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The Best Medicine

By Richard A. Gabriel
11/1/2017 • Military History Magazine

Death came slowly to soldiers wounded on the battlefields of antiquity. The muscle-powered weapons that hacked at their flesh only rarely inflicted sudden death. Bodies pierced by spears or slashed by swords lingered in agony, sometimes for hours, until the loss of blood brought on shock, convulsions and, finally, the unconsciousness that precedes death. That was the way it was from the beginning of warfare until modern times—with one surprising exception. In the Roman army wounded soldiers had a good chance to recover and live.

Emperor Augustus (63 BC–AD 14) established history’s first professional military medical corps following the 14-year power struggle sparked by the 44 BC assassination of his great-uncle Gaius Julius Caesar. Until then Roman casualties relied on whatever ad hoc arrangements their commanding generals made for them. Some, like Caesar, had physicians accompany the army. Others did nothing, leaving the wounded to whatever care their fellow soldiers could provide. Augustus realized that to maintain troop strength and morale in the professional army he established, he would have to provide soldiers with adequate medical care. The medical corps he organized was extraordinarily proficient, its ability to treat wounds, infection and disease unsurpassed until the end of the 19th century.

Good medical care starts with good doctors. To attract physicians to military service, Augustus conferred the status of knights (dignitas equestris) and the rights of full citizenship upon those who joined. They received the pensions and land grants that came with military retirement and were exempt from certain taxes. Many of the physicians were Greeks trained in the empirical practice of medicine, an approach that came to characterize the Roman medical corps.

Most of the major medical innovations made during Rome’s imperial period originated with serving or former military physicians. Later the army established schools to train doctors and even published its own medical books. These manuals standardized medical care for soldiers and ensured the rapid dissemination of new treatments.

Roman military medicine stood on a firm foundation: Only the healthiest recruits were permitted to join the army, and as disease had killed thousands of troops during Rome’s earlier conflicts, physicians sought to minimize noncombat losses through an emphasis on hygiene that sounds remarkably modern: systematic use of sewers in military encampments; safe water supplies; healthy and varied meals; regular health inspections; preventive-health measures such as mosquito netting and sunburn oil; cremation of the dead outside the camp walls; covered latrines; and an emphasis on personal cleanliness for the soldier, his clothes and his equipment. Not surprising, despite long service in wars and other arduous and dangerous activities, Roman soldiers lived nearly five years longer than the average Roman citizen.

The greatest achievement of Roman military medicine was the provision of immediate field care by medical personnel incorporated into each legion. By the 1st century even educated physicians were required to undertake the army’s standard training regimen for military medical personnel. No Western army took on the training of its own physicians again until 1865.

So important was military medicine that the commander of the medical service was the praefectus castrorum (camp prefect), the third-most senior commander of the legion. The legion’s medicus primus (chief medical officer) was a trained physician who entered military service for a specified period of duty. Other medici received training in the army and served full 25-year careers. One of these, C. Papirius Aelianus, remained on active duty until his death at age 85.

Physicians often specialized in such disciplines as internal medicine, ophthalmology and urology. Surgeons were considered the legion’s most valuable medical assets, followed closely by medici ordinarii, regular soldiers trained to assist physicians. Providing field care during combat—itself a major innovation— were special squads of capsarii (literally, bandagers), who wore the same gear as soldiers. Their job was to quickly attend the wounded and provide care until such soldiers could be transported to a field hospital for treatment by a physician; each legion had special units of horses, wagons, carriages and stretcher bearers for that purpose. The Romans’ establishment of field hospitals, supported by medics and an ambulance corps, is the first recorded instance of the modern-day principle of immediacy—treating the wounded as quickly and as close to the battlefield as possible. Roman doctors also practiced the second principle of modern military medicine, triage—the separation of casualties according to the severity of their wounds and the evacuation and treatment of the least severely wounded first. Another goal of the Roman medical corps was to salvage and return to duty as many wounded soldiers as possible. This principle of expectancy also remains a central premise of military medicine. On average the Roman medical corps saved the lives of 70 percent of the wounded that reached the field hospital, a survival rate not equaled until the 1904–05 Russo-Japanese War.

