CHAPTER 14
CHRISTINE F. SALAZAR
BATTLE wounds have been an inevitable consequence of warfare in any historical period, and one that is reflected in the medicine of its time. The frequency of armed conflict and the nature of warfare (at least in classical Greece and early Republican Rome with their citizen armies) meant that for most men in antiquity being wounded was a distinct probability. At the same time, any Greek or Roman doctor was likely to be called upon to treat war wounds on some occasion during his life, and he had to know how to do so, especially since specialization was not common until late antiquity, and doctors had to be able to deal with all emergencies. Conversely, treating those who had been wounded in combat was also a way of acquiring medical knowledge, especially of anatomy and physiology, and of developing new surgical techniques.
As far as the medical aspect is concerned, there was little difference between Greek and Roman wound treatment (allowing for the increased knowledge of anatomy from the Hellenistic period onward). Most Roman medicine, and surgery in particular, as it appears in our sources, was in fact Greek medicine, and therefore it seems legitimate not to discuss wound treatment in Greece and Rome separately.
SOURCES
An extraordinary variety of sources yields information about wounds and wound treatment in antiquity. The most obvious are of course medical authors, beginning with the so-called Hippocratic Corpus, a collection of anonymous medical writings spanning the fifth to approximately the third centuries B.C.1 Wound treatment in general is mentioned in several of the roughly seventy works, in particular Wounds in the Head (VC), Epidemics (Epid.) 5 and 7, Diseases (Morb.), Prorrhetics (Prorrh.) 2, the Aphorisms (Aph.),On Wounds (also translated as On Ulcers; Ulc.), In the Surgery (Off.), Fractures (Fract.), and The Physician (Medic.). Of these, only the case histories in Epidemics 5 and 7 deal with what are unambiguously battle wounds. Tantalizingly, there are references in later sources to a lost treatise about the treatment of war wounds, perhaps called On Wounds and Arrows (or two treatises with similar titles; for more details, see Salazar 1997).
Numerous wound remedies can be found in the work On Materia Medica by Pedanius Dioscorides (who may have been a Roman army doctor), written in the first century A.D., at approximately the same time as the earliest extant Roman medical treatise, Aulus Cornelius Celsus’s On Medicine (the only surviving part of his encyclopedia). Celsus, an upper-class Roman, certainly did not practice medicine professionally, but he appears to have had hands-on experience of medical treatment. Book 7, on surgery, contains one of only two detailed passages about the treatment of arrow wounds to have come down to us from antiquity, and is presumably based on Greek material that was available to Celsus but is now lost. Although Pliny the Elder, who died at the eruption of Vesuvius inA.D. 79, was not a “medical” writer, his Natural History also contains a large amount of medical information, especially on remedies.
The most prolific medical writer of antiquity, Galen, was born in Pergamum in Asia Minor circa A.D. 129, and eventually became physician to the emperor Marcus Aurelius. He stands out among ancient medical authors not only by the bulk (twenty-two volumes in the nineteenth-century Kühn edition with Latin translation) and the literary quality of his writings, but also by their strong individual flavor (compared to the rather impersonal style of most others) and the wealth of biographical information he inserts at every turn, along with rants against colleagues or predecessors. Thus Galen also tells his readers that, when still only twenty-nine, he was appointed doctor to the gladiators at Pergamum, a prestigious post, which he retained for five seasons and which would have given him great expertise in the treatment of wounds. Although he appears never to have written a work entirely dedicated to surgery or wounds, relevant details appear in many of his works, and he specifically cites the treatment of arrow wounds as a reason why it is important to have a thorough knowledge of anatomy (Anatomical Procedures/De Anat. Admin. 3/3.345 K.).
Although the work is small in volume, the Medical Questions (Quaest. Med.) by the second-century author Rufus of Ephesus conveys some valuable information about medical practice. The passages at 50f. and 55–62 are particularly relevant, dealing with arrow wounds and head wounds respectively. Two lost works by Rufus, On Wound Remedies and On Wounds of the Joints, presumably contained more about the topic.
Among the medical writers of late antiquity and the early Byzantine period, one ought to mention Oribasius (fourth century), the friend and court physician of the emperor Julian, as well as Aetius of Amida (sixth century). Paul of Aegina (seventh century) is a very late source as far as ancient medicine is concerned, but he makes extensive use of earlier authors, preserving excerpts from writings that are otherwise lost. His medical handbook—perhaps called Pragmateia (one of several words for “treatise”)—contains the only detailed chapter on the treatment of arrow wounds to survive in Greek, which may be based on the lost Hippocratic work (see Salazar 1998b for a translation of the entire chapter).
