(TO BE CONTINUED FROM 15/3/2011)
4. GRAECO-ROMAN ERA
Primitive health care associated with the temples of Asclepius are considered
by many to have been the forerunners of true hospitals (Thompson
1975:3, 4). Founded at Epidaurus in the 5th century BC (Fig. 32), the
Asclepian cult revolved around temple complexes usually built at scenic,
wooded sites with an abundant water supply. Asclepiea were later built
all over the Roman Empire, and flourished up to 391 AD when as pagan temples, they were officially closed by the Christian emperor Theodosius I. Their structure was fairly standardised, usually consisting
of large rooms, closed on three sides, orientated to the sun and opening
to the south with a row of pillars in the form of a Greek stoa (portico).
Big Asclepiea like that at Pergamum included treatment halls, libraries,
a stadium, baths and latrines.
Patients normally entered the temple for incubation sleep in the stoa
(Fig. 33). Their dreams were then interpreted by priests, who also suggested
the appropriate therapy (Thompson 1975:3-4). The hypochondriacal
Aelius Aristides for instance, relates how he spent considerable
time as a patient in the home of an Asclepian temple warden, and how
in consultation with a physician he was given a therapeutic medicament
after his dreams had been interpreted (Orations 48.34-35, 46-49).
Therapy was mainly of magico-mystic nature, and completely alien to
the co-existing Hippocratic medicine which was based on contemporary
scientific knowledge and abhorred the occult in medicine.
There was, however, ironically, a famous Asclepieum on the island of
Cos, where Hippocrates taught. The Hippocratic doctors visited and
treated patients at their homes and performed the occasional surgical
procedure, but there is no evidence in Classical Greece of the use of
hospitals in the modern sense of the word, although there is suggestive
evidence that rooms in private homes were occasionally adapted for longer
term medical treatment (Major 1954:121-136; Woodhead 1952:245;
Harig 1971:183).
The first official step taken by the Roman government in public
health care — other than the passing of various laws in this regard
(Cilliers 1993) — was the establishment in 293 BC of a temple of
Aesculapius on the Tiber island in the aftermath of a disastrous epidemic.
In the crisis the Senate took the traditional step and consulted
the prophetic Sibylline books; the recommendation was to import the
cult of Asclepius, the Greek god of medicine, from its main centre at
Epidaurus. Tradition has it (Ovid, Metamorphoses 15.669ff.; Livy 10.47
and Valerius Maximus 1.8.2) that a serpent (the symbol of the god)
came on board the ship at Epidaurus of its own accord, and when the
mission arrived at Rome, it swam ashore to an islet in the Tiber. After the
epidemic had subsided, the Romans in gratitude for their deliverance
built a temple to the god on the island. What probably happened in
reality was that the Roman state, due to the unsophisticated stage in
which health care was in the 3rd century BC, sought outside assistance.
The advice from the priests in Epidaurus was that it would be more hygienic
to treat the sick outside the built-up area of the city. Therefore
the temple of Aesculapius was built on an island in the Tiber, outside
the precincts of Rome. This Asclepieum (Fig. 34) later became known
as the “Slave hospital” because of the accumulation of slaves, taken
there when chronically ill (to avoid expenses for the owners) and never
re-collected by their masters.1 In Christian times the hospital became
famous as the St. Bartholomew Hospital and provided shelter for sick
pilgrims — a function which it has in effect retained since. On the site
once occupied by the ancient temple there now stands a modern hospital
run by a religious order (Staccioli 1989:60).
With the probable exception of valetudinaria (described below),
ancient Rome, like Greece, had no public institutions where sick civilians
could be treated for a longer period of time (Majno 1975:393).
The poorer patients were brought to the doctor’s iatreion/taberna where
they were treated and then sent home, while the rich were visited at
home by the doctor. This custom of treating the sick at home (cf.
Celsus I.65; Cato I.1 and 2; Columella XI.1.18; XII.1.60) still obtained
in the time of the Roman Empire, as is evident from an event
described by Tacitus (Annales IV.63). During a disaster which took
place in a small town near Rome when an amphitheatre collapsed, the
injured were taken to private houses where they were treated by physicians.
