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Friday, December 2, 2022

Military of ancient Rome

The military of ancient Rome, according to Titus Livius, one of the more illustrious historians of Rome over the centuries, was a key element in the rise of Rome over "above seven hundred years" from a small settlement in Latium to the capital of an empire governing a wide region around the shores of the Mediterranean, or, as the Romans themselves said, mare nostrum, "our sea". Livy asserts:

... if any people ought to be allowed to consecrate their origins and refer them to a divine source, so great is the military glory of the Roman People that when they profess that their Father and the Father of their Founder was none other than Mars, the nations of the earth may well submit to this also with as good a grace as they submit to Rome's dominion.

Titus Flavius Josephus, a contemporary historian, sometime high-ranking officer in the Roman army, and commander of the rebels in the Jewish revolt describes the Roman people as if they were "born readily armed". At the time of the two historians, Roman society had already evolved an effective military and had used it to defend itself against the Etruscans, the Italics, the Greeks, the Gauls, the maritime empire of Carthage, and the Macedonian kingdoms. In each war, it acquired more territory until, when the civil war ended the Roman Republic, nothing was left for the first emperor, Augustus, to do except declare it an empire and defend it.

The role and structure of the military were then altered during the empire. It became less Roman, the duties of border protection and territorial administration being more and more taken by foreign mercenaries officered by Romans. When they divided at last into warring factions the empire fell, unable to keep out invading armies.

During the Roman Republic, the function of the military was defined as service to the "Senatus Populusque Romanus" - an agency designated by SPQR on public inscriptions. Its main body was the senate, which met in a building still extant in the forum of Rome. Its decrees were handed off to the two chief officers of the state, the consuls. They could levy from the citizens whatever military force they judged was necessary to execute such decree. This conscription was executed through a draft of male citizens assembled by age class. The officers of the legion were tasked with selecting men for the ranks. The will of the SPQR was binding on the consuls and the men, with the death penalty often assigned for disobedience or failure. The men were under a rigorous code, known now for its punitive crucifixion.

The consular duties were of any type whatever: military defense, police work, public hygiene, assistance in a civil disaster, health work, agriculture, and especially the construction of public roads, bridges, aqueducts, buildings, and the maintenance of such. The soldiers were kept busy doing whatever service needed to be done: soldiering, manning vessels, carpentry, blacksmithing, clerking, etc. They were trained as required, but also previous skills, such as a trade, were exploited. They were brought to the task and were protected by the authority of the state.

The military's campaign history stretched over 1300 years and saw Roman armies campaigning as far east as Parthia (modern-day Iran), as far south as Africa (modern-day Tunisia) and Aegyptus (modern-day Egypt) and as far north as Britannia (modern-day England, southern Scotland, and Wales). The makeup of the Roman military changed substantially over its history, from its early days as an unsalaried citizen militia to a later professional force, the Imperial Roman army. The equipment used by the military altered greatly in type over time, though there were very few technological improvements in weapons manufacture, in common with the rest of the classical world. For much of its history, the vast majority of Rome's forces were maintained at or beyond the limits of its territory, to either expand Rome's domain or protect its existing borders. Expansions were infrequent, as the emperors, adopting a strategy of fixed lines of defense, had determined to maintain existing borders. For that purpose, they constructed extensive walls and created permanent stations that became cities.

Personnel

Population base of the early empire

Roman soldiers on the cast of Trajan's Column in the Victoria and Albert Museum, London

At its territorial height, the Roman Empire may have contained between 45 million and 120 million people. Historian Edward Gibbon estimated that the size of the Roman army "most probably formed a standing force of three hundred and seventy-five thousand men" at the empire's territorial peak in the time of the Roman emperor Hadrian (r. 117–138). This estimate probably included only legionary and auxiliary troops of the Roman army. However, Gibbon states that it is "not... easy to define the size of the Roman military with any tolerable accuracy". In the late imperial period, when vast numbers of foederati were employed by the Romans, Antonio Santosuosso estimated the combined number of men in arms of the two Roman empires numbered closer to 700,000 in total (not all members of a standing army), drawing on data from the Notitia Dignitatum. However, he notes that these figures were probably subject to inflation due to the practice of leaving dead soldiers "on the books" to continue to draw their wages and ration. Furthermore, it is irrespective of whether the troops were raised by the Romans or simply hired by them to fight on their behalf.

Recruitment

Relief scene of Roman legionaries marching, from the Column of Marcus Aurelius, Rome, Italy, 2nd century AD

Initially, Rome's military consisted of an annual citizen levy performing military service as part of their duty to the state. During this period, the Roman army prosecuted seasonal campaigns against largely local adversaries. As the extent of the territories falling under Roman suzerainty expanded, and the size of the city's forces increased, the soldiery of ancient Rome became increasingly professional and salaried. As a consequence, military service at the lower (non-staff) levels became progressively longer-term. Roman military units of the period were largely homogeneous and highly regulated. The army consisted of units of citizen infantry known as legions (Latin: legio) as well as non-legionary allied troops known as auxiliary. The latter were most commonly called upon to provide light infantry or cavalry support.

Military service in the later empire continued to be salaried yearly and professionally for Rome's regular troops. However, the trend of employing allied or mercenary troops was expanded such that these troops came to represent a substantial proportion of Rome's forces. At the same time, the uniformity of structure found in Rome's earlier military forces disappeared. The soldiery of the era ranged from lightly armed mounted archers to heavy infantry, in regiments of varying size and quality. This was accompanied by a trend in the late empire of an increasing predominance of cavalry rather than infantry troops, as well as an emphasis on more mobile operations.