Figure 14.1 Achilles binding Patroclus’s wounds (a scene not featured in the Iliad as we have it). A red figure drinking cup from Vulci, c. 500 B.C. Signed by Sosias (potter). INV: F2278. Photo: bpk, Berlin, Staatliche Museen/Johannes Laurentius/Art Resource, NY.
While medical writings would be the first category to come to mind, they are by no means the only one, and literary texts, too, are a rich source of references to wound treatment. Doubtless the most important non-medical source is the Iliad, which abounds not only in realistic descriptions of death and wounding, but also in scenes of wound treatment that show considerable medical knowledge (figure 14.1). The amount of medical detail is such that it has even been suggested that Homer was an army surgeon (Frölich 1879:64).
The historians writing about Alexander the Great (in particular Plutarch, Arrian, and Quintus Curtius), who often present his life in Homeric terms, form another important group of authors. Alexander was wounded several times, and some of the descriptions go into great detail about his wounds and their treatment.
Given the constant presence of war in the ancient world, and with it the possibility of being wounded, it is not surprising that mentions of wounds can be found in just about any genre of literature, be it historiography (Herodotus, Xenophon, Polybius, Dionysius of Halicarnassus, Cassius Dio, Ammianus Marcellinus, etc.), philosophy (Plato, Aristotle, Seneca, Cicero), epic poetry modeled on Homer (Virgil, Quintus Smyrnaeus, Nonnus, etc.), tragedy (Sophocles), or even comedy (Aristophanes, Menander, Plautus). A certain amount of medical knowledge could be expected among the educated elites. In addition, the military writers (Aeneas Tacticus, Philo, Vegetius, etc.) deal with issues arising from the presence of casualties or the prevention of disease, and inscriptions or papyri also contain useful information. Archaeological finds, especially of weapons, surgical instruments, and even artistic representations of wounded warriors, can provide further insights.2
TYPES OF WOUNDS
The treatment to be given depended on the nature of the wounds that the doctor would encounter. These were in turn determined by the weapons used and by the armor that the combatants wore. (For details about arms, armor, and weapons see further Jarva and Campbell, 395–418, 419–37.) The majority of wounds—made by swords, spears, javelins, or arrows—would have been to the arms and legs, which were exposed whatever the armor (with the exception of the scale armor of late-antique cataphract cavalry). The left arm was usually protected by the shield, and the heavily armed hoplite infantry wore greaves, leaving the right arm (when not in close phalanx formation) and the thighs as the easiest targets. It was common empirical knowledge that simple flesh wounds were the least dangerous—that is, wounds that were not too deep and did not involve major blood vessels or any of the structures covered by the Greek word tenon. This is one of many terms in Greek medicine that defy translation and that cannot be translated by any one English word. The meaning of tenon fluctuates between “tendon,” “sinew,” and “nerve,” so a wound to it was potentially disabling.
A wound deep enough to reach the bone was considered even more serious. This may not have happened very frequently with sword wounds, but spears (either in hand-to-hand fighting or hurled from a distance) and arrows easily had sufficient impact to penetrate as far as the bone (cf. Paul 6.88 or Procop. Goth. 6.1.26f., where an arrow grazes the tibia). Battle axes like those wielded by Amazons on Greek vase paintings (presumably based on weapons actually used in the Near East) and by the Dacians on Trajan’s Column were also likely to injure bones or even sever them. What we do not find in ancient sources are descriptions of bone-shattering wounds; these become common after the introduction of firearms.
The most dangerous—and again this was clear to medical as well as non-medical writers—were head, chest, and abdominal wounds. Bronze helmets gave reasonable protection, but they could be cracked by the force of a heavy blow, for example, a sword cut coming from above, and they were not worn by the majority of soldiers. The more lightly armed troops (e.g., peltasts or archers) were more likely to be wearing leather caps or no head protection at all.
Even though the cranium might be protected, every type of helmet left part of the face, and certainly the eyes, exposed. Surprisingly, eye wounds were not invariably fatal: there are many references to men losing an eye in battle and surviving the injury, for instance at Hdt. 3.78.2 or, more famously, the case of Philip of Macedon, shot in the eye at the siege of Methone in 353 B.C. (Diod. 16.34). In the case described at Epid. 5.49/5.236 K. L., the arrow that has struck a man’s eye is removed and he recovers without losing the eye. (The passage does not make it clear, though, whether he also retains his eyesight.)
Blows with blunt objects, or stones shot by slingers or catapults, could also cause head injuries, especially cranial fractures (although these forms of trauma could occur also in a civilian context). VC 4–8/3.194–210 K. L., and Paul 6.90 distinguish between five or six types of head injuries respectively, showing great wariness of the concomitant dangers.