If a hospital had existed, the injured would have been there,
not in private houses. Even as late as the 3rd century AD there is still no
evidence of hospitals, as is clear from a remark made by Aelius Lampridius
(Scriptores Historiae Augustae Alex. Sev. c.47) that the emperor
Alexander Severus (AD 222-235) distributed those who were seriously
ill between the individual families to be cared for.
With the extension of the Roman Empire, when it was no longer
possible to send wounded and sick soldiers home for treatment, military
hospitals were established. Two kinds of hospitalisation existed: permanent
fort hospitals erected at strategic points (valetudinaria) (Fig. 11),
and temporary field hospitals at the front during active campaigns (Scheider
1953:262-264; Thompson 1975:4-6; Jackson 1988:133-137).
The first valetudinarium was probably built in the 1st century BC
at Carnuntum (near Vienna). These soldiers’ hospitals became part of
established Roman fort architecture and were usually placed near the
outer wall in a quiet part of the fortification. Valetudinaria were placed
in major as well as in smaller forts for auxiliary troops — the size varying
with the size of the fort. The larger hospitals traditionally consisted
of four wings with a central open courtyard. The number of wards
roughly matched the number of centuries in the legion, each accommodating
no more than three beds, and designed for maximal privacy.
Usually there were treatment rooms, a dispensary, staff quarters, and
washing, cooking and latrine facilities. Calculations suggest that about
5% of the unit’s strength could be accommodated, although this number
could easily be doubled by utilising corridors and ancillary rooms.
Each military unit had its doctors (milites medici) and medical assistants
(capsarii — named after the bandage box, capsa). Behind the lines the
field hospital (housed in tents) was the medical responsibility of the camp prefect, second-in-command and most experienced soldier of the unit. It was actually administered by the optio valetudinarii, a junior HQ
officer who was an administrator rather than a doctor. Adequate supply
lines to these field hospitals had high priority; in times of starvation
the army was the last to suffer. The number and experience of
medical staff varied according to the size and prestige of the unit, and
staff were probably organised into an overall hierarchy of military doctors
serving the valetudinaria. There was also a specialised person (the marsus)
who looked after snake bites and other problems of envenomisation (the
Marsi were a mountain tribe famous for miraculous snake-bite cures,
Hornblower 1996:930).
Although Jackson (1988:65) points out that we have no archaeological
proof of civilian hospitals, there is evidence that hospitals, also
called valetudinaria, were later also established for the civilian population
and upper classes in particular, for imperial staff in provincial
cities (probably private institutions), and for gladiators and slaves on
large farms (latifundia) (Harig 1971:189, 193-195; Thompson & Golden
1975:4). Landowners realised the necessity of keeping their labour force
healthy in order to ensure that they could fulfil their duties.2 There
is little information on how these institutions were run, but they were
probably a combination of private and state-run establishments. Although
Woodhead (1952:245) suggests that doctors’ tabernae often evolved
into sanatoria and small house-hospitals (nosocomia), this is little more
than speculation. Harig (1971:183-187) warns that evidence for pronouncing
even the well-known “physician’s home” in Pompeii a househospital,
is slim. However, he speculates that serious accident cases
might well have received prolonged therapy in a doctor’s house. We
therefore must accept that the valetudinaria played no direct role in
the evolution of the public hospital — they were established for a particular
purpose and for a particular class of patient. Not even the term
valetudinarium survived — when hospitals for the general public did
arise, they initially became known by the Greek term xenodochia (Allan
1990:446-447). Well-to-do households did however have their own
treatment quarters for the ill (Seneca, De Ira 1.16.4). It is interesting to
note that the famous Roman architect, Vitruvius, insisted that careful analysis of the environment’s health status be performed before establishing new cities and presumably hospitals (De arch. I.4).
(TO BE CONTINUED )
By François P. Retief and Louise Cilliers
notes
1 According to Suetonius, Divus Claudius c. 25 and Digesta 40.8.2, such slaves were
freed by an edict of the emperor Claudius.
2 In a treatise on agriculture Columella (Rust. XI.1.18), a contemporary of St.
Paul, specifically pointed out the need for providing such valetudinaria for slaves.
WE THE ECOUMENISTS exontes zilon FOR AN OECOUMENIC POLIS 