The medical service was present at every level of the Roman military. Each legion had its own physician and staff. Cavalry and infantry battalions had their own medical officers and support staffs, as did irregular units. The navy, too, had a regular medical corps, with a doctor and staff assigned to each ship of the fleet. Unlike soldiers, who normally spent their careers in a single legion, physicians transferred among legions, making it possible to ensure medical support wherever the need was greatest.

An assessment of medical knowledge available to  Roman military surgeons relies upon the work of Aulus Cornelius Celsus (c. 14–37), himself a former combat physician. His treatise De Medicina records almost every aspect of Roman medical practice and is the only complete medical text that has survived from antiquity.

The Romans had no religious strictures against dissection, and the cadavers of criminals, gladiators and condemned prisoners provided physicians with a knowledge of human anatomy far better than in any other ancient society. Knowledge of the circulatory system, for instance, allowed physicians to locate blood vessels and deal accurately with severed veins and arteries.

This knowledge would have been useless, however, without two other Roman medical innovations: the hemostatic tourniquet to stem massive blood flow, and the arterial surgical clamp to close arteries for suturing. These implements permitted surgeons to stop bleeding and prevent shock, the two primary killers of the wounded in ancient battles. They also allowed Roman surgeons to raise amputation to a high art. Celsus was the first physician to suggest amputation through live tissue and to use a rasp to smooth the bone prior to closure. Archigenes was the first to perform amputation by identifying and tying off major blood vessels before completing the amputation. The ability to amputate gangrenous or otherwise infected limbs saved a great number of lives.

Roman military physicians used a variety of drugs to ease the pain of battlefield surgery. They regularly used lotions made from the opium poppy and henbane. Henbane seeds contain scopolamine, a compound still in use today as a preanesthetic. Pliny the Elder records the use of white mandrake, the root of which yields hyoscine and atropine, both of which are modern surgical drugs. Though these compounds probably eased pain considerably, as with all surgery until the introduction of anesthesia in 1846, the surgeon’s skill and speed remained critical.

Roman surgical skill was reflected in the quality and innovation of their surgical instruments. For one, the arrow extractor, a kind of hollow spoon that eased the removal of embedded arrowheads, was an enormous advance in battlefield surgery. At the heart of the surgeon’s instrumentarium were the various types of scalpels with replaceable blades. Roman physicians also invented several types of surgical forceps, including those with ring slides and rifled inner faces, allowing the instrument to be locked in place with one hand. Surgeons opened wound edges with another surgical innovation, the retractor, and closed with fibulae, something like modern surgical pins. These Roman surgical instruments were far more sophisticated than any available to surgeons in the West until at least the 18th century. Unfortunately, with the empire’s collapse, many such innovative devices were lost to medical practice for centuries.

If a physician did manage to save a wounded soldier from blood loss and shock, the next task was to prevent infection. As late as the mid–19th century the mortality rate for those undergoing surgery in hospitals was often higher than 50 percent. Only after the introduction of antisepsis in 1867 did this figure decline. Celsus devoted an entire chapter of his medical manual to infection and was the first physician to describe its clinical symptoms and progress in his famous formula (still taught to medical students today) that infection was recognized by rubor et tumor cum calore et dolore (“redness and swelling with heat and pain”).

It was standard Roman surgical practice to clean instruments in hot water before use, another important practice the West did not rediscover until the late 19th century. Roman doctors never used the same probe on more than one patient, an important clinical practice that helped avoid surgical contamination. Roman wound washes, especially acetum (a form of wine almost turned to vinegar), were more effective than the carbolic acid method promoted by 19th century English surgeon Joseph Lister. The use of barbarum, a powerful antiseptic compound that modern experiments have proven effective for treating deep flesh wounds, also reduced infection rates.

