowed the owners of slaves and animals to seek remedies for damage to their property, either malicious or negligent. Litigants used this law to proceed against the negligence of medici, such as the performance of an operation on a slave by an untrained surgeon resulting in death or other damage.

Social position

While encouraging and supporting the public and private practice of medicine, the Roman government tended to suppress organizations of medici in society. The constitution provided for the formation of occupational collegia, or guilds. The consuls and the emperors treated these ambivalently. Sometime they were permitted; more often they were made illegal and were suppressed. The medici formed collegia, which had their own centers, the Scholae Medicorum, but they never amounted to a significant social force. They were regarded as subversive along with all the other collegia.

Doctors were nevertheless very influential. They liked to write. Compared to the number of books written, not many have survived; for example, Tiberius Claudius Menecrates composed 150 medical works, of which only a few fragments remain. Some that did remain almost in entirety are the works of Galen, Celsus, Hippocrates and the herbal expert, Pedanius Dioscorides. The Natural History (Naturalis Historia, typically abbreviated to NH) of Pliny the Elder became a paradigm for all subsequent works like it and gave its name to the topic, although Pliny was not a physician himself.

Military medical corps

Republican

The state of the military medical corps before Augustus is unclear. Corpsmen certainly existed at least for the administration of first aid and were enlisted soldiers rather than

civilians. The commander of the legion was held responsible for removing the wounded from the field and insuring that they got sufficient care and time to recover. He could quarter troops in private domiciles if he thought necessary. Authors who have written of Roman military activities before Augustus, such as Livy, mention that wounded troops retired to population centers to recover.

Imperial

The army of the early empire was sharply and qualitatively different. Augustus defined a permanent professional army by setting the enlistment at 16 years (with an additional 4 for reserve obligations), and establishing a special military fund, the aerarium militare, imposing a 5% inheritance tax and 1% auction sales tax to pay for it. From it came bonus payments to retiring soldiers amounting to several years’ salary. It could also have been used to guarantee regular pay. Previously legions had to rely on booty.

If military careers were now possible, so were careers for military specialists, such as medici. Under Augustus for the first time occupational names of officers and functions began to appear in inscriptions. The valetudinaria, or military versions of the aesculapia (the names mean the same thing) became features of permanent camps. Caches of surgical instruments have been found in some of them. From this indirect evidence it is possible to conclude to the formation of an otherwise unknown permanent medical corps.

In the early empire one finds milites medici who were immunes (“exempt”) from other duties. Some were staff of the hospital, which Pseudo-Hyginus mentions[14] as being set apart from other buildings so that the patients can rest. The hospital administrator was an optio valetudinarii. The orderlies aren’t generally mentioned, but they must have existed, as the patients needed care and the doctors had more important duties. Perhaps they were servile or civilians, not worth mentioning. There were some noscomi, male nurses not in the army. Or, they could have been the milites medici. The latter term might be any military medic or it might be orderlies detailed from the legion. There were also medici castrorum. Not enough information survives in the sources to say for certain what distinctions existed, if any.

The army of Augustus featured a standardized officer corps, described by Vegetius. Among them were the Ordinarii, the officers of an Ordo or rank. In an acies triplex there were three such ordines, the centuries (companies) of which were commanded by centurions. The Ordinarii were therefore of the rank of a centurion but did not necessarily command one if they were staff.

The term medici ordinarii in the inscriptions must refer to the lowest ranking military physicians. No doctor was in any sense “ordinary”. They were to be feared and respected, just as they are today. During his reign, Augustus finally conferred the dignitas equestris, or social rank of knight, on all physicians, public or private. They were then full citizens (in case there were any Hellenic questions) and could wear the rings of knights. In the army there was at least one other rank of physician, the medicus duplicarius, “medic at

double pay”, and, as the legion had milites sesquiplicarii, "soldiers at 1.5 pay", perhaps the medics had that pay grade as well.

Augustan posts were named according to a formula containing the name of the rank and the unit commanded in the genitive case; e.g., the commander of a legion, who was a legate; that is, an officer appointed by the emperor, was the legatus legionis, “the legate of the legion.” Those posts worked pretty much as today; a man on his way up the cursus honorum (“ladder of offices”, roughly) would command a legion for a certain term and then move on.

The posts of medicus legionis and a medicus cohortis were most likely to be commanders of the medici of the legion and its cohorts. They were all under the praetor or camp commander, who might be the legatus but more often was under the legatus himself. There was, then, a medical corps associated with each camp. The cavalry alae (“wings”) and the larger ships all had their medical officers, the medici alarum and the medici triremis respectively.

Practice

As far as can be determined, the medical corps in battle worked as follows. Trajan's Column depicts medics on the battlefield bandaging soldiers. They were located just behind the standards; i.e., near the field headquarters. This must have been a field aid station, not necessarily the first, as the soldiers or corpsmen among the soldiers would have administered first aid before carrying their wounded comrades to the station. Some soldiers were designated to ride along the line on a horse picking up the wounded. They were paid by the number of men they rescued. Bandaging was performed by capsarii, who carried bandages (fascia) in their capsae, or bags.

From the aid station the wounded went by horse-drawn ambulance to other locations, ultimately to the camp hospitals in the area. There they were seen by the medici vulnerarii, or surgeons, the main type of military doctor. They were given a bed in the hospital if they needed it and one was available. The larger hospitals could administer 400-500 beds. If these were insufficient the camp commander probably utilized civilian facilities in the region or quartered them in the vici, “villages”, as in the republic.

A base hospital was quadrangular with barracks-like wards surrounding a central courtyard. On the outside of the quadrangle were private rooms for the patients. Although unacquainted with bacteria, Roman medical doctors knew about contagion and did their best to prevent it. Rooms were isolated, running water carried the waste away, and the drinking and washing water was tapped up the slope from the latrines.

Within the hospital were operating rooms, kitchens, baths, a dispensary, latrines, a mortuary and herb gardens, as doctors relied heavily on herbs for drugs. The medici could treat any wound received in battle, as long as the patient was alive. They operated or otherwise treated with scalpels, hooks, levers, drills, probes, forceps, catheters and arrow-extractors on patients anesthetized with morphine (poppy extract) and scopolamine

(henbane extract). Instruments were boiled before use. Wounds were washed in vinegar and stitched. Broken bones were placed in traction. There is, however, evidence of wider concerns. A vaginal speculum suggests gynecology was practiced, and an anal speculum implies knowledge that the size and condition of internal organs accessible through the orifices was an indication of health. They could extract eye cataracts with a special needle. Operating room amphitheaters indicate that medical education was ongoing. Many have proposed that the knowledge and practices of the medici were not exceeded until the 20th century CE.