Together with head wounds, the most likely to be fatal were penetrating chest and abdominal wounds, in particular those made by spears or arrows. Given sufficient strength of impact, even body armor was no reliable protection: Alexander the Great, whose armor must have been of the highest quality, sustained a near-fatal wound when an arrow pierced his breastplate in India in 326 B.C. (e.g., Arr. Anab. 6.10.1–11.2). The Theban general Epaminondas survived a spear wound to the chest in his youth (Plut. Pel. 4.5), and then died of a similar wound at the battle of Mantinea. Survival after chest wounds was obviously not unheard of, and there is evidence for the long-term consequences in Morb. 1.21/6.180 L., where the author describes empyema, that is, a collection of pus in the chest, resulting from spear, dagger, or arrow wounds having healed only on the surface. One of the miracles described in the Epidaurian iamata inscriptions tells of Gorgias, who comes to be healed by Asclepius, with the arrowhead still in his chest a year and a half after being wounded, and with the wound having become chronically purulent (LiDonnici 1995: 30).
In the case of large gashes to the abdomen, there was the additional problem of intestines prolapsing through the wound. In Galen’s discussion of wounds that he treated when in charge of the gladiators at Pergamum—in On the Method of Healing (MM/10.410–23 K.)—he also describes how to reposition the intestines and suture the wound. Although these wounds were dangerous, they were not considered necessarily fatal.
In all the different categories of wounds, the presence of foreign bodies—arrows, javelins, spears, and the lead bullets, stones, or shells used by slingers—was an aggravating factor. This clearly made the treatment a job for a well-trained surgeon, who also needed to have the necessary instruments.
Along with these typical battle wounds, the same injuries as in civilian life would of course also have occurred in an army, as would illness, especially if the fighting continued over a long period. On the campaigns of Alexander the Great, for example, battle wounds will have accounted for only a small percentage of casualties and fatalities. The majority would have been caused by accidents, drowning, heat, dehydration, malnutrition, hypothermia, exhaustion, snakebite and various diseases (fevers, typhoid, eye infections, etc.). However, treatment for these cases was not in any way specific to war or to armies, so I shall be concentrating on war wounds for the purpose of this chapter.
Brief mention should also be made of an issue that has only come to be acknowledged (reluctantly) in recent conflicts, namely the psychological impact of warfare. It would of course be unwise to look for modern nosological categories in ancient medicine, and no Greek or Roman author ever suggests a link between psychological problems and the experience of battle. However, some stories found in ancient authors, such as Alexander the Great’s killing of his friend Cleitus in a sudden rage (e.g. Arr. Anab. 4.8) or the spontaneous blindness of Epizelus amid the carnage of Marathon (Hdt. 6.117) show great similarity with modern accounts of PTSD.3
DIAGNOSIS AND PROGNOSIS
Greek and Roman medical writers stress the importance of making a correct diagnosis and, based on it, an accurate prognosis. In the absence of any kind of official medical qualifications, these skills were useful tools for winning a patient’s trust, especially if the doctor had not yet made a reputation for himself. In a military setting, there was a more immediate motivation for getting the prognosis right. In a scenario where there were many casualties after a battle, the number of available doctors was bound to be insufficient, and efficient triage was paramount. Surgeons could not afford to waste time treating fatally wounded soldiers, perhaps depriving others of their chance of being seen to in time. It is not surprising, therefore, that several authors provide lists of fatal and life-threatening wounds.4 These lists are based on empirical knowledge, and although there are slight divergences, the authors largely agree, in particular on the brain, the heart, the liver, the bladder, and large blood vessels (presumably arteries). VC19/3.250–54 L. also describes the signs of approaching death from head wounds. Along with knowing which of the wounded were likely to live, it was also useful for the doctor to be able to prognosticate on loss of function or disablement resulting from a wound (cf. Prorrh. 2.15/9.40f. L or Art. 9/4.100 L.).
A further reason why prognosis was important was that it was a means of avoiding blame if the treatment was unsuccessful or ended in death, and various authors state this fact unabashedly. According to Celsus (5.26.1.C), “it becomes a prudent man first not to touch one who cannot be saved, and not to appear to …have killed one whom his own fate has destroyed.” Paul (6.88.5) explains the reason for refusing treatment even more bluntly as “so that we do not, in addition to being of no help, offer the laymen an excuse for reproach.” When death is not certain, both advocate taking on the treatment, having first warned the patient or those around him. Where the casualty was a king or a general, it could be more than the doctor’s reputation that was at stake. When Alexander’s friend Hephaestion died of an illness in Ecbatana, Alexander had his doctor executed (hanged in Arr. Anab. 7.14.4, or crucified according to Plut. Alex. 72.2). In the light of this risk, the hesitation of Alexander’s doctors to treat him on the occasions of his illness before the battle of Issus (a detail mentioned by all the Alexander historians with the exception of Diodorus Siculus) and of his most serious wound (Curt. 9.5.25–27) may be more than a narrative device.
