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Roman civic medicine: the archaeology of practices and practitioners in the Imperial age

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Roman civic medicine: the archaeology of practices and practitioners in the Imperial age

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Content ROMAN CIVIC MEDICINE: THE ARCHAEOLOGY OF PRACTICES AND PRACTITIONERS IN THE IMPERIAL AGE by Sarah Katherine Yeomans A Dissertation Presented to the FACULTY OF THE USC GRADUATE SCHOOL UNIVERSITY OF SOUTHERN CALIFORNIA In Partial Fulfillment of the Requirements for the Degree DOCTOR OF PHILOSOPHY ART HISTORY August 2021 2021 Sarah Katherine Yeomans ii Dedication For my father, mother and Peter Gratias vobis iii Acknowledgements When it comes to the journey that is the Ph.D. process, it truly “takes a village” of willing and generous people to help make that journey a successful one. In my case, I have been incredibly fortunate in the robust and multi-faceted “village” of teachers, mentors, colleagues, family and friends that made my own journey possible. I am fortunate to have been able to earn my degree at the University of Southern California, and I am grateful to the faculty, staff and administration of USC who provided me with the educational and financial resources to realize this educational goal of mine. I am particularly grateful to my committee members, John Pollini, Ann Marie Yasin and Cavan Concannon, who deftly steered me through the dissertation and defense processes during a period when the world was in a state of almost-unprecedented upheaval. There were many things I worried about as the Covid19 pandemic began to impact virtually every facet of our lives, and yet thanks to the skilled stewardship of our department’s chair, Kate Flint, and the general excellence of our department’s faculty and staff as well as the administration of USC’s graduate school, the fate of my degree was not one of them. Thank you. I could not have asked for a better mentor and guide for this undertaking than my advisor, John Pollini. I am incredibly grateful for his skillful oversight of my academic evolution. His generosity with his knowledge, insights, patience, encouragement and support were sine qua non for my successful passage through this process. In addition to his many intellectual gifts, he also demonstrated on numerous occasions a facility for talking despairing graduate students off the proverbial ledge. Thank you, John, for being the mentor and scholarly example that most developing scholars can only dream of having. Many graduate students are fortunate if they have even one extraordinary mentor to help them develop the skills and abilities necessary to earn a doctorate; I was lucky enough to have iv two. Throughout the entire process, Ann Marie Yasin’s generosity with her time and considerable expertise had an enormously positive impact on both this project and on my intellectual growth in general. I am fortunate to have had her as a model of what an excellent scholar and professional should look like. I am extremely fortunate to have been able to pursue my doctorate under the tutelage of the incomparable faculty of the University of Southern California’s Art History Department. Every seminar, every lecture, every faculty interaction added incrementally to my knowledge and contributed to my evolution as a scholar. To all of them I wish to express my heartfelt gratitude, in particular Sonya Lee, who introduced me to a whole new world of subject material that I continue to find fascinating, and who was such a bright light for me as I traveled along this academic path. I am also very grateful to our department’s support staff, whose unfailing professionalism and administrative magic made everything run so smoothly, as well as to the staff of USC’s libraries for routinely procuring even the most esoteric texts. Of course, as an archaeologist one’s research is rarely confined to a single geographical place, and I have been fortunate indeed in the institutions, colleagues and friends in multiple countries who made this present work possible. I am extremely grateful to the American Research Institute of Turkey, whose generous financial support made my much of work in Turkey possible. Professor İsa Kızgut was not only gracious enough to meet with me to discuss his work at Rhodiapolis, but he has made it possible for me to continue my work in Turkey next year as a Fulbright fellow. I am very much looking forward to the opportunity to continue my intellectual journey alongside a scholar of his caliber. Levent Oral, Cenk Eronat and the entire Tutku “family” not only pulled off logistical miracles to deliver me to some of their country’s most remote and beautiful sites, but their v unfailing and exceptionally generous friendship through the years is the reason that I have come to love Turkey, its people, and its culture as much as I do. Dr. Mark Wilson has also been a critical part of this process; his support in the form of (many) letters of recommendation, his keen editorial eye and his generosity with his expertise on all things Turkish (academic subjects and otherwise) have been invaluable. To all of you I say “çok teşekkür ederim arkadaşlarım.” I look forward to many more adventures together in the years to come, and I am so grateful that esteemed colleagues became such wonderful friends. In Italy, Professor Jacopo Ortalli, Dr. Stefano di Carolis, Anna Bondini of the Soprintendenza Archeologia dell'Emilia-Romagna, Angela Fontemaggi, Orietta Piolanti and their colleagues at the wonderful Museo di Città in Rimini all have my extreme gratitude for their generosity with their time, their knowledge and for granting me access to the extraordinary site that is the “Domus del Chirurgo.” Every archaeological site should be so beautifully excavated, conserved and presented by such knowledgeable and skilled experts. I was especially delighted to have been invited to present at the conference held in honor of the 10-year anniversary of the site’s opening to the public. It was a privilege to have been included in such an august and gracious panel of scholars, and I hope to collaborate again in the future. In Rome, I relied heavily on the resources of the École Française de Rome and the American Academy, and thank the staff and administration of both institutions for making it possible for me to conduct my research in la Città Eterna. To my Roman friends – those who are Roman by birth and those who are Roman by choice – grazie mille for making it such a joy to live and work in la città nel mio cuore. In Bulgaria, Professor Alexander Minchev’s graciousness in meeting with me and discussing his remarkable discovery at Marcianopolis made it possible for me to include it here vi in this study. He generously gave up an entire afternoon to not only introduce me to the Marcianopolis instrumentarium, but also to the sites of his beautiful museum and city. Dr. Ivan Sutev, the director of Devnya’s Museum of Mosaics and his museum’s staff, as well as Dr. Vassil Tenekedjiev of the Varna Regional Museum, all have my gratitude for their help in chasing down and confirming critical details. Closer to home, several years ago I was fortunate enough to have met Latin professor extraordinaire Dr. Linda Hall, whose linguistic and teaching superpowers not only got me over the finish line of the most challenging part (for me) of my comprehensive exams, but through whose thoughtfulness I was able to be connected with the equally wonderful Dr. Michael Taber. The two of them initially made it possible for me to become an ad hoc member of the extraordinary community that is the Department of Philosophy and Religious Studies at St. Mary’s College of Maryland. My place here among all of you these last few years has been an incredible gift without which I am not sure how I could have possibly finished this work. Coming down the final year of a dissertation was a lonely road, made more so by the empty offices of “Maggie B” Hall during the year of Covid19 closures. However, I always felt the presence of this department’s wonderful and supportive community of scholars and friends, to whom I say “thank you.” I am especially grateful to Provost Michael Wick and Dr. Barrett Emerick for continuing to include me as part of this vibrant SMCM community as a Scholar in Residence and to the incomparable librarians at SMCM’s library, particularly the inestimable Brenda Rogers. Ms. Rogers not only bore my endless esoteric book requests with grace and patience, but also regularly worked miracles to obtain them during a period when many of the country’s academic libraries were either shut down or operating at reduced capacity. vii Back before obtaining a doctorate was even on the horizon, I was fortunate enough to join the right tour group (thanks to my Tutku family) and sit in the right seat on the right bus. The result was meeting Dr. Aaron Gale, the director of the Religious Studies Program at West Virginia University. His encouragement, support, mentorship and friendship have been mainstays of this intellectual journey of mine from before the beginning. It’s a rare individual with whom, under the influence of extreme jetlag at 6:00AM in the desert when it’s already 85 degrees and we’re covered in dirt, I can laugh wholeheartedly. For the many travel adventures, the professional doors he has generously opened for me, the many (many) letters of support and most especially his friendship, I am very grateful. For supporting me and for being such an important and enjoyable part of my professional development, I wish to thank Sue Laden and my colleagues at the Biblical Archaeological Society. I am particularly grateful to Megan Sauter, the Biblical Archaeology Review’s very talented managing editor, who graciously drafted the map that appears in Figure 1.1 of this study. Of course, a doctoral program and the dissertation process cannot be achieved by work alone – at least not by me, anyway. I am sincerely grateful for the family and friends who have supported, encouraged, and at times tolerated me during the long, arduous, and often-serpentine path from graduate student to scholar. Thank you to Dr. Ben Witherington, who first planted the seed of the idea that became my doctoral journey, and to Dr. Mark Fairchild for his support, encouragement and for always instigating off-path adventures in remote parts of Turkey. My friends on both coasts not only provided critical support and encouragement when it was (frequently) needed, but the many happy hours, dinners, time spent on your various couches laughing, commiserating and/or connecting, and above all the security of knowing I am graced with friendships that can withstand the (unintentional) abuse of long absences and silences were, viii and are, some of my life’s greatest blessings. To Christa, Natalie, Lana, Heidi, Caroline, Danae, Stephanie, Arden and the many other fabulous women in my life: “thank you” is inadequate - I owe you all drinks and then some. “Thank you” is similarly inadequate for my parents, who gave me every opportunity, educational and otherwise, to thrive. When I was a teenager, my brilliant father told me “do what you love, and you will never ‘work’ a day in your life.” He was right (about that and so many other things). Oh, there has definitely been some hard work involved, but my career thus far has been such an enriching, fulfilling and interesting part of my life that I don’t regret a single late night or weekend spent at the library. My father has read every single word of this dissertation multiple times; he allowed me the use of both his shoulder and his ear at so many critical points in this process that I feel like we did this together. Dad, you are the most encouraging and supportive editor, mentor, and friend anyone could ever ask for - I am so grateful to you for being the father that you are. Both parents have been my biggest and loudest cheering section through the many years of my various academic (and non-academic) journeys. To them and my brother: Thank you. No part of this journey would have been possible without la mia pietra. Peter, you have always been in my corner, supported my dreams and somehow managed to be everything I needed, whenever I needed it while simultaneously building and navigating your own dynamic career. There are no words to express my gratitude for your love and support. I am looking forward to many more adventures and the chasing of dreams together. Thank you so much, my love, for making this possible – an officer and a gentleman indeed. Finally, I am so very grateful to Dr. Philip Ditchfield, who reminded me at a time when I most needed to hear it that pacta sunt servanda. Thank you, my friend. Pacta sunt servata. ix Table of Contents Dedication ....................................................................................................................................... ii Acknowledgements ....................................................................................................................... iii List of Figures ................................................................................................................................. xi Abstract .......................................................................................................................................... xv Introduction: Toward a Clearer View of Roman Civic Medicine in the Imperial Era .................... 1 Parameters of the Study ............................................................................................................... 4 History of Scholarship ................................................................................................................. 7 Sources and Methodology ......................................................................................................... 13 Organization and Preview of Chapters ...................................................................................... 16 Chapter 1: The Archaeological Sites of Ariminum, Allianoi, Rhodiapolis and Marcianopolis .... 22 Domus del Chirurgo (Rimini, Italy) .......................................................................................... 23 Allianoi (Turkey) ....................................................................................................................... 32 Rhodiapolis (Turkey) ................................................................................................................. 40 Marcianopolis (Bulgaria) ........................................................................................................... 49 Chapter 2: The Intersection of Military and Civilian Medicine .................................................... 62 Military Medicine ...................................................................................................................... 65 Retired Military Physicians in Civilian Practice ....................................................................... 78 Civilian Physicians in the Employ of the Roman Army ........................................................... 86 Military Physicians Treating Civilians ...................................................................................... 89 Archaeological Evidence: Marcianopolis .................................................................................. 92 Archaeological Evidence: Rimini .............................................................................................. 97 Chapter 3: The Shaping of Medical Practices, Practitioners, and the Profession ....................... 110 Tax Laws and the Office of the “Public Physician” ................................................................ 116 Laws Regulating Professional Practices .................................................................................. 128 The Physicians’ Collegia ......................................................................................................... 131 Medical Competitions ............................................................................................................. 139 Medical Education and Libraries ............................................................................................. 142 Medical Meritocracy? The “Free Market” of Medical Competence ....................................... 151 Allianoi: A Medical Market? ................................................................................................... 157 Chapter 4: Physicians’ Expertise and the Tools of the Medical Trade ....................................... 169 Instrument Design and Manufacture ....................................................................................... 174 Instrumentaria from Sepulchral Contexts ............................................................................... 181 Medical Specialization ............................................................................................................ 186 Rimini Physician ..................................................................................................................... 188 Marcianopolis Physician ......................................................................................................... 200 x Allianoi .................................................................................................................................... 210 Conclusion ................................................................................................................................... 220 Civilian and Military Medicine ............................................................................................... 220 Organizing Influences on Civic Medicine ............................................................................... 222 Allianoi’s Medical Economy ................................................................................................... 224 Medical Libraries as Training Centers? .................................................................................. 225 Extant Archaeological Sites of Civic Medicine as Representative Examples ......................... 227 Figures ......................................................................................................................................... 230 Bibliography ................................................................................................................................ 264 xi List of Figures Chapter 1 1. 1 Locations of Rimini, Allianoi, Rhodiapolis and Marcianopolis (produced by and courtesy of Megan Sauter). ............................................................................................................................ 231 1. 2 Domus del Chirurgo, located in the northeast section of the archaeological complex in Piazza Ferarri, Rimini (modified from the Soprintendenza Archeologia, belle arti e paesaggio per la città metropolitana di Bologna e le province di Modena, Reggio Emilia e Ferrara, http://www.archeobo.arti.beniculturali.it/rimini/domus_chirurgo/domus_chirurgo.htm). ......... 232 1. 3 Identified rooms/structures in the Domus del Chirurgo (modified from the Soprintendenza Archeologia, belle arti e paesaggio per la città metropolitana di Bologna e le province di Modena, Reggio Emilia e Ferrara, http://www.archeobo.arti.beniculturali.it/rimini/domus_chirurgo/domus_chirurgo.htm). ......... 233 1. 4 Orpheus Mosaic (after Fontemaggi and Piolanti 2016, 86). ................................................ 234 1. 5 Reconstruction of the medica taberna and patient’s cubiculum in the Domus del Chirurgo. Museo della Città, Rimini (courtesy of the Museo della Città, Rimini). ..................................... 234 1. 6 3D map of ancient Ariminum. The Domus del Chirurgo is circled in red (modified from Arimini Caput Viarum, http://www.riminiromana.it/). ............................................................... 235 1. 7 Site plan of Allianoi (modified from Baykan 2012a, 194). .................................................. 236 1. 8 Close-up of the the north locus depicting the “yard-type structure and the medical instrument distribution (modified from Baykan 2012a, 207). ....................................................................... 237 1. 9 View of the bath complex of Allianoi, prior to its flooding in 2011. View to the west (after Eurasianet, https://eurasianet.org/turkey-roman-ruins-lost-amid-economic-development). ..... 238 1. 10 View of the bath complex of Allianoi, prior to its flooding in 2011. View to the northeast (after Eurasianet, https://eurasianet.org/turkey-roman-ruins-lost-amid-economic-development). ..................................................................................................................................................... 238 1. 11 City plan of Rhodiapolis (after Çevik et al. 2010, 57, fig. 2). ............................................ 239 1. 12 Theater of Rhodiapolis with the Opramoas monument beyond the skene (backdrop of the stage). View to the southeast (author). ........................................................................................ 240 1. 13 Medical complex of Rhodiapolis (modified from Çevik 2010, 57, fig. 2). ........................ 241 1. 14 Interior of the Temple of Asklepios and Hygieia with the dedicatory inscription by Heraclitus (Inv. 557). View to the west (author). ........................................................................ 242 xii 1. 15 Inscription commemorating the works of Heraclitus (TAM II 910) in front of the remains of a section of the triple portico. View to south/southeast (author). ........................................... 242 1. 16 Network of Roman roads in the Balkans in the first – fifth centuries C.E. (after Evangelidis et al. 2015, 265, fig. 1). ................................................................................................................ 243 1. 17 Heinrich Hartl’s 1898 survey map (after Kalinka 1906, 360, fig. 160). ............................ 243 Chapter 2 2. 1 Second-century C.E. tomb relief of Asclepiades, archiatros of Odessos. Note the images of military weapons along the bottom of the relief. Varna Regional Museum of History. IGBulg. I2 150. Photo by V. Yotov (modified from Aparaschivei 2012c, 76, fig. 7). .................................. 244 2. 2 Portion of the Diocles’ Spoon from the Domus del Chirurgo, which was used to extract barbed projectile points. Museo della Città, Rimini (courtesy of Ministero per i Beni e le Attività Culturali - Soprintendenza Archeologia, Belle Arti e Paesaggio per le Province di Ravenna, Forlì-Cesena e Rimini). ............................................................................................................... 245 2. 3 Image of the votive hand representative of the cult of Iuppiter Dolichenus from the Domus del Chirurgo (ca. 12cm x 4cm). Museo della Città, Rimini (after Jackson 2009b, 92). .............. 245 2. 4 The votum pro salute monument dedicated to Iuppiter Dolichenus by T. Flavius Galata Eutyches for his freedman Amarantus. Museo della Città, Rimini (after Cenerini 2000, 68). ... 246 2. 5 Third-century iron weapon points recovered from the Domus del Chirurgo. Such weapons were characteristic of the Roman military in this period. From left to right: A. pilum (javelin), B. spear C. lance. Museo della Città, Rimini (modified from Ortalli 2009, 28). ............................. 246 Chapter 3 3. 1 Foot of Hermarchus statue recovered from the Domus del Chirurgo. Museo della Città, Rimini (after Ortalli 2009, 28). .................................................................................................... 247 3. 2 Third-century C.E. statue of Hermarchus (copied from a third-century B.C.E. Greek original) recovered from the Roman bath complex in Sarteano, Italy. Museo Archeologico Nazionale di Firenze (modified from Biondini et al. 2017, 14). ................................................. 247 3. 3 Set of five ophthalmic needles and their container (far left) which were recovered from the river Saône in Montebellet, France. The center needle is an inventively designed retractable needle, which measures 13.5cm. Musée Greuze, Tournus, France (after Bliquez 2015, 400, fig. 30). ............................................................................................................................................... 248 3. 4 Interior view of the retractable ophthalmic needle. Musée Greuze, Tournus, France (from Bliquez 2015, 401, fig. 31). ......................................................................................................... 248 3. 5 Drawing of finely calibrated, copper-alloy plunger forceps. The rod-like plunger handle compresses the jaws of the forceps as it is depressed. The plunger could then be locked in place, freeing the user from the necessity of holding it closed or having to engage a sliding lock-ring. Ashmolean Museum, Oxford (after Jackson 2014, 133, fig. 18.6). ............................................ 249 xiii 3. 6 Plan of valetudinarium at Vetera I, a Roman legionary base on the Lower Rhine near Xanten, Germany. Cf. Fig. 1.8 (after Johnson 1983, 160, fig. 117). ........................................... 250 3. 7 Plan of valetudinarium at Novae, a Roman legionary base on the Danube in northern Bulgaria. Cf. Fig. 1.8 (after Johnson 1983, 160, fig. 117). ......................................................... 250 3. 8 Plan of south locus depicting the indicated location of the two pithoi in quadrant EXI, circled in red (modified from Yaraş 2010, 98, plan 1). ............................................................... 251 3. 9 The two pithoi, in situ (after Yaraş 2010, 98, fig. 1). ........................................................... 251 Chapter 4 4. 1 First-century C.E. relief from the tomb of L. Cornelius Atimetus in Ostia. Vatican, Galleria Lapidaria Inv. 9277 (after Krug 2008, 26, fig. 13) ...................................................................... 252 4. 2 Second-century C.E. relief from the tomb of Verrius Euhelpistus in Ostia depicting the metalsmith at work in his workshop. Tomb #29 (courtesy of OstiaAntica.org https://www.ostia- antica.org/valkvisuals/html/tombe_29_3.htm). ........................................................................... 252 4. 3 Second-century C.E. relief from the tomb of Verrius Euhelpistus in Ostia depicting a display of metal tool and blades. Tomb #29 (courtesy of OstiaAntica.org https://www.ostia- antica.org/valkvisuals/html/tombe_29_3.htm). ........................................................................... 253 4. 4 Scalpel handles from Pompeii decorated with a bust of the demi-god Hercules. National Archaeological Museum of Naples, Inv. 77694 and 117667 (after Bliquez 1994, 119, fig. 20).254 4. 5 A copper alloy, bifurcated blunt hook used in lithotomy procedures, modified from a double lancet. Museum of Classical Archaeology, Cambridge UK, Inv. 171 (after Jackson 2010, 396, fig. 2.5). ....................................................................................................................................... 254 4. 6 Second-century C.E. tomb relief of Aelius Pius Curtianus depicting a physician’s basic instrument kit in a folding case (right) with a drawn reconstruction (left). National Archaeological Museum of Palestrina (after Krug 2008, 34, figs. 18 and 19). ........................... 255 4. 7 Reproductions of bronze cupping vessels (courtesy of the Claude Moore Health Sciences Library, University of Virginia). ................................................................................................. 255 4. 8 Basic physician's instrument collection from the Domus del Chirurgo in Rimini. Note the double scalpel with different blades at each end (far left). Museo della Città, Rimini. Photo by Ralph Jackson (after Jackson 2009b, 83, fig. 1). ......................................................................... 256 4. 9 Two bronze trephines (drills) with the folding handle (bow) used to rotate them. Römisch- Germanisches Zentralmuseum, Mainz, Germany (after Parapia 2007, 15, fig. 2). ..................... 256 4. 10 Illustration of a trepanning procedure using a trepan drill and bow (courtesy of The Romans in Britain https://www.romanobritain.org/13_roman_medical/roman_surgery.php). ................ 257 xiv 4. 11 Drawing of folding trepan drill bow depicting a stylized snake motif on the terminal. Museo della Città, Rimini (after Jackson 2009b, 77 fig. 26). ..................................................... 257 4. 12 The largest cluster of bone surgery instruments from the Domus del Chirurgo. The straight- jawed sequestrum forceps with decorated handles can be seen at the bottom center, while the folding trepan drill bow can be seen protruding from the cluster on the upper left. Museo della Città, Rimini (after Jackson 2009b, 84, plate 2). ......................................................................... 258 4. 13 Ceramic medicine jars from the Domus del Chirurgo containing camedrium (left) and abrotonum (right). Museo della Città, Rimini (after Gazzaniga 2009, 98). ................................ 258 4. 14 Instruments from the Marcianopolis instrumentarium, including bronze trepans bow (center), modified, bifurcated lithotomy scope (bottom right), and a decorated ophthalmic needle handle (upper right). Varna Regional Museum (after Trakova 2016, 19). .................................. 259 4. 15 Instruments from the Marcianopolis instrumentarium, including caustic forceps (center), a traction hook (second from right) and a lithotomy knife handle (far right). Varna Regional Museum (after Trakova 2016, 18). .............................................................................................. 259 4. 16 Example of a trivalve vaginal speculum (courtesy of the Claude Moore Health Sciences Library, University of Virginia). ................................................................................................. 260 4. 17 Example of a bivalve speculum (courtesy of the Claude Moore Health Sciences Library, University of Virginia). ............................................................................................................... 260 4. 18 Fragmented bronze “cupping vessel” (cf. Fig. 4.7). North locus, Allianoi. Bergama Museum (after Baykan 2012a, 157 no. 348). .............................................................................. 261 4. 19 Blades of a bronze, double-sided serrated saw (serrula). North locus, Allianoi. Bergama Museum (after Baykan 2012a, 206, plate 20). ............................................................................ 261 4. 20 Hemostatic forceps. North locus, Allianoi. Bergama Museum (after Baykan 2012a, 145 no. 297). ............................................................................................................................................. 262 4. 21 Catheter fragments from Allianoi (after Baykan 2012a, 202, plates 10 and 11). ............... 262 4. 22 Examples of two male catheters (top and middle) and a female catheter (bottom). Italy, first century C.E. British Museum Inv. 1968,0626.24 (courtesy of Mikael Häggström, MD). .......... 263 4. 23 Pair of caustic forceps with intricately decorated handle. North locus, Allianoi. Bergama Museum (after Baykan 2012a, 205, plate 17). ............................................................................ 263 xv Abstract The purpose of this study, unlike previous works in the field of ancient medicine, is to examine four archaeological sites involved in the practice of Graeco-Roman medicine in civilian, urban environments during the Imperial period (ca. first-fifth centuries C.E.). Investigations of the four archaeological sites – one in Rimini, Italy (“Domus del Chirurgo”), two in Turkey (Allianoi and Rhodiapolis) and a fourth in Bulgaria (Marcianopolis) – have yielded information about medicine as it was practiced outside of military and temple environments. However, while each site has been the subject of site-specific publications and reports in varying detail, none of them has seriously been considered in the existing literature concerned with presenting a comprehensive view of Graeco-Roman medicine. By analyzing the material from these four sites in light of what we already know of the medical landscape of the Imperial era, this project attempts for the first time to bring these sites into their deserved place within the broader scholarly discourse and, in the process, fill in some of the lacunae in our knowledge. One such gap in our understanding is the nature of the relationship between medicine as it existed in the Roman military and that which was available to the civilian population. This study undertakes a consideration of this relationship and examines the various ways in which physicians themselves moved between the two different contexts, transmitting their knowledge in the process. Furthermore, the material from Rimini, Marcianopolis and Allianoi, considered together with other known examples from sites like Pompeii and Herculaneum as well as various tombs contexts, allow for the conclusion that the same types of surgical implements – and the procedures they represent – that existed in military contexts were also present in civilian, urban environments. xvi Since there is no evidence to suggest that the state-sponsored medical infrastructure established for the care of soldiers existed for civilians, this study investigates other types of organizing forces that were at work upon the medical profession in Roman civic society. Such forces include the institution of the collegium (professional organization), as well as the dynamics of a free-market economy as it existed in the civilian medical market. I believe that both would have had varying degrees of influence in the determination of a physician’s professional success. Furthermore, I advance for the first time the hypothesis that in Allianoi we have an example of a town that featured a robust medical economy, based not only on the dynamic between patients as “consumers” and physicians as “suppliers” but also on the production and/or procurement of instruments and other medically related materials. In considering the ways in which a physician might have obtained his training, I investigate the evidence for a medical library in Rhodiapolis and suggest that such institutions may in fact have been more ubiquitous throughout the Graeco-Roman world than previously believed. I believe, furthermore, that at least some of these medical libraries may also have served as centers where physicians could receive clinical training in addition to access to medical texts and that the famous medical center in Alexandria, Egypt, was probably not unique in this respect. An evaluation of the medical implements recovered from Rimini, Allianoi and Marcianopolis allows for a more detailed understanding of the types of medical procedures that were performed by physicians in civic contexts and the various types of medical specializations practiced by members of the profession. For example, we know from evidence recovered from military valetudinaria (hospitals) that physicians with medical expertise in bone surgery and traumatic wound-mitigation were mainstays of the medical corps. The evidence from Rimini, xvii Allianoi and Marcianopolis demonstrates that such expertise was also to be found in civilian environments. Finally, I advance the theory that since there is no evidence that Rimini, Rhodiapolis and Marcianopolis were considered particularly noteworthy as centers of medicine/healing by ancient Romans, the medical technologies and practices identified in these urban environments should not be considered unique to these particular towns. While the sites themselves are quite rare as archaeological examples of their kind, I propose that the medical practices and practitioners associated with them can, in all likelihood, be considered representative of similar urban contexts throughout the Empire. 1 Introduction: Toward a Clearer View of Roman Civic Medicine in the Imperial Era The last several decades have seen an increasing interest in, and an increasing number of publications on, the subject of medicine in the ancient Roman world. An emphasis on inter- disciplinary approaches to the investigation of ancient cultures has positively affected the study of Roman medicine and its practitioners. Thanks to the combined efforts of archaeologists and scholars of classical literature and history – as well as the unprecedented access to publications and data made possible by the age of electronic journals and internet databases – our understanding of the field has deepened significantly. However, despite these advances, those who study Roman medicine are necessarily limited by the extant evidence. Such evidence is frustratingly sparse, particularly as it concerns the civilian sphere of Roman society. By comparison, military valetudinaria (hospitals) are relatively well-documented, particularly along the northeastern borders of the Empire, and as such we have a more profound view of medicine as it existed for the care of soldiers than we do for that of their civilian counterparts. 1 Therefore, while any new site with medically related finds is important, those that yield information concerning medical practices in civilian environments are particularly valuable sources of data. Within the last 40 years or so, four significant archaeological sites of civilian medicine dating to the Imperial period (ca. first – fifth century C.E.) have been discovered. Considered together, these sites produce a clearer picture of the state of civilian medical care in this period than we have previously seen. The four sites under consideration in this study are as follows: 1) 1 There are a number of relatively recent and excellent studies concerning valetudinaria and Roman military medicine more broadly. Examples include (but are by no means limited to) Aparaschivei 2017, Bader 2014, Baker 1998 and 2004, Dyczek 1995, 2002, 2005 and 2008, Press 1994, Strobel 2006 and Israelowich 2016. 2 the “Domus del Chirurgo” (Rimini, Italy), the site of a mid-third century medica taberna (medical clinic) in which a cache of ca. 150 medical instruments were found, 2) a series of building complexes in the ancient spa town of Allianoi (ca. 20 km northeast of Bergama, Turkey) where almost 350 medical instruments and other medically related objects were documented by the site’s excavators before the site was ultimately destroyed in 2010, 3) a medical complex consisting of a library, an Asklepian temple and a series of rooms possibly used for clinical practice and/or training in the ancient Graeco-Roman city Rhodiapolis (Kumluca, Turkey), and 4) a possible domus (Roman house) in Marcianopolis (Devnya, Bulgaria) where over 30 medical instruments, ranging in date from the late-second to the mid-fifth century were recovered. 2 These sites are not “new” in the sense that they have only just been discovered; for example, the medical instruments in Marcianopolis were excavated approximately 40 years ago, and the spectacular Domus del Chirurgo in Rimini, after having been systematically excavated for almost two decades, has been open to the public for almost 15 years. However, for a variety of reasons that are addressed in more detail in Chapter 1 of this study, only one of these sites has been comprehensively published by the excavators (the Domus del Chirurgo in Rimini), and none of these sites have been discussed in any significant way in the current comparative literature on the subject. This is a true deficit, particularly when one considers the sheer amount of material recovered from these sites. In the case of surgical instruments alone, the caches of such implements recovered from three of these four sites (Rimini, Allianoi and Marcianopolis) represent three of the largest deposits of such objects identified anywhere in the Graeco-Roman world – from any time period. Furthermore, since the data from these sites have been largely 2 Allianoi was submerged by a water reservoir in 2010 upon the completion of the Yortlanī Dam, whose construction was intended to supply water to surrounding farmland. See discussion in Chapter 1. 3 ignored, or perhaps unknown, by those scholars currently publishing in the field, there has yet to be a comprehensive investigation of these sites that brings them into the broader discourse concerning Roman medicine in the Imperial era. This project represents an attempt to rectify this. Collectively, these four sites have light to shed on several aspects of civilian medicine in the Imperial period, such as the nature of the relationship between military and civilian medicine, the various forces at work that acted to shape and influence the medical profession in the civic sphere, as well as the lives of physicians and the nature of their medical expertise. In the course of investigating these topics in this study, certain other aspects of civilian medicine about which we previously knew very little begin to emerge. For example, based on the evidence from Rhodiapolis, I conclude that medical libraries may have also functioned, at least in some instances, as training centers where physicians and aspiring physicians could acquire “hands-on” experience in addition to the knowledge contained in the libraries’ collections. In my opinion, the evidence from Allianoi in particular also provides us with our first glimpse into the civilian medical economy, e.g., the relationship between the physician as the “supplier” of services and the patient as the “consumer,” as well as the market for specialized instruments and medicines. Additionally, I advance the view that while the sites of Rimini, Allianoi, Rhodiapolis and Marcianopolis are rare and unique as archaeological sites in our present times, the medical paradigms they exemplify are representative of urban, civilian environments across the Empire. By extrapolating from what we now know of these four sites, we can begin to acquire a broader view of the medical landscape as it existed for the Empire’s civilian inhabitants. 4 Parameters of the Study Thus far, scholarship concerning the material culture of Roman medicine has largely been focused on two distinct categories of archaeological sites: 1) “religious” or “mystical” medical sites, such as Asklepia and other cultic sites associated with “faith-healing” techniques (i.e., techniques that involved a patient seeking divine remediation for illness or injury), or 2) military valetudinaria, hospital facilities for Roman soldiers where practical medical treatments, such as surgical interventions, took place. 3 It should be noted that the categories of medical sites I am introducing here in order to define the parameters of this study (e.g., “military,” “religious/sacred,” and “civilian”) were not defined in this way by the Romans themselves. Indeed, the realm of religious medicine and what I define as “practical” (i.e., direct physical invention in the form of medicines or surgical procedures) were deeply emmeshed and frequently considered complimentary rather than incongruent. For example, seeking medical intervention from priests at an Asklepion would not have precluded a patient from also soliciting treatment from a doctor outside of sacred contexts. Physicians who practiced their craft in cities and towns could – and did – serve as priests of Asklepios. 4 In military valetudinaria, Asklepian shrines are common features, and Asklepian iconography appears as decorative motifs on medical instruments recovered from non-religious contexts. 5 In order to clearly define the nature 3 In the context of this study I use the term “practical” to connote those treatments that consisted of physical interventions such as the dispensing of medications, surgery or both as opposed to “mystical” or “magical” treatments that involved prayer, worship, dream interpretation, etc.; There is a broad corpus of work on evidence for the cult of Asklepios and the healing activities of Asklepian sanctuaries. Examples include (but are by no means limited to): Compton 1998, Jones 1998, Hortsmanshoff 2004, Renberg 2006, Wickkiser 2008 and 2010, Petsalis- Diomides 2010, Israelowich 2012, Cilliers and Retief 2013, Petridou 2014, Panagiotidou 2016 and Van der Ploeg 2018. 4 Epigraphic examples of physicians who also participated in the religious life and activities of Asklepian sanctuaries are well documented from the fifth/fourth centuries B.C.E onwards at Asklepia such as those at Cos and in Athens. See Wickkiser 2010 and Nutton 2013a, 112. Heraclitus of Rhodiapolis, a subject of this current study, was also a priest of Asklepios. Īplikçioğlu 2014. 5 Risse 1999, 56-9; For examples of surgical instruments featuring Asklepian imagery, see Chapter 4 of this study. 5 and parameters of the sites and topics under consideration here in this study, I take the liberty of imposing certain modern notions of healing categories onto an ancient medical paradigm by separating the “religious” from the “secular.” I freely acknowledge that we have no evidence of such clear delineations on the part of patients and practitioners in antiquity; my reasons for making them here are solely for the purpose of clarity. Due to a dearth of relevant archaeological sites, a broader view of civilian, secular (i.e., non-religious) medicine in ancient Rome, as evidenced by archaeological investigations, has received negligible treatment. Those studies that do exist are based upon a scattered assortment of small finds (e.g., medical implements found in tombs or unprovenanced artifacts in museum collections), references in ancient texts and a small number of poorly documented sites, such as those in Pompeii and Herculaneum, in which the majority of medically related sites were uncovered before systematic excavation protocols were practiced. 6 The discoveries at Rimini, Allianoi, Rhodiapolis and Marcianopolis have significant potential to begin addressing some of the gaps in our knowledge regarding medical care outside of religious and martial contexts during the first several centuries of the Imperial period. This study is therefore focused on the medical landscape as it existed for the care of civilians in non-religious environments (i.e., outside of temple sanctuaries and faith-healing milieux). A consideration of some aspects of military medicine are undertaken in Chapter 2 of this study. However, this is done with an eye toward investigating the relationship between military and civilian medicine and the ways in which the two may have overlapped. I therefore consider only those aspects of military medicine 6 The earliest comprehensive publication on the medically related material from Pompeii and Herculaneum is Benedetto Vulpes’ Illustrazione di Tutti gli Strumenti Chirurgici Scavati in Ercolano e in Pompei, etc., published in 1847. For more recent studies of the medically related sites in and material from Pompeii and Herculaneum, see Lazer 1996, Bon et al. 1997, Cinaldi 2002, Bliquez 1995, 2015 and particularly his 1994 publication Roman Surgical Instruments and other Minor Objects in the National Archaeological Museum of Naples, which is the most complete accounting to date of the various sites and objects related to medical objects and practices within Pompeii and Herculaneum. 6 that are germane to the discussion of the ways in which martial and civic medicine interacted and intersected with each other; a broad, comprehensive examination of medicine as it existed for the care of Roman soldiers falls outside the scope of this study. Likewise, there are a number of excellent studies on putative therapeutic practices in religious contexts (e.g., Asklepian sanctuaries and shrines), faith-healing practices, magic rituals, etc. These topics are robust categories of scholarly inquiry in and of themselves. As such, they enter into discussion here only inasmuch as they are relevant to the more narrowly defined topic at hand: secular medicine in the Roman civic sphere in the Imperial era. The medically related evidence from Pompeii and Herculaneum, coming as it does from civilian contexts, certainly falls within the scope of this study. However, their longstanding reign as two of the Roman period’s most eminent archaeological sites means that there is a tremendous amount of existing secondary literature on various aspects of these ancient cities, including the medical finds identified within them. 7 While, as mentioned above, the more than two centuries of excavation history of these sites has resulted in a paucity of detail when it comes to some of the archaeological evidence, that which does exist has been thoroughly documented and considered. I do not undertake to repeat – or reconsider - these studies here. However, relevant evidence from Pompeii, Herculaneum and a number of other sites and sources of archaeological evidence will be introduced throughout this study as appropriate. The topic of Roman medicine, even separated from martial and religious contexts, is still a vast one. Civic medicine in this era could quite rightly be described as including “domestic” 7 Since the 19 th century, a number of journals have been dedicated to reporting the various discoveries at Pompeii and Herculaneum, such as Fiorelli’s Pompeianarum Antiquitatum Historia (PAH), the Giornale degli Scavi di Pompei (GdS), the Notizie degli Scavi di Antichità (NSc) and the Giornale dei Nuovi Scavi di Ercolano (GSE). Giovanni Carratelli’s 11-volume encyclopedic work Pompei: Pitture e Mosaici (1990-2003) is perhaps the most comprehensive accounting of Pompeii. For studies of the medically related sites and material specifically from Pompeii and Herculaneum, see above n. 6. 7 medicine (i.e., medicine practiced by a slave or family member for the benefit of the members of an individual household), midwifery, and that which may have been provided to the slaves and workers on agricultural estates outside of urban contexts. 8 These subsections of civic medicine, legitimate though they are, have been excluded from this study in the interest of maintaining focus on the contributing evidence from the four principal archaeological sites under consideration. Likewise, this study is limited to the first – fifth centuries C.E., as this is the period encompassing the four sites I am investigating. History of Scholarship The expansion that the field of Graeco-Roman medicine has seen in the last several decades has been driven in large part by the emphasis on interdisciplinary approaches to historical detective work. By considering several different categories of evidence and deploying the resources of a variety of academic disciplines, the landscape of Graeco-Roman medicine has been brought into sharper focus by scholars of classical literature, archaeology, and the social sciences. However, interdisciplinary approaches to medical practices in antiquity are relatively recent. Particularly in the 19 th century, scholars of Graeco-Roman medicine generally fell into one of two distinct categories: classicists who included the corpus of Greek and Roman medical literature in their literary studies, and physicians whose fascination with the medical collections recovered from Pompeii and Herculaneum moved them to more closely study these objects that so resembled their own instruments. An interest in the medical literature of Greece and Rome did not, of course, emerge spontaneously in the 19 th century. Indeed, the Hippocratic corpus (Corpus Hippocraticicum), 8 For examples of studies that address these aspects of Graeco-Roman medicine, see Bliquez 1995, Demand 1995, Draycott 2016 and 2019. 8 which dates from the sixth to the fourth centuries B.C.E., was one of the most authoritative medical texts well into the 17 th century. 9 By the mid-19 th century, modern medical science began to gradually replace ancient medical philosophy and practices. However, the Hippocratic corpus remains one of the foundational reference points for the textual scholar seeking to understand the medical ethos of Greece and Rome. 10 Later works from the Roman period provide further insight, though of course we are restricted to those texts that have survived. A number of ancient sources offer the student of classical literature glimpses into the landscape of Graeco-Roman medicine in the Imperial period. These include the pharmacopoeia of encyclopedists such as Pliny the Elder (23-79 C.E.), Celsus (ca. 25 B.C.E – 25 C.E.) and Dioscorides (ca. 40 – 90 C.E.), the case studies and musings of physicians such as Galen (129 – ca. 216 C.E.), and Soranus (98 – 138 C.E.) and even the hypochondriacal laments of Aelius Aristides (117 – ca. 181 C.E.). However, it is when these texts are overlayed with the medical material culture that the portrait of Graeco-Roman medicine starts to come into sharper focus. Interest in Graeco-Roman medicine as a distinct field was sparked by the 18 th -century discoveries of Pompeii and Herculaneum. Among the treasure trove of artifacts recovered from early explorations of these sites were several collections of medical instruments and related parasurgical objects (e.g., mortars, pestles, jars, and utensils used for preparing and storing medications, cupping vessels, etc.). Eventually, several hundred surgical instruments from Pompeii and Herculaneum would become part of the substantial holdings of the Naples 9 For a survey of the importance of the Hippocratic Corpus throughout history, see Wesley Smith’s The Hippocratic Tradition (Smith 1979). For an analysis of the effects that the 17 th century’s “scientific revolution” had upon western medicine, see Wear 1995, 340-59. 10 It is generally acknowledged that Roman medicine as it existed in the Republican and Imperial periods was founded upon the medical practices, philosophies and paradigms of ancient Greece. While an examination of this phenomenon is outside of the scope of this current study, several examples of work on this subject over the last century include Milne 1907, Allbut 1921, Scarborough 1969, 15-51, Jackson 1988 9-31, Marasco 1995, Nutton 1995a, 2012, 2013, 160-73, Israelowich 2012 and 2015, Rigato 2015 and Alonso 2018, 53. 9 Archaeological Museum. 11 In the mid-19 th century, a physician named Benedetto Vulpes, the Chief Surgeon in the Ospedale Real di Napoli, gave a series of lectures on the museum’s collection of instruments. The lectures were eventually organized into a book that included the first high-quality drawings of the instruments, Illustrazione di Tutti gli Strumenti Chirurgici Scavati in Ercolano e in Pompei, etc. which was published in 1847. 12 Vulpes’ work would be a crucial part of the seminal catalog later produced by John Stuart Milne, a Scottish surgeon with a proficiency in classical languages and literature. His book, titled Surgical Instruments in Greek and Roman Times, was published in 1907. It remained the definitive work on the subject of surgical instrumentaria (sets of surgical instruments) until 2015, when Lawrence Bliquez’s, The Tools of Asclepius: Surgical Instruments in Greek and Roman Times was published. Bliquez’s study is a superb integration of not only his predecessors’ work, but also a substantial amount of his own as well as that of Ernst Künzl. Künzl’s 1983 study, