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With their belief in the healing power of gods combined with the inuence of the Greeks in €nding empirical evidence of the origins of diseases, ancient Romans made signi€cant contributions to the ฀history of . Healthy lifestyle ฀Daily life in Rome was generally harsh by today’s standards. Besides the many hazards of simply surviving daily life, physical illness and injury were significant concerns. How did the Romans deal with these challenges? !ey stayed €t. ฀ The Romans believed that a healthy mind equaled a healthy body. !ey also observed that a €t body could €ght diseases more e"ectively than an un€t one. Rather than spend money on doctors, Romans spent their income on staying €t. Celsus, a Roman writer generally believed to have lived circa 175 or 180 CE, is credited with saying, “A person should put aside some part of the day for the care of his body. He should always make sure ersityof Virginia. that he gets enough exercise, especially before a meal.” 9 All eight volumes of Celsus’s De Medicina (On Medicine ) have been discovered intact. From his writings, historians concluded that Celsus knew the di"erence between fresh and ulcers that were slow to heal. He also knew how to prevent hemorrhages by clamping blood ves - sels. Complex surgical procedures, such as goiter and cataract remov - ervices,Claude Moore Health Sciences Library, Univ al, were described in his works, as well as plastic surgical procedures, including “countercircumcision” and gynaemastia (breast reduction). 3

CoverImage: Courtesy of Historical Collections &S AUGUST 2006 The Surgical Technologist 11 272 AUGUST 2006 1 CE CREDIT

Ancient beliefs pipes to improve the public health of all Roman !e Romans maintained that diseases and cat- citizens. “In this sense, the Romans were the €rst astrophic natural occurrences were caused by civilization to introduce a program of public gods. Prayers, sacrifices, and pagan rites were health for everyone regardless of wealth.” 9 considered the only ways for healing to occur. The Romans also took great care in where “Prior to the Christian era, there were tem - they built their cities, homes, and military ples, such as the Aesculapium on the Tiber encampments: Island, where the sick spent the night in prayer to “When building a house or farm, special care the gods hoping to receive a cure, and ‘doctors’ should be taken to place it at the foot of a wooded made rounds doing what little they could. And hill where it is exposed to health-giving winds. there were establishments to house the dying or Care should be taken where there are swamps sick, essentially to keep them o" the streets. !e in the neighborhood, because certain tiny crea - concept was not to cure or even care, but to keep tures which cannot be seen by the eyes breed the wretched and sickly poor o" the streets. Out there. !ese oat through the air and enter the of sight, out of mind, so to speak.” 11 body by the mouth and nose and cause serious Thanks to the influence of the Greeks, the disease.”—Marcus Varro 9 Romans were also starting to discover at this “!ere should be no marshes near buildings, time, that there were often explanations for for marshes give o" poisonous vapors during the many seemingly unexplainable phenomena. hot period of the summer. At this time, they give For example, the Romans noticed an increase in birth to animals with mischief-making stings disease among people who lived near malaria- which y at us in thick swarms.”—Columella 9 infested swamps and in areas with bad sewage Clean water was also very important in problems. !is led them to conclude that illness - Roman society. Towns, military camps, and vil - es could have a natural cause, which resulted in las were almost always built near springs, so that their creating a system of aqueducts and sewer a ready supply of moving water was available.

FIGURE !: ginia. Scalpels deMoore Health Sciences Library, University of Vir Courtesyof Historical Collections &Services, Clau

AUGUST 2006 12 The Surgical Technologist But as the cities grew in population, the need for Most Roman households had toilets, as did all water increased. !e lead pipes of the time were military forts. “By 315 CE, it is said that the city of not sturdy enough to handle the large amount of Rome had 144 public toilets, which were ushed water needed to ush waste out of an expanding clean by running water.” 9 To ush this vast sys- city, and bronze—although available—was too tem of wastewater out of the cities, Romans expensive for such a massive undertaking. invented and created highly e>cient sewers, con - !e techniques for manufacturing cast iron sidered by some to be one of the ’s pipes were not known to the ancient Romans, so greatest achievements. they instead invented a system of conduits that moved water overland. When the water need - Lack of hospitals ed to cross valleys or rivers, the Romans built Hospitals, as they are known today, did not exist in aqueducts that served as bridges for the water ancient Rome. Medical facilities were only available to cross. As the water neared the cities, it was in military camps. Some of the wealthier families directed into smaller bronze or ceramic pipes, had buildings called valetudinaria on the grounds which slowed the water’s speed and allowed the of their estates, but these were built primarily “to Romans to direct water into homes and build - deal with sick or injured slaves and to isolate them ings. By 97 CE, an estimated one billion liters of from the rest of the sta" and family.” 11 water were pumped into Rome each day. !e concept of the modern hospital did not Good personal hygiene, which was impor - come into existence in Europe until well a@er the tant to the Romans, could be achieved with this time of Constantine and the rise of Christian - system of clean water, and Romans eventually ity. “While these early Christian hospitals were became famous for their baths—used by both rich grossly inadequate in terms of medical capabili - and poor citizens. Even the sick were encouraged ties (they essentially served as last stops for the to bathe regularly, because it was believed that dying or quarantine centers), the concept of pro - cleanliness would speed the healing process. viding care to the public was the actual intent.” 11

ginia. FIGURE ": Bone levers deMoore Health Sciences Library, University of Vir Courtesyof Historical Collections &Services, Clau

AUGUST 2006 The Surgical Technologist 13 FIGURE #: ginia. Surgical scissors deMoore Health Sciences Library, University of Vir Courtesyof Historical Collections &Services, Clau

Roman services on the streets, going so far as to perform !e medical profession in ancient Rome was not simple in front of crowds to increase highly regarded. It was considered “a low social their notoriety.” 2 position, €t for slaves, freedmen and non-Latin Beauty supplies and cosmetics were common- citizens, mainly Greeks. While there were some ly sold by doctors, and most were willing to treat who were respected, most were considered just any ailment, if the price was right. !is was despite as they were—cheaters, liars and quacks. The their recognition that their treatments were usually majority of doctors, at least early on, were self- ine"ective. !ere are even reports of doctors being taught or apprenticed practitioners who simply hired as assassins and poisoning their patients. 2 claimed to be healers, with little basis in scien- With the establishment of a medical school ti€c, medical knowledge. Many doctors did try around the €rst century in the Common Era, the to €nd e"ective treatments and perform valuable field of ancient medicine became more uniform services for the community, but even more were and practical. Surgeons grew more skilled and val - simply engaging in ways to con and cheat their ued. !e largest gains in knowledge, though, con - patients. Since there were no licensing boards, no tinued to originate from procedures and observa - formal requirements or education for entrance to tions performed by the medical corps of the Roman the profession, anyone could call himself a doc - military. !ese advances formed the basis for the tor. If his methods were successful, he attracted entire €eld of medicine for the next two millenia. 2 more patients; if not, they simply moved on to another career.” 2 With their less-than-spectacu- lar success rates, Roman physicians were viewed By far the most famous and important with suspicion and scorn by the rest of society. of the Roman world was Galen, who was born in Some of the wealthier physicians established 129 CE. Galen served as a physician for the glad - practices that resemble those of today, with an iator school in his hometown of Pergamum, in o>ce and sta". “Others simply advertised their modern-day Turkey. !e knowledge and experi -

AUGUST 2006 14 The Surgical Technologist ginia. FIGURE $: Cupping vessels for bloodletting deMoore Health Sciences Library, University of Vir Courtesyof Historical Collections &Services, Clau

ence he gained in trauma and treatment His public dissections were very valuable in had an enormous impact on the history of medi - debating the biological theories of the time and cine and led him to regard wounds as “windows were one of the primary means of academic into the body.” 6 learning in Rome for citizens as well as for medi - After leaving the gladiator school, Galen cal students. So signi€cant were the €ndings of moved to Rome and became personal physician to his research that his writings were still used as the Emperor Marcus Aurelius. As part of his royal manuals for physicians in the early 1800s, and duties, Galen performed many surgeries that were Galen—together with —is consid - not replicated for almost 2,000 years, including ered one of the earliest and most signi€cant con - brain and eye . 6 “To perform cataract sur- tributors to the . 6 gery, Galen would insert a long, needle-like instru - ment into the eye behind the lens. He would then Surgical procedures pull it back slightly and remove the cataract. !e In ancient Rome, it was commonly recognized slightest slip could cause permanent blindness.” 6 that blood moved through the body via a system Galen continued to do experimental surger - of and veins. Surgeons knew how to stop ies throughout his life, including public vivisec - the ow of blood by using tourniquets, arterial tions of animals to study the and func - clamps, and ligatures. They also knew how to tion of the kidneys and spinal cord. In one of these prevent deadly by performing ampu - public displays, Galen dissected a live pig, cutting tation of the infected limbs. its nerve bundles one at a time and ending with Historians have learned that Roman surgeons the laryngeal nerve (now also known as Galen’s performed cataract surgery by pushing a thin nerve), which ended the pig’s squealing. In other needle through the eye to break up the cataract. demonstrations, he tied the ureters of live animals Then the small pieces were suctioned through to prove that urine is produced in the kidneys, and the small hole in the needle, restoring at least a he severed spinal cords to study paralysis. 6 moderate amount of sight to the patient.

AUGUST 2006 The Surgical Technologist 15 “Other operations involved . One survival rates of many surgeries that led Roman report discusses an individual getting his earlobes society to place such a high value on diet, gym - repaired after years of wearing heavy earrings. nastics, exercise, massage, and sea-bathing. The excess lobe was trimmed, and the hole sewn together. Freed slaves prompted another common, Surgical instruments but expensive, plastic surgery. !e brandings and !e surgical tools found by researchers, especial- scars of the freed slave could be removed for a price. ly those discovered in the remains of Pompeii, the !is would minimize the recognition and stigma city buried by volcanic lava from Mount Vesuvius of having been a slave in this ancient society.” 13 in 79 CE, provide insight into the tools used by “Perhaps the most amazing operations were surgeons in Rome. In the home of one Pompei - performed on the brain. Trepanation, the name of ian surgeon, many surgical instruments, includ - the procedure used, provided relief to patients with ing scalpels, scissors, and bone forceps, were found incurable headaches and relieved pressure on the in pristine condition under the ash of the volcano. brain resulting from head injuries. The surgeon “Much of what we know about Roman medicine is used a cylindrical drill bit to cut a circle in the skull. because of the ‘House of the Surgeon’.” 13 He would rotate the drill using a bow-like device, “The instruments found at Pompeii repre- much like the ones used to rub sticks together in sent the normal range that a surgeon of the time making a fire. Patients had a high survival rate, would have needed. They were mostly bronze, and, amazingly, no anesthetic was needed.” 13 brass or copper, but blades and needles were When used, anesthestics in ancient Roman almost invariably made of iron or steel. Most of times could not compare to today’s standards. the instruments could be heated up and used for “Surgeons wanted to minimize the screaming cautery. By heating the instruments, the surgeons and €ghting of patients during surgery; the were, without realizing it, sterilizing them.” 3 of the patient, however, still scared many. They used opium, henbane, and mandrake. Opium Instruments found numbed the patient and limited movement. Hen - Scalpels, usually were manufactured of either bane induced sleeping and a slight amnesia. Final - steel or bronze, or a combination of the two (for ly, mandrake slowed the heart rate and deadened example, steel blade and a bronze handle). !ey pain. Even with the help of these anesthetics, the were used to make incisions and were typically standard for a good surgeon was speed!” 12 stored and carried in a wooden box, laid head to It was perhaps because of this and the low- tail and separated by small, €xed partitions.

FIGURE %: ginia. Obstetrical hooks/ sharp hooks deMoore Health Sciences Library, University of Vir Courtesyof Historical Collections &Services, Clau

AUGUST 2006 16 The Surgical Technologist Hooks, both sharp and blunt, were employed ancient doctors. Most of the vaginal specula con- regularly by Roman physicians in much the same sist of a screw device, which, when turned, forces way that surgeons today use them. “Blunt hooks a cross-bar to push the blades outwards.”7 were primarily used as probes for dissection and cups collected blood from a patient for raising blood vessels. Sharp hooks were used to in a diseased area of the body. It was thought that hold and li@ small pieces of tissue so that they could removal of the blood would rid that area of the be extracted and to retract the edges of wounds.”7 disease. !e larger cupping vessel was selected Bone drills, which resembled modern cork for larger areas of the body, such as the back or screws, were used to remove diseased bone tis- thighs, while the smaller cup was likely chosen sue from the skull and to extract foreign objects, for smaller areas, such as the arms. such as weapons, from bones. Bone forceps were Roman physicians carried wooden medicine utilized to extract small objects that were other- boxes to contain their forceps, scalpels, cathe- wise di>cult to remove with the surgeon’s €n- ters, and even arrow-extractors. gers. During trepanation of the skull, the sur- gery described above to relieve headaches, was Instrument sterility performed in such a way so that the drill did not It is unclear whether Romans understood the penetrate quickly into the dura matter. !e sur- importance of sterilizing their surgical instru- geon frequently plunged the drill into cold water ments, but they did use many techniques to kill to avoid overheating the bone. germs that were not formally invented until much Catheters, like their modern successors, were later. For example, they boiled their tools before employed by Roman surgeons to open up blocked use and would not reuse the same tool on a patient urethra to treat urinary tract . without placing it into boiling water a second time. Uvula crushing forceps were often used by Wounds were typically washed with acetum, which the famous physician Galen for treating coughs. is actually a better than the carbolic acid Galen used the forceps to crush the uvula and used by more than 1,500 years later. then cut it o". !is harmless, but senseless, opera- tion was one of Galen’s primary sources of income Conclusion as well as a popular treatment in ancient Rome. The lack of truly sterile equipment, few if any Several types of vaginal specula have been painkillers or anesthetics, and the reliance on discovered, and “they generally demonstrate the superstitions and myths would probably make high degree of engineering skill available to the any modern-day surgeon cringe when reading FIGURE &: Tile cautery Courtesyof Historical Collections &Services, Claude Moore Health Sciences Library, University of Virginia.