The Roman practice of removing decayed or foreign matter from the wound before and after repeated cleansing helped reduce the rate of tetanus and gangrene, as did loose bandaging, regular bandage changes and the use of surgical clips instead of sutures to close wounds. The use of lint and honey, an old Egyptian wound dressing, was particularly effective, as honey was the most powerful and effective known bactericide until the 1928 discovery of penicilin.

Roman medical skills extended even beyond these procedures. Plutarch recorded the surgical skill of Cleanthes, a military surgeon who treated a soldier’s lower chest wound by replacing the spilled entrails, stopping the hemorrhage, and stitching and bandaging the wound. Physicians didn’t even attempt that level of surgery again until the 18th century.

The high survival rates for wounded Roman soldiers meant that many then needed short-term  and/or convalescent care. During campaigns, before the Romans built permanent forts, physicians provided such care in tents arranged in an open rectangle. When the Romans did build permanent medical facilities, they retained the same configuration. A Roman military hospital was called a valetudinarium. Overseeing it was a chief medical officer, the optio valetudinari, who reported directly to the legion’s praefectus castrorum. The plan of these hospitals reflected a level of medical sophistication not seen before in the ancient world and not seen again in the West for centuries. The entrance opened into a large hall lighted by clerestory windows, used as a triage center when dealing with mass casualties. Beyond this hall was an operating theater, also lighted by multiple windows. Adjacent to the surgical theater was a hearth room for the sterilization of instruments and dressings. The east side of the hospital contained the kitchen and pantries that provided special diets for convalescing soldiers. The western outer wing contained baths, dressing rooms and lavatories. Three wings comprised the wards, with small cubicles arranged in pairs on either side of a wide corridor —a common floorplan in modern-day hospitals. Small side corridors separated the rooms from the main corridor, reducing noise and lessening the risk of contagion. Hospital staff set aside a few rooms for patients requiring isolation. Other areas housed examination rooms and the hospital mortuary. The roof was designed to provide adequate cooling and ventilation, and a central heating plant insured adequate warmth. Each legion hospital was constructed to accommodate 5 to 10 percent of a legion’s strength, or 250 to 500 casualties.

Pedanius Dioscorides, a 1st century Roman military physician, was the most famous pharmacologist of antiquity and the author of De Materia Medica, the ancient world’s largest compendium of herbal and chemical remedies. The standard work for more than a millennium, it is still read today. Incorporation of most of the “known world” into the Roman Empire expanded the store of clinical knowledge upon which physicians could draw for new drugs and medical techniques. Roman medicine borrowed Indian surgical techniques, including plastic surgery and cataract removal. And so many drugs came from India that Pliny complained about it in his writings.

Roman military medicine was successful because Roman physicians possessed the highest level of medical knowledge and skill in the ancient world. But without the organizational genius to create a permanent medical service within the legions, to train adequate numbers of doctors and other medical personnel to deliver rapid, effective care to the wounded, Roman medical knowledge would have had far less impact on combat survival rates than it did.

Roman pragmatism, unfettered by traditional religious strictures, placed a premium upon medical inventiveness and emphasized what worked. Thus the Romans developed medical innovations that in more conservative cultures would have been impossible. Their military physicians never lost sight of the goal of reaching wounded troops as quickly as possible and saving as many as possible. Anything that hindered that goal was rejected.

Medical science progressed greatly under the Roman army’s systematic approach and myriad innovations. But, tragically, with the fall of the empire the great medical legacy that was Rome’s vanished into a dark age, not to be rediscovered until the modern era.

 

For further reading Richard A. Gabriel recommends his and Karen S. Metz’s two-volume A History of Military Medicine (1992), and his forthcoming Man and Wound in the Ancient World (Potomac Books, September 2011).

Originally published in the July 2011 issue of Military History. To subscribe, click here

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