Military subculture

The British historian Peter Heather describes Roman military culture as being "just like the Marines, but much nastier". The army did not provide much social mobility, and it also took quite some time to complete one's service. The pay was not the best for the time but could be remedied by advance in rank, loot from wars, and additional pay from emperors. Also, the army did provide a guaranteed supply of food (many times soldiers had to pay for food and supplies), doctors, and stability. In the legions of the Republic, discipline was fierce and training harsh, all intended to instil a group cohesion or esprit de corps that could bind the men together into effective fighting units. Unlike opponents such as the Gauls, who were fierce individual warriors, Roman military training concentrated on instilling teamwork and maintaining a level head over individual bravery − troops were to maintain exact formations in battle and "despise wild swinging blows" in favor of sheltering behind one's shield and delivering efficient stabs when an opponent made himself vulnerable.

Loyalty was to the Roman state but pride was based in the soldier's unit, to which was attached a military standard − in the case of the legions a legionary eagle. Successful units were awarded accolades that became part of their official name, such as the 20th Legion, which became the XX Valeria Victrix (the "Valiant and Victorious 20th").

Of the martial culture of less valued units such as sailors, and light infantry, less is known, but it is doubtful that its training was as intense or its esprit de corps as strong as in the legions.

Literacy was highly valued in the Roman military, and literacy rates in the military far exceeded that of the Roman society as a whole.

Funding and expenditures

Private funding

Roman coins grew gradually more debased due to the demands placed on the treasury of the Roman state by the military.

Although early in its history, troops were expected to provide much of their equipment, eventually, the Roman military became almost entirely funded by the state. Since soldiers of the early republican armies were also unpaid citizens, the financial burden of the army on the state was minimal. However, since the Roman state did not provide services such as housing, health, education, social security, and public transport that are part and parcel of modern states, the military always represented by far the greatest expenditure of the state.

Plunder economy

During the time of expansion in the Republic and early Empire, Roman armies had acted as a source of revenue for the Roman state, plundering conquered territories, displaying the massive wealth in triumphs upon their return and fuelling the economy to the extent that historians such as Toynbee and Burke believe that the Roman economy was essentially a plunder economy. Nathan Rosenstein has questioned this assumption, indicating that Rome ran the majority of its campaigns in the 2nd century BC at a loss and relied on rare windfalls such as Aemilius Paullus' campaign in the east in 168 BC to make up the cost of war. Regardless, after the empire had stopped expanding in the 2nd century AD, this source of revenue dried up; by the end of the 3rd century AD, Rome had "ceased to vanquish". As tax revenue was plagued by corruption and hyperinflation during the Crisis of the Third Century, military expenditures began to become a "crushing burden" on the finances of the Roman state. It now highlighted weaknesses that earlier expansion had disguised. By 440 AD, an imperial law frankly states that the Roman state has insufficient tax revenue to fund an army of a size required by the demands placed upon it.

Several additional factors bloated the military expenditure of the Roman Empire. First, substantial rewards were paid to "barbarian" chieftains for their good conduct in the form of negotiated subsidies and the provision of allied troops. Secondly, the military boosted its numbers, possibly by one third in a single century. Third, the military increasingly relied on a higher ratio of cavalry units in the late empire, which were many times more expensive to maintain than infantry units.

Taxation

As military size and costs increased, new taxes were introduced or existing tax laws reformed in the late empire to finance it, even though more inhabitants were available within the borders of the late empire, reducing the per capita costs for an increased standing army was impractical. A large number of the population could not be taxed because they were slaves or held Roman citizenship, both of which exempted them from taxation. Of the remaining, a large number were already impoverished by centuries of warfare and weakened by chronic malnutrition. Still, they had to handle an increasing tax rate and so they often abandoned their lands to survive in a city.

Of the western empire's taxable population, a larger number than in the east could not be taxed because they were "primitive subsistence peasant[s]" and did not produce a great deal of goods beyond agricultural products. Plunder was still made from suppressing insurgencies within the empire and on limited incursions into enemy land. Legally, much of it should have returned to the imperial purse, but these goods were simply kept by the common soldiers, who demanded it of their commanders as a right. Given the low wages and high inflation in the later Empire, the soldiers felt that they had a right to acquire plunder.

Capabilities

Readiness and disposition

Locations of Roman legions, 80 AD

The military capability of Rome – its preparedness or readiness – was always primarily based upon the maintenance of an active fighting force acting either at or beyond its military frontiers, something that historian Luttwak refers to as a "thin linear perimeter. This is best illustrated by showing the dispositions of the Roman legions, the backbone of the Roman army. Because of these deployments, the Roman military kept a central strategic reserve after the Social War. Such reserves were only re-established during the late empire when the army was split into a border defense force and mobile response field units.

Power projection

The Roman military was keen on the doctrine of power projection – it frequently removed foreign rulers by force or intimidation and replaced them with puppets. This was facilitated by the maintenance, for at least part of its history, of a series of client states and other subjugate and buffer entities beyond its official borders, although over which Rome extended massive political and military control. On the other hand, this also could mean the payment of immense subsidies to foreign powers and opened the possibility of extortion in case military means were insufficient.

Sustainability

The empire's system of building an extensive and well-maintained road network, as well as its absolute command of the Mediterranean for much of its history, enabled a primitive form of rapid reaction, also stressed in modern military doctrine, although because there was no real strategic reserve, this often entailed raising fresh troops or withdrawing troops from other parts of the border. However, border troops were usually very capable of handling enemies before they could penetrate far into the Roman hinterland.

The Roman military had an extensive logistical supply chain. There was no specialised branch of the military devoted to logistics and transportation, although this was to a great extent carried out by the Roman navy due to the ease and low costs of transporting goods via sea and river compared to overland. There is archaeological evidence that Roman armies campaigning in Germania were supplied by a logistical supply chain beginning in Italy and Gaul, then transported by sea to the northern coast of Germania, and finally penetrating Germania via barges on inland waterways. Forces were routinely supplied via fixed supply chains, and although Roman armies in enemy territory would often supplement or replace this by foraging for food or purchasing food locally, this was often insufficient for their needs: Heather states that a single legion would have required 13.5 tonnes of food per month, and that it would have proved impossible to source this locally.

Policing

For the most part, Roman cities had a civil guard used for maintaining peace. Due to fear of rebellions and other uprisings, they were forbidden to be armed at militia levels. Policing was split between the city guard for low-level affairs and the Roman legions and auxiliary for suppressing higher-level rioting and rebellion. This civil guard created a limited strategic reserve, one that fared poorly in actual warfare.

Engineering

The massive earthen ramp at Masada, designed by the Roman army to breach the fortress' walls

The military engineering of Ancient Rome's armed forces was of a scale and frequency far beyond that of any of its contemporaries. Indeed, military engineering was in many ways institutionally endemic in Roman military culture, as demonstrated by the fact that each Roman legionary had as part of his equipment a shovel, alongside his gladius (sword) and pila (spears). Heather writes that "Learning to build, and build quickly, was a standard element of training".

This engineering prowess was, however, only evident during the peak of Roman military prowess from the mid-republic to the mid-empire. Before the mid-republic period, there is little evidence of protracted or exceptional military engineering, and in the late empire likewise, there is little sign of the kind of engineering feats that were regularly carried out in the earlier empire.

Roman military engineering took both routine and extraordinary forms, the former a proactive part of standard military procedure, and the latter of an extraordinary or reactionary nature. Proactive military engineering took the form of the regular construction of fortified camps, in road-building, and the construction of siege engines. The knowledge and experience learned through such routine engineering lent itself readily to any extraordinary engineering projects required by the army, such as the circumvallations constructed at Alesia and the earthen ramp constructed at Masada.

This engineering expertise practiced in daily routines also served in the construction of siege equipment such as ballistae, onagers and siege towers, as well as allowing the troops to construct roads, bridges, and fortified camps. All of these led to strategic capabilities, allowing Roman troops to, respectively, assault besieged settlements, move more rapidly to wherever they were needed, cross rivers to reduce march times and surprise enemies, and to camp in relative security even in enemy territory.

International stance

Third-century Roman soldiers battling barbarian troops on the Ludovisi Battle sarcophagus (250–260)

Rome was established as a nation by making aggressive use of its high military potential. From very early on in its history, it would raise two armies annually to campaign abroad. The Roman military was far from being solely a defense force. For much of its history, it was a tool of aggressive expansion. The Roman army had derived from a militia of main farmers and the gain of new farmlands for the growing population or later retiring soldiers was often one of the campaign's chief objectives. Only in the late empire did the preservation of control over Rome's territories become the Roman military's primary role. The remaining major powers confronting Rome were the Kingdom of Aksum, Parthia and the Hunnic Empire. Knowledge of China, the Han dynasty at the times of Mani, existed and it is believed that Rome and China swapped embassies in about 170 AD.

Grand strategy

In its purest form, the concept of strategy deals solely with military issues. However, Rome is offered by Edward Luttwak and others as an early example of a state that possessed a grand strategy which encompassed the management of the resources of an entire nation in the conduct of warfare. Up to half of the funds raised by the Roman state were spent on its military, and the Romans displayed a strategy that was more complicated than simple knee-jerk strategic or tactical responses to individual threats. Rome's strategy changed over time, implementing different systems to meet different challenges that reflected changing internal priorities. Elements of Rome's strategy included the use of client states, the deterrent of armed response in parallel with manipulative diplomacy, and a fixed system of troop deployments and road networks. Luttwak states that there are "instructive similarities" between Roman and modern military strategy.

Rome would rely on brute force and sheer numbers when in doubt. The soldiers were trained to memorize every step in battle, so discipline and order could not break down into chaos. They were largely successful because of this.

Campaigns

Equipment

Although Roman iron-working was enhanced by a process known as Carburizing, the Romans are not thought to have developed true steel production. From the earliest history of the Roman state to its downfall, Roman arms were therefore uniformly produced from either bronze or, later, iron. As a result, the 1300 years of Roman military technology saw little radical change at the technological level. Within the bounds of classical military technology, however, Roman arms and armor were developed, discarded, and adopted from other peoples based on changing methods of engagement. It included at various times stabbing daggers and swords, stabbing or thrusting swords, long thrusting spears or pikes, lances, light throwing javelins and darts, slings, and bow and arrows.

Relief from Trajan's Column showing a legionary with lorica segmentata, manning a carroballista

Roman military personal equipment was produced in large numbers to established patterns and used in an established way. It, therefore, varied little in design and quality within each historical period. According to Hugh Elton, Roman equipment gave them "a distinct advantage over their barbarian enemies." Elton, Hugh, 1996, "Warfare in Roman Europe, AD 350-425", who were often, as Germanic tribesmen, completely unarmoured. However, Luttwak points out that whilst the uniform possession of armour gave Rome an advantage, the actual standard of each item of Roman equipment was of no better quality than that used by the majority of its adversaries. In Luttwack, E., "The Grand Strategy of the Roman Empire", JHUP, 1979, Luttwack states that "Roman weapons, far from being universally more advanced, were frequently inferior to those used by enemies. The relatively low quality of Roman weaponry was primarily a function of its large-scale production, and later factors such as governmental price-fixing for certain items, which gave no allowance for quality and incentivized cheap, poor-quality goods.

The Roman military readily adopted types of arms and armor that were effectively used against them by their enemies. Initially, Roman troops were armed after Greek and Etruscan models, using large oval shields and long pikes. On encountering the Celts they adopted much Celtic equipment and again later adopted items such as the gladius from Iberian peoples. Later in Rome's history, it adopted practices such as arming its cavalry with bows in the Parthian style and even experimented briefly with niche weaponry such as elephants and camel-troops.

Besides personal weaponry, the Roman military adopted team weaponry such as the ballista and developed a naval weapon known as the corvus, a spiked plank used for affixing and boarding enemy ships.

Medicine

Need for specialized care

General set up of ancient Roman military hospital.

The expansion of the Roman Empire was achieved through military force in nearly every case. Roman culture as a whole revolved around its military for both expansion and protection. Geographic areas on the outskirts of the empire were prone to attack and required heavy military presence. The constant barrage of attacks and the increase of expansion caused casualties. Due to attack there was a need for specialized medical care for these armies in order to keep them in operational status. The specialized form of care however, was not created until the time of Augustus (r. 27 BC – AD 14). Prior to this there is little information about the care of soldiers. It is assumed soldiers were self-reliant, treating their own wounds and caring for other ailments encountered. They would also turn to civilians for help throughout the villages they would come across. This was considered a custom of the time, and was quite common for households to take in wounded soldiers and tend to them. As time progressed, there was an increase in care for the wounded as hospitals appeared. The idea was held by the Romans that a healed soldier was better than a dead one and a healed veteran was better than a new recruit.

Roman hospitals

With the need for soldier health a growing concern, places for the sick to go in the army were starting to show up. Dates ranged from AD 9 to AD 50, but this is when the first evidence of hospitals was seen in archeological remains. These hospitals were specific places for only military members to go to if they were injured or fell ill. Similar hospitals were set up for slaves in areas where slaves were used in large numbers. Military hospitals were permanent structures set up in forts. These buildings had clear patient rooms and were designed to accommodate large numbers of soldiers. The size of these hospitals varied based on their location. Some of the large facilities, such as the hospital in Hod Hill England, was large enough to accommodate roughly 12% of the force within the hospital. In more stable areas such as Inchtuthil in Scotland, there was room for as little as 2% of the force within the hospital. In areas with more conflict, there were larger medical facilities as they saw more casualties. These hospitals were solely designed for the use of the military. If a civilian fell ill or needed surgery they would likely go to the physician's home and stay, not a hospital. Prior to these permanent structures there were tents set up as mobile field hospitals. Soldiers suffering from severe wounds were brought to these for treatment. These were quickly assembled and disassembled as the army moved. The tents served as a precursor for the permanent structured hospitals. These permanent hospitals and mobile treatment centers were a relatively new concept in this time period.

Physicians

Capsarii tending to injured soldiers depicted on Trajan's Column

Doctors serving in the army were considered to be a member of the military. Just like everyone else they would take the military oath and be bound by the military law. They would also start among the lower fighting ranks. Even though they took the military oath and were among the lower ranks it did not mean they would be fighting among the masses. These doctors were not always professionals or career physicians. Oftentimes they were slaves who were forced into that career.

The capsarii were a group that also treated wounded soldiers on the battlefield. These men were not trained physicians even though they played the role of one. Typically they were soldiers who demonstrated they had knowledge in wound treatment and even simple surgical techniques. These men were used before the actual trained doctors were largely implemented. Physicians got their knowledge from experience and information being passed down from person to person. Likely they never used medical texts, as it was not commonplace even in the civilian field. Generals and emperors were exceptions, as they would typically have their physicians with them. This was a common occurrence as emperors such as Marcus Aurelius employed famous physicians such as Galen. There were also physicians among the ranks of the Roman soldiers.

Distinctions in practice

With any large number of people being in close quarters, there was a constant threat of disease. When one individual in a large group gets sick with a communicable disease, it spreads to others very quickly. This premise remains true even today in the modern military. The Romans recognized the difference between disease and wounds, each requiring separate treatment. Drainage of excess water and waste were common practices in camps as well as the permanent medical structures, which come at a later date. As the medical corps grew in size there was also specialization evolving. Physicians surfaced that specialized in disease, surgery, wound dressing and even veterinary medicine.

Veterinary physicians were there to tend to livestock for agricultural purposes as well as combat purposes. The Roman cavalry was known for their use of horses in combat and scouting purposes. Because of the type of injuries that would have been commonly seen, surgery was a somewhat common occurrence. Tools such as scissors, knives and arrow extractors have been found in remains. In fact, Roman surgery was quite intuitive, in contrast to common thought of ancient surgery. The Roman military surgeons used a cocktail of plants, which created a sedative similar to modern anesthesia. Written documentation also showed surgeons used oxidation from a metal such as copper and scrape it into wounds, which provided an antibacterial effect; however, this method was most likely more toxic than providing an actual benefit. Doctors had the knowledge to clean their surgical instruments with hot water after each use. Wounds were dressed, and dead tissue was removed when bandages were changed. Honey and cobwebs were items used to cover wounds, and have even been shown today to increase healing. Because of the wide array of cases, it was not uncommon for surgeons to begin their careers in the army to learn their trade. Physicians such as Galen and Dioscorides served in the military. Most major advancements in knowledge and technique came from the military rather than civil practice.

Diet

Diet was an issue that is often discussed through this time, as an aspect of medical care. Since our idea of modern technology did not exist, the diet was a simple way for Romans to attain a healthy life. This remains true in the Roman military as the soldiers required appropriate nutrition in order to function at high activity levels. Because of the number of the people requiring food, there were unique circumstances in the acquisition of food. During a campaign, the soldiers would often forage food from their enemy's land. In fact, as part of the standard kit, Roman soldiers would carry a sickle, which would be used to forage food. They would carry a three-day ration of food in case they were in a situation where foraging was not available. This would largely consist of items such as wheat and barley.

During a time of peace, the Roman army would have had a typical diet consisting of bacon, cheese, vegetables, and beer to drink. Corn is mentioned in their works as well, however; this was a common term that was applied to their use of grain. The Roman use of the term corn is not to be confused with maize, which did not come to Europe until the discovery of the New World. Items such as poultry and fish were also likely part of the standard diet. The soldier was given a ration, which was taken from his pay. This shows that the soldiers were well-fed in times of peace. If the soldiers were well fed, they were healthier and able to maintain a high level of physical activity, as well as to stave off disease. The disease is easier to prevent rather than treat. This idea holds in the event a fort was under siege; certain food items were rationed such as poultry. The reasoning behind this was that poultry was very inexpensive to maintain and in the event of a siege. It was also noted that poultry had benefits for those who were sick. This demonstrates the idea was present that the army needed to maintain the health of its members regardless of circumstances. These discoveries were made while looking at the remains of Roman military sites. By excavating these sites and looking at fecal matter found, scientists were able to determine what was eaten. It is a simple fact that poor diet negatively affects a military's combat readiness. The variety of food found shows the Romans were not focused on just caloric intake, as they knew a variety of food was important to health.

Scale

By the time of Trajan (r. 98–117), the medical corps was well on the way to being an organized machine. At this time, physicians were attached to nearly every army and navy unit in all the Roman military. By this time the army was massive, consisting of twenty-five to thirty legions, each of which contained nearly 6,000 men. Each one included both soldiers and physicians. Despite these large numbers there was still no formal requirements for being a physician. At this point all physicians were either self-taught or learned their trade through an apprenticeship. Despite this, there was an attempt at organization, as the army did have a medical manual that was passed out to its physicians. The medici were used on both the front line as emergency care providers and in the rear as the main physicians. The capsarii'' were mainly used as the front line care providers and bandages, but also assisted the medici behind the lines.

Source of knowledge

Romans received their medical knowledge largely from the ancient Greeks. As Rome started to expand, it slowly embraced the Greek culture, causing an influx of medicinal information in Roman society. Because of this influx, it allowed this knowledge to become the foundation of all Western medical tradition. The Greek theories were kept alive and their practices continued well into the future. This knowledge was also the foundation used in military medicine since it contained the overarching ideas of their medical knowledge. As time progressed these medical texts would be translated into Arabic and then back into Latin as the flow of information changed. Based on this, we can presume that some of the information in these texts has been lost in translation. Despite this, we are still able to illustrate a clear picture of what military medicine was like during the reign of the Roman Empire.

Plague doctor

From Wikipedia, the free encyclopedia
 
 
Paul Fürst, engraving (coloured), c. 1721, of a plague doctor of Marseilles (introduced as 'Dr Beaky of Rome'). His nose-case is filled with herbal material to keep off the plague.[1]

A plague doctor was a physician who treated victims of bubonic plague[2] during epidemics mainly in the 16th and 17th century. These physicians were hired by cities to treat infected patients regardless of income, especially the poor that could not afford to pay.[3][4]

Plague doctors had a mixed reputation, with some citizens seeing their presence as a warning to leave the area.[5] Some plague doctors were said to charge patients and their families additional fees for special treatments or false cures.[6] In many cases these doctors were not experienced physicians or surgeons, instead being volunteers, second-rate doctors, or young doctors just starting a career.[7] In one case, a plague doctor was a fruit salesman before his employment as a physician. Plague doctors rarely cured patients, instead serving to record death tolls and the number of infected people for demographic purposes.[5]

In France and the Netherlands, plague doctors often lacked medical training and were referred to as "empirics." Plague doctors were known as municipal or "community plague doctors", whereas "general practitioners" were separate doctors and both might be in the same European city or town at the same time.[2][8][9][10]

History

According to Michel Tibayrenc's Encyclopedia of Infectious Diseases,[11] the first mention of the iconic plague doctor is found during the 1619 plague outbreak in Paris, in the written work of royal physician Charles de Lorme, serving King Louis XIII of France at the time. After De Lorme, German engraver Gerhart Altzenbach published a famous illustration in 1656, which publisher Paulus Fürst’s iconic Doctor Schnabel von Rom is based upon. In this satirical work Fürst describes how the doctor does nothing but terrify people and take money from the dead and dying.[12]

The city of Orvieto hired Matteo fu Angelo in 1348 for four times the normal rate of a doctor of 50 florin per year.[9] Pope Clement VI hired several extra plague doctors during the Black Death plague to tend to the sick people of Avignon. Of 18 doctors in Venice, only one was left by 1348: five had died of the plague, and twelve were missing and may have fled away.[13]

The need for the elaborate costume came from the belief that the bubonic plaque was transmitted through miasma "poisoned air". Which was a theory from Hippocrates and Galen long before the plaque.[14]

Methods and tasks

Plague doctors practiced bloodletting and other remedies such as putting frogs or leeches on the buboes to "rebalance the humors."[15] A plague doctor's principal task, besides treating people with the plague, was to compile public records of plague deaths.[5]

In certain European cities like Florence and Perugia, plague doctors were requested to do autopsies to help determine the cause of death and how the plague affected the people.[16] Plague doctors also sometimes took patients’ last will and testament during times of plague epidemics,[17] and gave advice to their patients about their conduct before death.[18] This advice varied depending on the patient, and after the Middle Ages, the nature of the relationship between doctor and patient was governed by an increasingly complex ethical code.[19][20]

Costume

Plague doctor outfit from Germany (17th century).

Some plague doctors wore a special costume consisting of an ankle-length overcoat and a bird-like beak mask, often filled with sweet or strong-smelling substances (commonly lavender), along with gloves, boots, a wide-brimmed hat, a linen hood, and an outer over-clothing garment.[21][22][23][24][25] However, the costume was not worn by all medieval and early modern physicians studying and treating plague patients.[26] The exact origins of the costume are unclear, however have been dated back to Italy and France.[27] Most depictions come from satirical writings and political cartoons.[28] The beaked plague doctor inspired costumes in Italian theatre as a symbol of general horror and death, though some historians insist that the plague doctor was originally fictional and inspired the real plague doctors later.[26] Depictions of the beaked plague doctor rose in response to superstition and fear about the unknown source of the plague.[21] Often, these plague doctors were the last thing a patient would see before death; therefore, the doctors were seen as a foreboding of death. It appears that the only contemporary sources which claim witness to this infamous costume are based in Italy during the 17th century. Later sources based in other areas do claim that this costume was in use in their country (most specifically during the black death), however, it is possible that they are being influenced by theatre and other works of fiction, already cited in this article.

The typical mask had glass openings for the eyes and a curved leather[27] beak shaped like a bird's beak with straps that held the beak in front of the doctor's nose.[8] The mask had two small nose holes and was a type of respirator which contained aromatic items. The first known observation of the herbal-stuffed beak was from an the epidemic in Rome in 1656.[27][29] The beak could hold dried flowers (like roses and carnations), herbs (like lavender and peppermint), camphor, or a vinegar sponge,[30][31] as well as juniper berry, ambergris, cloves, labdanum, myrrh, and storax.[5] The herbs right up against the nose inside the beak allowed for the doctor to have both of their hands free in order to examine the patient or corpse.[27] The purpose of the mask was to keep away bad smells such as decaying bodies and the smell taken with the most caution was[14] known as miasma or the "poisonous air"[14] which were thought to be the principal cause of the disease.[32] Doctors believed the herbs would counter the "evil" smells of the plague and prevent them from becoming infected.[33]

The wide-brimmed leather hat indicated their profession,[22][23][24][25][34] they used wooden canes in order to point out areas needing attention and to examine patients without touching them.[35] The canes were also used to keep people away[36][37] and to remove clothing from plague victims without having to touch them.[38] The doctor's long robe was made from linen because it was said germs did not stick to linen as easily as other materials.[27] The robe was also sometimes made from goat skin which was said to be stronger against the plague than linen because of its small pores and polished texture. It was heard of for the robe to be sealed with oil or wax for an extra layer of protection so the "poisoned air" could not seep through the holes of the linen material. [27] The costume of the plague doctor is the one of the first examples we have of a hazmat suit.[14]

Contract

A plague doctor's contract was an agreement between a town's administrators and a doctor to treat bubonic plague patients. These contracts are present in European city archives.[7] Their contractual responsibility was to treat plague patients, and no other type of patient, to prevent spreading the disease to the uninfected.[39] A plague doctor had to serve a long quarantine after seeing a plague patient. The doctor was regarded as a "contact" who by agreement had to live in isolation to be quarantined.[40][19]

Negotiations

The bargaining which always preceded the final contract often consisted of serious negotiations. For example, the town administrators of Turin in 1630 were considering the terms of an agreement requested by one Dr. Maletto to become their plague doctor. After much negotiating, they instructed their broker representatives to make a fair and prompt deal as soon as possible with this Dr. Maletto. They were told to get the best possible deal for their city, but to be careful not to lose the opportunity of hiring this plague doctor, as it would be difficult to find someone else to perform these dangerous duties at such a low rate.[7]

As an example of the tough negotiating that went on between plague doctors and infected European towns, there is in Pavia an original agreement between one Giovanni de Ventura and the city in their archives that shows a sixteen clause contract that was further amended after it was originally written. Clause one originally showed 30 florins per month for pay but was later modified to be net of living expenses. Clause two was originally that the pay was to be given two months in advance but later modified to monthly. Clause five provided originally a severance pay of two months but later modified that to one month's pay. Clause six said the said master Giovanni shall not be bound nor held under obligation except only in attending the plague patients which was later amplified with ...the doctor must treat all patients and visit infected places as it shall be found to be necessary. Clause seven had to do with full citizenship and the original text was modified with according to how he shall behave himself.[7][41]

Bernardino di Francesco Rinaldi obtained a clause in his contract when he was hired as plague doctor by the city of Volterra in 1527 that said essentially that the city had the obligation to provide Bernardino with all and everything necessary for his life support (i.e. food, water), and for these living expenses to be paid through the city expenditures.[42]

Reprimands

In 1527, in the city of Prato, a plague doctor named Stefano Mezzettino was seen attending to other patients without a custodian. The rule in the plague doctor contract was that a custodian must always be with the plague doctor when he visits other patients. This created much danger for the public. He was fined for his illegal act and breaking the rule of the plague doctor contract.[7]

Notable plague doctors

 

History of medicine in the United States

The history of medicine in the United States encompasses a variety of approaches to health care in the United States spanning from colonial days to the present. These interpretations of medicine vary from early folk remedies that fell under various different medical systems to the increasingly standardized and professional managed care of modern biomedicine.

Colonial Era

At the time settlers first came to the United States, the predominant medical system was humoral theory, or the idea that diseases are caused by an imbalance of bodily fluids. Settlers initially believed that they should only use medicines that fit in this medical system and were made out of "such things only as grown in England, they being most fit for English Bodies," as said in The English Physitian Enlarged, a medical handbook commonly owned by early settlers. However, as settlers were faced with new diseases and a scarcity of the typical plants and herbs used to make therapies in England, they increasingly turned to local flora and Native American remedies as alternatives to European medicine. The Native American medical system typically tied the administration of herbal treatments with rituals and prayer. This inclusion of a different spiritual system was denounced by Europeans, in particular Spanish colonies, as part of the religious fervor associated with the Inquisition. Any Native American medical information that didn't agree with humoral theory was deemed heretical, and tribal healers were condemned as witches. In English colonies it was more common for settlers to seek medical help from Native American healers. However, their medical knowledge was still looked down upon as it was assumed that they didn't understand why their treatments worked because their medical system differed.

Disease environment

Mortality was very high for new arrivals, and high for children in the colonial era. Malaria was deadly to many new arrivals. The disease environment was very hostile to European settlers, especially in all the Southern colonies. Malaria was endemic in the South, with very high mortality rates for new arrivals. Children born in the new world had some immunity—they experienced mild recurrent forms of malaria but survived. For an example of newly arrived able-bodied young men, over one-fourth of the Anglican missionaries died within five years of their arrival in the Carolinas. Mortality was high for infants and small children, especially from diphtheria, yellow fever, and malaria. Most sick people turn to local healers, and used folk remedies. Others relied upon the minister-physicians, barber-surgeons, apothecaries, midwives, and ministers; a few used colonial physicians trained either in Britain, or an apprenticeship in the colonies. There was little government control, regulation of medical care, or attention to public health. By the 18th century, Colonial physicians, following the models in England and Scotland, introduced modern medicine to the cities. This allowed some advances in vaccination, pathology, anatomy and pharmacology.

There was a fundamental difference in the human infectious diseases present in the indigenous peoples and that of sailors and explorers from Europe and Africa. Some viruses, like smallpox, have only human hosts and appeared to have never occurred on the North American continent before 1492. The indigenous people lacked genetic resistance to such new infections, and suffered overwhelming mortality when exposed to smallpox, measles, malaria, tuberculosis and other diseases. The depopulation occurred years before the European settlers arrived in the vicinity and resulted from contact with trappers.

Medical organization

The city of New Orleans, Louisiana opened two hospitals in the early 1700s. The first was the Royal Hospital, which opened in 1722 as a small military infirmary, but grew to importance when the Ursuline Sisters took over the management of it in 1727 and made it a major hospital for the public, with a new and larger building built in 1734. The other was the Charity Hospital, which was staffed by many of the same people but was established in 1736 as a supplement to the Royal Hospital so that the poorer classes (who usually could not afford treatment at the Royal Hospital) had somewhere to go.

In most of the American colonies, medicine was rudimentary for the first few generations, as few upper-class British physicians emigrated to the colonies. The first medical society was organized in Boston in 1735. In the 18th century, 117 Americans from wealthy families had graduated in medicine in Edinburgh, Scotland, but most physicians learned as apprentices in the colonies. In Philadelphia, the Medical College of Philadelphia was founded in 1765, and became affiliated with the university in 1791. In New York, the medical department of King's College was established in 1767, and in 1770, awarded the first American M.D. degree.

Smallpox inoculation was introduced 1716–1766, well before it was accepted in Europe. The first medical schools were established in Philadelphia in 1765 and New York in 1768. The first textbook appeared in 1775, though physicians had easy access to British textbooks. The first pharmacopoeia appeared in 1778. The European populations had a historic exposure and partial immunity to smallpox, but the Native American populations did not, and their death rates were high enough for one epidemic to virtually destroy a small tribe.

Physicians in port cities realized the need to quarantine sick sailors and passengers as soon as they arrived. Pest houses for them were established in Boston (1717), Philadelphia (1742) Charleston (1752) and New York (1757). The first general hospital was established in Philadelphia in 1752.

19th Century

A cartoon depicting Thomson (on the right) saving a patient from contemporary European medical practices (an MD. and Fellow of the Royal Society of London on the left).

Moving into the early 19th century, there was a general move to distinguish America from its ex-colonial ruler, Britain. Part of this spilled over into medical systems as well. Given that contemporary European medical interventions included things like blistering, blood letting, and calomel, there was a push to find a less damaging alternative. Samuel Thompson introduced his own alternative medical system, Thomsonianism, in the early 19th century. It quickly became extremely popular as a medical system in New England, especially in the northeast. While Thompson claimed his medical system was entirely his own, it was more so a repackaging of the humoral and Native American medical theories combined. Thomsonianism was all about maintaining heat in the body, and he accomplished this through various herbal interventions. His most commonly used drug, which he himself referred to as his number 1 drug, was Indian Tobacco, a commonly used native American medicinal herb. Thompson attributed his discovery of the herb and its medicinal properties to his explorative youth, but he also credits an old lady in his village with introducing him to the herb. Scholars have suggested that this lady was actually Native American, but that Thomson occluded that fact due to the general stigma and inferiority associated with Native Americans at the time.

Civil War

In the American Civil War (1861–65), as was typical of the 19th century, more soldiers died of disease than in battle, and even larger numbers were temporarily incapacitated by wounds, disease and accidents. Conditions were poor in the Confederacy, where doctors and medical supplies were in short supply. The war had a dramatic long-term impact on American medicine, from surgical technique to hospitals to nursing and to research facilities.

The hygiene of the training and field camps was poor, especially at the beginning of the war when men who had seldom been far from home were brought together for training with thousands of strangers. First came epidemics of the childhood diseases of chicken pox, mumps, whooping cough, and, especially, measles. Operations in the South meant a dangerous and new disease environment, bringing diarrhea, dysentery, typhoid fever, and malaria. Disease vectors were often unknown. The surgeons prescribed coffee, whiskey, and quinine. Harsh weather, bad water, inadequate shelter in winter quarters, poor sanitation within the camps, and dirty camp hospitals took their toll.

This was a common scenario in wars from time immemorial, and conditions faced by the Confederate army were even worse. The Union responded by building army hospitals in every state. What was different in the Union was the emergence of skilled, well-funded medical organizers who took proactive action, especially in the much enlarged United States Army Medical Department, and the United States Sanitary Commission, a new private agency. Numerous other new agencies also targeted the medical and morale needs of soldiers, including the United States Christian Commission as well as smaller private agencies such as the Women's Central Association of Relief for Sick and Wounded in the Army (WCAR) founded in 1861 by Henry Whitney Bellows, and Dorothea Dix. Systematic funding appeals raised public consciousness, as well as millions of dollars. Many thousands of volunteers worked in the hospitals and rest homes, most famously poet Walt Whitman. Frederick Law Olmsted, a famous landscape architect, was the highly efficient executive director of the Sanitary Commission.

States could use their own tax money to support their troops as Ohio did. Following the unexpected carnage at the battle of Shiloh in April 1862, the Ohio state government sent 3 steamboats to the scene as floating hospitals with doctors, nurses and medical supplies. The state fleet expanded to eleven hospital ships. The state also set up 12 local offices in main transportation nodes to help Ohio soldiers moving back and forth. The U.S. Army learned many lessons and in 1886, it established the Hospital Corps. The Sanitary Commission collected enormous amounts of statistical data, and opened up the problems of storing information for fast access and mechanically searching for data patterns. The pioneer was John Shaw Billings (1838-1913). A senior surgeon in the war, Billings built the Library of the Surgeon General's Office (now the National Library of Medicine, the centerpiece of modern medical information systems. Billings figured out how to mechanically analyze medical and demographic data by turning it into numbers and punching onto cardboard cards as developed by his assistant Herman Hollerith, the origin of the computer punch card system that dominated statistical data manipulation until the 1970s.

Modern Medicine

After 1870 the Nightingale model of professional training of nurses was widely copied. Linda Richards (1841 – 1930) studied in London and became the first professionally trained American nurse. She established nursing training programs in the United States and Japan, and created the first system for keeping individual medical records for hospitalized patients.

After the American Revolution, the United States was slow to adopt advances in European medicine, but adopted germ theory and science-based practices in the late 1800s as the medical education system changed. Historian Elaine G. Breslaw describes earlier post-colonial American medical schools as "diploma mills", and credits the large 1889 endowment of Johns Hopkins Hospital for giving it the ability to lead the transition to science-based medicine. Johns Hopkins originated several modern organizational practices, including residency and rounds. In 1910, the Flexner Report was published, standardizing many aspects of medical education. The Flexner Report is a book-length study of medical education and called for stricter standards for medical education based on the scientific approach used at universities, including Johns Hopkins.

World War II

Nursing

As Campbell (1984) shows, the nursing profession was transformed by World War II. Army and Navy nursing was highly attractive and a larger proportion of nurses volunteered for service higher than any other occupation in American society.

The public image of the nurses was highly favorable during the war, as exemplified by such Hollywood films as Cry "Havoc", which made the selfless nurses heroes under enemy fire. Some nurses were captured by the Japanese, but in practice they were kept out of harm's way, with the great majority stationed on the home front. The medical services were large operations, with over 600,000 soldiers, and ten enlisted men for every nurse. Nearly all the doctors were men, with women doctors allowed only to examine patients from the Women's Army Corps.

Women in Medicine

In the colonial era, women played a major role in terms of healthcare, especially regarding midwives and childbirth. Local healers used herbal and folk remedies to treat friends and neighbors. Published housekeeping guides included instructions in medical care and the preparation of common remedies. Nursing was considered a female role. Babies were delivered at home without the services of a physician well into the 20th century, making the midwife a central figure in healthcare.

The professionalization of medicine, starting slowly in the early 19th century, included systematic efforts to minimize the role of untrained uncertified women and keep them out of new institutions such as hospitals and medical schools.

The Woman's Medical College of the New York Infirmary. [Announcement, 1868-69].

Doctors

In 1849 Elizabeth Blackwell (1821–1910), an immigrant from England, graduated from Geneva Medical College in New York at the head of her class and thus became the first female doctor in America. In 1857, she and her sister Emily, and their colleague Marie Zakrzewska, founded the New York Infirmary for Women and Children, the first American hospital run by women and the first dedicated to serving women and children. Blackwell viewed medicine as a means for social and moral reform, while a younger pioneer Mary Putnam Jacobi (1842-1906) focused on curing disease. At a deeper level of disagreement, Blackwell felt that women would succeed in medicine because of their humane female values, but Jacobi believed that women should participate as the equals of men in all medical specialties. In 1982, nephrologist Leah Lowenstein became the first woman dean of a co-education medical school upon her appointment at Jefferson Medical College.

Nursing

Nursing became professionalized in the late 19th century, opening a new middle-class career for talented young women of all social backgrounds. The School of Nursing at Detroit's Harper Hospital, begun in 1884, was a national leader. Its graduates worked at the hospital and also in institutions, public health services, as private duty nurses, and volunteered for duty at military hospitals during the Spanish–American War and the two world wars.

The major religious denominations were active in establishing hospitals in many cities. Several Catholic orders of nuns specialized in nursing roles. While most lay women got married and stopped, or became private duty nurses in the homes and private hospital rooms of the wealthy, the Catholic sisters had lifetime careers in the hospitals. This enabled hospitals like St. Vincent's Hospital in New York, where nurses from the Sisters of Charity began their work in 1849; patients of all backgrounds were welcome, but most came from the low-income Catholic population.

Representation of a Lie group

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