AUGUST 2006 The Surgical Technologist 17 about the medical practices of ancient Rome. Galen (also known as Claudius Galenus), see the Septem- In many respects, though, the Romans laid the ber !""# and November !""$ issues of this journal. For more foundation for certain areas of modern medi- information on ancient medicine, visit http://www.health system.virginia.edu/internet/library/historical/artifacts/antiqua/. cine. From the Romans, surgical methods began to be based on their extensive study of anatomy Images: All images are courtesy of Historical Collections & and as well as their examinations of Services, Claude Moore Health Sciences Library, Universi- the human body’s reactions to disease and inju- ty of Virginia. %e editors want to express appreciation to ry. e use of physical examinations improved as Andrew Jacobs, BA, who is pursuing a Masters degree in more detailed patient histories began to be kept, Secondary English Education, and Claudia Sueyras, BA, Historical Collections Specialist, who is pursuing a Masters which allowed surgeons to eventually compare degree in Library Science. %eir assistance in obtaining the cases and share information. high resolution imagery greatly facilitated the publication In addition, the vast experience that Roman of this article. Both are a'liated with the Historical Collec- physicians gained on the battle€eld from treat- tions and Services at the University of Virginia. ing wounded and ailing soldiers, led to a tre- mendous advancement in knowledge and surgi- References cal practices. Furthermore, the bureaucracy of 1. Adkins L, Adkins R, eds. Handbook to Life in Ancient Rome insisted that the treatments and knowl- Rome . New York, NY: Oxford University; 1994. 2. Ancient Roman Doctors. Available online at: http:// edge perfected by military physicians be taught www.unrv.com/culture/ancient-roman-doctors.php. Accessed in the new medical schools being formed. July 3, 2006. Although physicians still were not regarded 3. Ancient Surgery. Available online at: http://www.chan- highly in Roman society, and many citizens con- nel!.com/history/microsites/H/history/a-b/ancientsurgery". tinued to believe that the head of the household was html. Accessed July 3, 2006. more capable than a doctor of tending to the care of 4. Asclepion. Available online at: http://ablemedia.com/ctc- web/consortium/demandasclepion.html. Accessed July 5, his family, the €eld of medicine expanded tremen- 2006. dously during the time of the Roman Empire. 5. Bishop WJ. The Early History of Surgery. New York, NY; Barnes and Noble Publishers: 1995. About the author 6. Galen. Available online at: http://en.wikipedia.org/wiki/ Margaret Sterling, !"#, $%&, (), is the educa- Galen. Accessed July 5, 2006. tional coordinator for surgery at Shore Memo- 7. Greek and Roman Surgical Instruments. Available online at: http://ablemedia.com/ctcweb/consortium/deman- rial Hospital in Somers Point, New Jersey. She is dinstruments.html. Accessed July 5, 2006. responsible for planning, implementation and 8. Haeger K. %e Illustrated History of Surgery . New York, evaluation of formal and informal learning and NY; Crown Publishers:1988. assisting surgical services personnel to perform 9. Medicine in Ancient Rome. Available online at: http:// competently. She also serves on hospital com- www.historylearningsite.co.uk/medicine_in_ancient_rome. mittees that deal with clinical ladders, clinical htm. Accessed July 3, 2006. 10. Milne JS. Surgical Instruments in Greek and Roman competency and cultural diversity. Times . Oxford, England; Claredon Press:1907. Sterling has been working in the O.R. exclu- 11. Roman Hospitals. Available online at: http://www.unrv. sively since 1982 and began her perioperative com/culture/roman-hospitals.php. Accessed July 3, 2006. career in 1968. “I have been involved in the ‘mir- 12. Roman Medicine—Drugs. Available online at: http:// acle of medicine’ for the last 35 years.” At the www.dl.ket.org/latin#/mores/medicine/drugs.htm. Accessed AST Annual Conference in Las Vegas she pre- July 5, 2006. 13. Roman Medicine—Surgery. Available online at: http:// sented “Ancient Surgery.” www.dl.ket.org/latin#/mores/medicine/surgery.htm. Accessed Editor’s Note: The notations BCE (Before the Common July 5, 2006. Era) and CE (Common Era) are terms that refer to BC 14. Surgical Instruments from Ancient Rome. Available (Before Christ) and AD (Anno Domini) as time referenc- online at: http://www.healthsystem.virginia.edu/internet/library/ es. More information about these terms is available online historical/artifacts/roman_surgical/ Accessed July 3, 2006. at http://en.wikipedia.org/wiki/BCE. For more information on

18 The Surgical Technologist AUGUST 2006 1. One of the most in!uential Roman 7. In ancient Rome... physicians was: a. Public vivisections were considered vulgar a. Celsus c. Galen and were prohibited b. Pergamum d. Aesculapius b. Trepanations were performed to remove CE ExamExam272 AUGUST 2006 1 CE CREDIT cataracts 2. The Romans were in!uenced by whose c. Physicians prevented gangrene with belief that diseases had natural causes? a. Egyptians c. Mayans d. Anesthetics weren’t used due to high cost b. Greeks d. Turks 8. As the population of Roman cities 3. Which of the following were Roman increased... beliefs? a. Pipes and aqueducts were built to a. A healthy mind equals a healthy body. transport water overland b. Physical !tness is important. Surgery in b. Sewage system pipes were made from c. Gods control health and healing. sturdy cast iron d. All of the above ancient Rome c. Military forts were built near marshes 4. Romans are credited with being the d. Plastic surgery became too expensive for Earn CE credits at home "rst civilization to... most citizens You will be awarded continuing education (CE) credit(s) for a. Perform plastic surgery recerti!cation after reading the designated article and com - 9. Romans’ use of sterilization included... b. Implement public health programs that pleting the exam with a score of 70% or better. a. Misting the surgical table with carbolic acid bene!ted all citizens If you are a current AST member and are certi!ed, credit b. Washing wounds with acetum c. Discover natural causes for diseases earned through completion of the CE exam will automatically c. Storing blood in sterilized bleeding cups d. Believe in pagan rites and sacri!ces as be recorded in your !le—you do not have to submit a CE report - d. Wearing washed-wool gloves during methods of healing ing form. A printout of all the CE credits you have earned, includ - examinations ing Journal CE credits, will be mailed to you in the !rst quarter 5. Roman baths... 10. Which of the following is not true of following the end of the calendar year. You may check the status a. Were available only to wealthy citizens Roman society? of your CE record with AST at any time. b. Were built near aqueducts a. Surgeons demonstrated a high degree of If you are not an AST member or are not certi!ed, you will be c. Were recommended for healing diseases skill despite crude instruments. noti!ed by mail when Journal credits are submitted, but your d. All of the above b. Romans believed cleanliness contributed credits will not be recorded in AST’s !les. 6. Facilities resembling modern-day to good health and healing. Detach or photocopy the answer block, include your check or hospitals... c. Exercise, diet, mental health and massage money order made payable to AST, and send it to the Accounting a. Weren’t seen until after the rise of Christianity were valued highly. Department, AST, 6 West Dry Creek Circle, Suite 200, Littleton, CO b. Were called valetudinaria d. Their use of detailed patient histories 80120-8031. c. Were prevalent throughout Roman society wasn’t replicated until modern times. Members: $6 per CE, nonmembers: $10 per CE d. Were introduced to the Romans by the Greeks 272 AUGUST 2006 1 CE CREDIT

Surgery in ancient Rome a b c d a b c d

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Address ______4 Q Q Q Q 9 Q Q Q Q

City ______State ______ZIP______5 Q Q Q Q 10 Q Q Q Q

Telephone ______Mark one box next to each number. Only one correct or best answer can be selected for each question.

AUGUST 2006 The Surgical Technologist 19