Military Hospital Expertise At The Wall Forts.

[romanonick]

Paul Elliott in 'The Last Legionary' (p.67) mentions that qualified medical staff present at the larger fort valetudinarium may well have carried out more complex surgical operations alongside the more routine wear and tear human maintenance.
Have we any evidence to support this ? Or was it a case of more qualified staff at the main 'central' hospital' (eg Eboracum) having to carry out surgical work on the 'delivery' of a patient from a distant location or in more serious cases would they undertake travelling to the patient's location to carry out more involved surgical work?

To what level was surgical work carried out say to a basic level 'grunt'?

Also, was there an ascending level of patient care bearing in mind the rank of the individual and his corresponding 'pay back' value to the state?

Regards,

Romanonick/Nick Deacon

[Carlton Bach]

That kind of question is quite hard to answer, really. First off, to my knowledge we have no sources regarding the medical policies of the Roman army. So if they had had something like a triage system or even a way of giving discharges to the expensively ill to leave them to the tender mercies of the private sector, we wouldn't know. I doubt, however, that such considerations informed the medical service - the emperor was the patron of his soldiers, not their owner.

As to the procedures that were undertaken - it is likely that they were quite complex for their time. Archeological evidence from the border provinces (the Rhine area and the Netherlands have been particularly rich, partly no doubt for having been so thoroughly dug over) yields things like lithotomes, cataract needles, trephines and clamps along with the usual scalpels, spatulae and medicine containers. Of course we have - again - no way of telling statistically how common these were or whether they were limited to the civilian sector. Interestingly, the exceedingly complex and finely worked, usually somewhat baffling instruments found at Pompeii and often depicted in contexts of military medicine to show how advanced the Romans were (they are included in the illustration of a surgical procedure in 'Hadrian's Wall in the Days of the Romans' among other instances) are gynecologiucal specula and thus very likerly not military, but that just as an aside.

As to the quality of the medical staff, again we are left to speculation. On the one hand, there was no programme in which soldiers were sent to medical school because there was no medical school. Until the time of the archiatroi in the Late Empire, anyone could call himself a medicus and start practising (though informal procedures of recommendation and control probably existed much earlier). Not knowing how the military ensured the qualifications of applicants, we can only guess that things must have depended on supply, demand, and the opinion of serving medici. On the other hand, one of the most influential medical authors of Roman antiquity - Dioscurides - was a military physician, so quality could occasionally be very high indeed.

Surgery would, of course, usually have been limited by the constraints of preindustrial times - the absence of reliable anaesthetic (Dioscurides and Galen describe techniques, but they rely on potentially lethal drugs in doses very close to poison and must hae been difficult to apply) and the ever-present threat of infection (we hear of operations on the intestines, but generally the torso was off limits). Within this world, Roman doctors did some pretty remarkable things and there's no reason to assume that military doctors didn't. If anything, they might have been more willing to take risks and push the limits because they didn't depend on a reputation to draw customers.

One thing you wouldn't see is the emergency-room trauma surgery that is the stuff of TV drama and central to military medicine today. Any patient that reaches a doctor is a patient that can be transported and thus has already survived trauma, shock, blood loss and organ damage. No Roman medicus ever stood over a multitrauma patient, hands in his abdominal cavity to the wrists, shouting "Code Blue!". If later practice is anything to go by, doctors tried to build up their patients' strength before operating on them by careful therapeutic measures wherever possible. Emergency procedures were likely straghtforward - removing foreign objects, amputating destroyed limbs, staunching bleeding, debriding and bandaging or suturing wounds, removing bone splinters and such. That kind of work could largely be left to the more artisanal skill of the capsarii, I suspect.

It is, of course, possible that doctors would be called from their valetudinarium to the bedside of a patient, but given the distances involved and their duties at the base this can't have been a standard operating procedure. I would think it much more likely the patients wherever possible would come to the doctor to be diagnosed, receive treatment and rest at the valetudinarium, and be 'in good hands'. By far the majority of cases are likely to have been able to get there if not under their own power, then at least by usual means of transport. Again - the kind of people we find in intensive care today in Roman times would have died, Roman doctors mostly would have treated patients today considered less serious cases.

Officers, but likely also common soldiers if they had the funds, would have had access to the services of civilian doctors as well. It is at least likely that the care available to soldiers was better than that civilians could get in the border areas, though. Of course men of senatorial or equestrian rank might bring their own medicus or summon the best man in the city or province in an emergency.

All informed speculation, of course.

[Robert Vermaat]

Ask Maarten Dolmans, he's a fellow-member writing a PhD on Roman military surgery.

[Lochinvar]

Salve Nick,

Volker pretty much hits the nail on the head.

As a sweeping generalisation, military as opposed to civilian surgery from history has tended to be the fount of innovation. Almost every major conflict brings medical advances as surgeons are drawn to conflict.

Again, as a sweeping generalisation and from a modern view, one might want to consider patients arising as a result of physical injury (both battle and non-battle injury), physical ill-health (disease) and mental illness. To a Roman (or Greek) surgeon, the distinction between battle injury and non-battle injury may not have been as important as today.

In trauma, ie. the first batch of the three, time to effective intervention is one of the major determinants in survival. This would tend to pull medical staff forward in terms of time and space, and yet there is a balance to be struck. If the surgeon is travelling, he's not cutting, so Volker's observation about patients being brought to the doctor are probably about right.

Anyone living through a journey to, say, York would pretty much have 'self-selected' as a survivor. If you move your medical facility forward, your in-hospital death rate tends to go up.

[Gaius Julius Caesar]

Yet the Forts on the wall had hospitals...?

[Lochinvar]

Thanks, you've probably just proved the points.

[romanonick]

Thanks hugely to all and particularly to Volker for a comprehensive "informed speculation" response.

Gaius points out that the forts contained hospitals - perhaps these fell into a basic second line 'A & E' category as 'outstations' to the main establishment?

Volker - pardon my ignorance -but was is the meaning of the term 'archiatroi' in your referral to the late Empire ?

Regards,

Romanonick/Nick Deacon

[Carlton Bach]

Volker - pardon my ignorance -but was is the meaning of the term 'archiatroi' in your referral to the late Empire ?

'Archiatros' means something like 'first physician' and is believed to be the root of the German word 'Arzt'. The function of an archiatros is somewhat nebulous, but iot appears that by the late third century each larger city paid a stipend to one particularly trusted doctor who would oversee the conduct of other physicians, advise the government on medical matters, and may have been available to treat the indigent. Our problem is really that the title shows up long before the third-entury rescripts outlining his supervisory capacity, so it's unclear whether that was his original function or something the government stuck hiom with. He may originally have been nothing more than a glorified town doctor - Greek cities paid doctors stipends to encourage them to settle fairly early.

[Carlton Bach]

Yet the Forts on the wall had hospitals...?

I think assuming that legionary fortresses served as rear echelon bases for the entire army is misleading. A legionary valetudinarium may just have been that - a legionary valetudinarium, to serve the needs of a legion. But even if the idea was to concentrate the sick and injured there, it does make sense to have medical facilities wherever you concentrate large numbers of troops.

Also, just because we can not identify specific medical facilities does not mean there weren't any. A Roman hospital did not need operating theaters, intensive care wards, gurney-sized elevators or really anything that would stand out in the archeological record, so while purpose-built facilities can easily be identified, we have no way of knowing if a barracks block served as the unit hospital.

[Gaius Julius Caesar]

I suppose in the heat of a campaign, they would not be too fussy!