TREATMENT
Treatment obviously varied a great deal according to the type and gravity of the wound. Many wounds needed only cleaning, usually with water. This gesture appears as early as the Iliad, where Patroclus washes Eurypylus’s wound with “luke-warm water” (11.846). Larger or more serious wounds necessitated more extensive pharmacological and/or surgical treatment.
With any major wound, the greatest immediate danger is from hemorrhage, and it was common knowledge that unchecked bleeding could kill very quickly. Therefore hemostasis was an urgent concern; detailed instructions can be found, for example, in Galen (MM 2.1–7/10.318f. K.), Celsus (5.26.21), and Paul (6.53). They variously recommend raising the limb, applying pressure (with a dry dressing) or cold water, pulling up and twisting the bleeding vessel with a hook, applying styptic substances, or cauterizing the wound with caustic substances or a red-hot cautery. The doctor could also ligate the blood vessel in two places and then cut it between the ligatures (this was not done before the Hellenistic period). More surprisingly, from a modern point of view, it was also believed (e.g., Celsus 5.26.21.C) that phlebotomy or cupping on a different part of the body would divert the blood flow. While these measures were aimed at stopping excessive bleeding, too little was also considered dangerous. According to Celsus (5.26.22), blood should be let from the patient’s arm if there had been less bleeding than one would expect.
As head wounds required a very specialized approach and were also potentially fatal, it is not surprising that an entire treatise in the Hippocratic Corpus (VC) is dedicated to them. Celsus (8.4), Rufus (Quaest. Med. 55), and Paul (6.90) also list the symptoms of cranial fractures, which in absence of modern diagnostic means were difficult to recognize. (The author of Epid. 5 admits at 27/5.226 L. that he once failed to do so.) If a fracture was suspected, one way of verifying was to pour writing ink (Paul 6.90.3) onto the skull and scrape the bone on the subsequent days. If the black line indicating the crack in the bone did not disappear, it was a case for trepanning. This meant removing part of the cranium by means of chisels, drilling, or a crown trepan (i.e., a circular saw). Although this was a dangerous operation, it appears that a considerable number of patients survived it.
One of the most demanding tasks for an army surgeon was the extraction or excision of a missile. This is also the activity that defines medical treatment in the Iliad, in the much-quoted verse (11.514f.): “For a physician is a man worth many others, for cutting out arrows and applying soothing remedies.” Given that most ancient armies had contingents of archers, and arrow wounds were frequent, it is surprising that in extant medical literature there are only two step-by-step instructions (Celsus 7.5 and Paul 6.88.3–9) for removing an arrow. (On the other hand, it should perhaps surprise us that there are any, since these skills would have been passed on by apprenticeship rather than by books.) Judging from archaeological finds, a large percentage of arrowheads used in war were barbed in order to make them harder to extract. Paul (6.88.2) and Cassius Dio (36.5) also mention arrowheads with separate pieces of metal attached to them, which would stay behind in the wound and cause complications, as well as poisoned arrows.
When a man was hit by an arrow, his first impulse was often to pull it out himself or to ask a comrade to do so, as we see in the Iliad (e.g., 5.112 or 13.598). Rufus (Quaest. Med. 51) warns that the soldiers must be told to wait until they can have the arrows removed by an expert. Apparently it could happen quite easily, “even to an altogether experienced man” (Quaest. Med. 51), to pull out only the shaft and leave the arrowhead behind. (This happens to the doctor in Epid. 5.95/5.254 L.) In most cases the surgeon had to probe (figure 14.2) the wound to obtain more information about its depth or direction, whether the arrow was barbed, whether it had struck a bone, and—if the shaft was no longer attached—whether the arrowhead ended in a tang or in a socket.5 If no bone was involved, the arrow (or arrowhead) could be withdrawn by grasping it with the fingers or with a forceps (figure 14.3), having made a preliminary incision where necessary. Celsus also describes an arrow scoop called the “spoon of Diocles,” but it sounds impractical and is not mentioned by any other writer. If the arrow was stuck in a bone and would not respond to traction, the bone had to be scraped, drilled into, or excised. If an arrow had almost pierced a limb, it could alternatively be removed through a counter-opening in a technique called diosmos (literally “pushing through”). Slingers’ bullets could also produce deep, narrow wounds. Having located the missile by probing, the surgeon then had to enlarge the wound by cutting, and lift out the object with the fingers, a spoon probe, a forceps, or a lever.
Figure 14.2 Roman probe excavated in London (1st–5th centuries A.D.). One end is an “olivary” probe (purênomêlê), the other a “spoon probe” (kuathiskomele). Science Museum, London: A63490. © Wellcome Images.
Figure 14.3 Roman forceps, perhaps a “root forceps” (rhizagra) or a “bone forceps” (ostragra), from Pompeii. National Museum, Naples. This image is © Wellcome Images, but has been altered into a Derivative Work by C. Salazar by clipping.
Large, gaping wounds were sutured, usually with flax or linen thread, but Celsus (5.26.23.B) distinguishes between this sutura and what he calls fibulae, which appear to have involved some kind of metal pin. Both he (7.16.4f.) and Galen (MM 6/10.415f. K.) describe abdominal suture separately (in Celsus’s case a two-handed technique).
Wound dressings could be linen bandages or sponges, either dry or soaked in water, vinegar, wine or oil, or wool, which could be either greasy (supposed to keep the wound warm) or washed. A moist dressing would often be covered in fresh leaves to stop it from drying out.
While only the most serious wounds needed surgery, pharmacological treatment of some kind was usual for nearly all wounds. Wound remedies, which can be found in many medical writings, ranged from single plants or mineral substances to composite drugs with complex recipes.6 The Hippocratic Corpus does not contain many such remedies, with the exception of a list in Ulc. (11/6.410 26 L.), but their number increases rapidly in later writings, for example, Dioscorides, Galen, Oribasius, Aetius, and Paul. Pliny, too, lists the medicinal qualities of many substances. The remedies were usually divided into various categories, and a widespread system was to classify them by their properties. The three most commonly mentioned groups are styptics, agglutinants, and anti-inflammatory drugs—although there was no general consensus on the properties of individual pharmaka.
The term styptic (styptikon), like ischaimon and similar expressions, refers to substances that would staunch the bleeding from a wound, but it covers a wider semantic range. It could also mean a remedy against internal hemorrhage, excessive menstruation, or even diarrhea, so it is often difficult to know which pharmaka were specifically intended for wounds—if the Greeks made that distinction. Among the styptics are charred oak gall extinguished with vinegar, spider’s web, or frankincense. The agglutinants (kolletika) were substances supposed to make wounds “stick together,” that is, to promote wound healing. Some examples are bitumen, oak leaves, or egg white, all applied externally.
As one of the stages of wound healing, inflammation was an expected and natural process, as long as it was not too severe or too prolonged, and a range of aphlegmanta was used to control it. These included verdigris, celery, and achilleion (Achilles’s wound wort? With many plants mentioned by ancient authors, identification is problematic.). One also finds remedies for the more dangerous complications that could arise, such as sepsis, gangrene, or tetanos (not necessarily what we mean by tetanus). As a certain amount of suppuration was considered a necessary part of the cleansing process—not surprisingly in a preantiseptic age—there were also drugs that promoted the production of “good pus,” the pyopoïka or kathartika, for example, lard or pitch.
However, no internal (and hardly any external) analgesics appear in the extant texts. When painkillers are mentioned, this is usually in connection with colic, pleurisy, and similar painful conditions, but not with pain resulting from a wound. The analgesics include wild lettuce and anise, but also powerful substances, such as sleepy nightshade, henbane, mandrake and various kinds of poppy, in particular opium poppy, so that it is sometimes suggested that the Greeks and Romans used anesthetics for surgery (Dioscorides [4.75.7] even claims that surgeons use mandrake before surgical operations). While it is true that very effective drugs were available to them, most doctors would simply have considered them too dangerous, opium for example being listed among the lethal poisons (e.g., Galen, De Antidotis 2/14.138 K.). Not only do medical writers never mention any kind of anesthetics, but there are also casual references to having one’s patients bound or held down (e.g., Off. 6/3.288 L. or Aetius 15), as well as Celsus’s famous passage (7.proem 4) about the ideal surgeon being impervious to the patient’s screams. The stories about the fortitude of Alexander the Great (Curt. 9.5.27f.) and Marius (Plut. Mar. 6.3) undergoing surgery without having to be restrained also only make sense in a world without anesthetics.
Care for the wounded continued after the first surgical or pharmacological treatment, often in the form of a special diet. Wine was generally considered bad for the wound, unless the casualty was so weak that he needed it as a restorative, and usually during the first few days very little food was allowed. Purges and phlebotomy were also commonly used, adding up to a fairly debilitating regime.
MEDICAL SERVICES IN GREEK ARMIES
With good reason, research on medical services in ancient armies has usually concentrated on Imperial Rome. As far as the armies of the various Greek city-states and kingdoms are concerned, there is very little information available about anything that one could call a medical service, but the way in which doctors treating the wounded are mentioned in passing in non-medical literature suggests that their presence was not considered out of the ordinary (for a more detailed survey and further sources, see Salazar 1998a). Thus, for example, Xenophon, who knew Sparta well, describes the marching order of the Spartan army (Lac. 13.7), the “soothsayers, doctors and flute-players and those commanding the army” marching after the first three moirai. This suggests that doctors were part of the standard non-combatant staff of the Spartan army.
Figure 14.4 Wounded Aeneas attended by a doctor, between Venus and Ascanius. Fresco from the Casa di Sirico, Pompeii, first century A.D. Museo Archeologico Nazionale, Naples. Photo: Erich Lessing/Art Resource, New York.
In the specific situation of a city under siege or serving as the basis for military operations in its vicinity, it is likely that the city physician (iatros demosios/iatros demosieuon) would treat the sick and wounded at the city’s expense. Two inscriptions corroborate this conjecture: the first (fifth/fourth centuries B.C.) comes from Cyprus, and thanks several members of a medical family for their care for those wounded in battle. In the second (late third century B.C.), the city of Gortyn honors the doctor Hermias—sent from Cos at their request—for treating the casualties of a civil war. It seems that in either case the doctors were employed by the city for a specific emergency. This is precisely the advice of Philo of Byzantium (probably second century B.C.) when discussing the preparations for a siege (Mechanica Syntaxis 5.96.15–29). As he puts it, the city has to hire doctors “who are experienced in the treatment of wounds and in the extraction of arrows.” These experts in army surgery need to bring their own drugs and instruments, while the city “must provide cerate, honey, dressings and bandages.” From the doctor’s point of view, on the other hand, war was an excellent opportunity to acquire expertise, as the author of Medic. (14/9.220 L.) puts it: “He who wants to practice surgery, must go to war and follow mercenary armies, for thus he will be[come] experienced for this necessity.” The author(s?) of Epid. 5 and 7 may also have been hired especially for the war, either by one of the cities in northern Greece (e.g., Daton) or by the advancing Macedonians.
As one would expect, most of the passages dealing with medical treatment in Greek armies are about kings and commanders, and the sources tend to be silent about what care common soldiers received when wounded. The king or general is carried back, usually to his tent, or at least to the camp, where “doctors” (usually anonymous and in the plural) examine and treat his wound. We know that Alexander had his own doctors, and this was clearly the norm for kings and emperors. It seems also that these doctors could then be ordered by the commander to treat the latter’s friends or high-ranking officers.
When it comes to treatment for the rank and file, we have very little information. There were no ambulances going out on the battlefield in classical antiquity, so casualties were carried back by their comrades, sometimes on their shields (like the fallen). Xenophon’s vivid description (An. 3.4.32) of many being unable to fight, “the wounded and those carrying them, and those who had taken on the weapons of those carrying [the wounded]” gives an idea of the effect that the presence of even a few casualties could have on an army. It appears that—at least in the army of the Ten Thousand—there were no people whose job it was to transport the wounded. Slightly earlier (An. 3.4.30f.), Xenophon provides a curious piece of information: in the hills west of the Tigris, the Greek troops, retreating after the defeat at Cunaxa, “appointed eight physicians, for the wounded were many.” It is not explained by whom the doctors are appointed, nor whether they are Greeks or locals, but the reason for their appointment is clearly the large number of casualties. (It is unlikely that up to then the Greeks had no doctors at all, but rather that their number was no longer sufficient.)
There is also no indication in our sources as to where the wounded, with the exception of the leaders, were treated. There are descriptions of generals visiting them, presumably in their tents, but this may be just where they were recovering, not where they had been treated. There are no records of surgeons going out on the battlefield, and casualties were carried (or walked) back to the camp. The sources do not make it clear whether there was a central place where they would be treated, but this seems more likely than the doctors moving about, with their assistants carrying the instruments and other equipment. The aftercare for the wounded is also never described in terms of who did the nursing and where, and whether it took place under medical supervision. Given that slaves were taken along to war for menial tasks, the most likely answer is that they (or the helots in the Spartan army) provided basic nursing care.
Many uncertainties still remain, regarding for example the number of doctors in different armies, the way in which they were hired, who paid them and how (a salary or a share in the booty?), whether foreign doctors would be recruited locally, and how the necessary drugs were supplied. Unfortunately the surviving material offers no answers to these questions.
ROME
Here one needs to distinguish between Republican and Imperial Rome. For the Republic, the available sources—admittedly not contemporary—do not supply proof for anything that could be called an army medical service. Livy (2.47.12, speaking about the war of 480 B.C. against the Etruscans), Dionysius of Halicarnassus (5.36.3, about Etruscan soldiers), and Tacitus (Ann. 4.63, in a comparison) refer to the wounded being billeted on patrician families, who presumably did not provide medical treatment themselves. As long as Rome’s wars were geographically limited to Italy, taking the wounded home or leaving them in friendly towns was feasible, but as they became more far-flung, an organized medical service became necessary.7
The development of such a service cannot be seen in isolation from the history of Roman medicine in general. If there is a grain of truth in Pliny’s story about Archagathus, the first Greek doctor to practice in Rome as early as 219 B.C. (HN 29.6), supposedly soon reviled because of his cruel methods, then it could be an echo of Romans finding Greek medicine incompatible at that stage. With the Roman victory at Pydna in 168 B.C. and Greece becoming a Roman province in 146 B.C., all aspects of Greek culture became available (and fashionable), including Greek medicine, often in the form of Greek doctors.
The first literary evidence for a medicus in the army is in Cicero (Tusc. 2.16.38), in a discourse contrasting the battle-hardened soldier’s reaction to being wounded with the panic of the raw recruit who has been wounded for the first time. The surgeon is mentioned in passing, not as something extraordinary or new, so at least Cicero did not find his presence unusual. The earliest clearly dated piece of epigraphic evidence is A.D. 82: a votive tablet with the dedication Asclepio et saluti commilitonum by themedicus of the 5th Praetorian cohort, Sextus Titius Alexander (CIL 6.20 = ILS 2092; see Wilmanns 1995:141–259 for the most complete collection of all the inscriptions of military medici). Like the names of many other army medici (e.g., Hymnus, Symphorus, Asclepiades, Alcinus, or Callimorphus), his cognomen seems to point to a Greek ethnic background.
In the epigraphic sources, medicus is often qualified by a variety of epithets. Some indicate the doctor’s medical specialization (medicus clinicus or medicus chirurgus) or the unit to which he was attached (medicus legionis, medicus cohortis, medicus alae). It seems likely that the medicus castrorum or castrensis belonged to the medical services in the context of the castra, and that the medicus duplicarius (found only in the navy) received double pay. Some terms appear to refer to the doctor’s rank, such as the miles medicus (not an officer?) and the medicus ordinarius. The meaning of the latter has given rise to some controversy, but Nutton (1969: 268) and Wilmanns (1995: 56) both convincingly suggest a medicus with the rank of a centurion. It seems that there never was an autonomous medical corps with its own hierarchical structure, but that doctors were attached to specific military units.
Alongside the medici, the inscriptions also refer to capsarii, who were subordinate to the doctors and presumably “medical orderlies,” their name being derived from the capsa in which they carried the bandages. These were clearly not trained doctors, but the term discentes capsariorum on an inscription from Lambaesis (CIL 2438) suggests that becoming a capsarius involved some form of instruction or apprenticeship. In North Africa, the medical personnel also included specialists in the treatment of snakebite, theMarsi.8
We do not know how army doctors were recruited, but it seems likely that some doctors joined the military for the full term of service, while others only signed a contract for shorter periods. Given that there were trainee capsarii in the army, it is likely that somemedici only started their medical training after joining. They would then be apprenticed to a fully trained doctor, just as they would in a civilian context. As for the number of doctors available at any given time, it can only be conjectured from the numbers per legion, cohort, and so on, as they can be found in the epigraphic material. J. Wilmanns (1995: 69f.) calculates a ratio of roughly ten doctors per legion for the second century A.D., but the numbers will have fluctuated.
While the highly organized medical corps in itself was something that had not existed before Roman times, the greatest Roman innovation in this field is the valetudinarium, or army hospital. As the Empire expanded and the troops often found themselves far away from any settlements where the sick and wounded could be left to recover in safety, it became necessary to have appropriate facilities in the army camps or forts. The idea of a military hospital is without precedent in the ancient Mediterranean world, but there may be a clue to its origins in the ground plan of the earliest (mid-Augustan) valetudinarium, excavated at Haltern in Westphalia. V. Nutton (1969: 266, n. 1) points out that it resembles a collection of tents, so the embryonic form of the valetudinarium may have been a hospital tent. In keeping with the reason for their creation, all the valetudinaria that have been found are at the edges of the Empire, especially along the Rhine-Danube limes and in Britain.
The valetudinarium not only had its place within the standard layout of a Roman camp,9 it also had a recognizable ground plan, even if it varied because of the size of the camp or the terrain. Characteristically, it had a large entrance hall, possibly for the initial treatment, and behind it a courtyard with peristyle. The building forming the other three sides of the courtyard was subdivided into small rooms opening off both sides of a central corridor. The small size of the rooms—which are assumed to have been wards—would have contributed to the necessary peace and quiet, as well as making it easier to control the spread of infections.
Archaeological and literary/epigraphic evidence for the valetudinarium is mutually corroborative. As well as in the inscriptions, it appears also in the Digesta (50,6,7). There the optio valetudinarii, presumably the official in charge of the hospital and not a doctor, is listed (together with the medici and capsarii) among the immunes, that is, those who are exempt from fatigues. Medical instruments have been found in several valetudinaria (e.g., the large find from Vindonissa/Windisch in Switzerland; cf. Künzl 1983), indicating their use there, and the charred remains of medicinal herbs discovered at Novaesium/Neuss are evidence of pharmacological treatment.
It should not be forgotten that the Romans not only provided treatment for the sick and wounded, but that prophylactic measures were also taken into account. According to Vegetius (Mil. 3.2f.; cf. 1.22; 3.8), the generals needed to ensure—probably with the doctors’ advice—that the troops were well fed and well trained, and that the camp was constructed in a salubrious place and kept clean.10 He also (ibid. 3.1) stresses the importance of clean water, warning that bad water can cause diseases.
The famous scene on Trajan’s Column that clearly depicts two men in the outfit of auxiliaries, providing medical care to two soldiers, has often been taken as evidence of field dressing stations because of its apparent proximity to the battlefield (Cichorius 1896: plates 30–31). However, it should not be assumed that it was intended as a realistic representation of medical personnel in Trajan’s army. In the absence of literary evidence, the relief cannot be regarded as proof for medical treatment available on, or close to, the battlefield while the fighting was still going on.
The earliest reference to something resembling an ambulance service comes in a very late source, which deserves to be mentioned as a coda. The sixth-century Strategicon of Mauricius (2.9) describes the depotatoi, whose task it is to retrieve the wounded and those who have fallen off their horses, and to revive them with water from their flasks if necessary. The depotatoi have no medical training, but they are soldiers assigned to this duty, with the incentive of a reward for every soldier they manage to save. Their saddles have extra stirrups, so as to allow the casualty to mount behind them, but the passage does not make it clear what they are to do with those who are too badly wounded to mount a horse.
Neither Greek nor Roman sources mention medical assistance given to enemy casualties, other than in exceptional cases,11 and it is more likely that in general they were merely dispatched. It seems equally likely that prisoners who were considered valuable—either for the purpose of negotiations and ransom or because they were likely to fetch a good price when sold as slaves—would have had their wounds treated, but there are no sources to confirm this.
Summing up, one can say that the medical treatment of casualties itself did not change very drastically in the roughly ten centuries between classical Greece and late antiquity, as far as we can tell from its reflection in medical literature. (Neither did the wounds that had to be treated.) The main changes would be arterial ligature, more adventurous surgery and a trend toward polypharmacy from Hellenistic times onward. The way in which the care for the sick and wounded in armies was organized, on the other hand, progressed dramatically, from the random provisions of Greek antiquity to the establishment of a professional medical corps and of army hospitals in Imperial Rome.
BIBLIOGRAPHY
Cichorius, C. 1896–1900. Die Reliefs der Traianssäule. 3 vols. Berlin. (Plates reprinted as: Lepper, F., and S. Frere. 1988. Trajan’s Column: A new edition of the Cichorius plates. Gloucester.)
Frölich, H. 1879. Die Militärmedicin Homers. Stuttgart.
Kanz, F., and K. Grossschmidt. 2006. “Head injuries of Roman gladiators.” Forensic Science International 160: 207–16.
Künzl, E. 1983. Medizinische Instrumente aus Sepulkralfunden der römischen Kaiserzeit. Kunst und Altertum am Rhein 115. Cologne/Bonn.
LiDonnici, L. R. 1995. The Epidaurian miracle inscriptions: Texts, translation and commentary. Atlanta.
Majno, G. 1975. The healing hand: Man and wound in the ancient world. Cambridge.
Nutton, V. 1969. “Medicine and the Roman army: A further reconsideration.” MH 13: 260–70.
Salazar, C. F. 1997. “Fragments of lost Hippocratic writings in Galen’s glossary.” CQ, ns 47: 543–7.
———. 1998a. “Die Verwundetenfürsorge in Heeren des griechischen Altertums.” AGM 82: 92–7.
———. 1998b. “Getting the point: Paul of Aegina on arrow wounds.” AGM 82: 170–87.
———. 2000. The treatment of war wounds in Graeco-Roman antiquity. Leiden.
Tritle, L. A. 2003. “Alexander and the killing of Cleitus the Black,” in W. Heckel and L. A. Tritle (eds.), Crossroads of History: The Age of Alexander. Claremont, 127–46.
Wilmans, J. 1995. Der Sanitätsdienst im Römischen Reich. Medizin der Antike, vol. 2. Hildesheim.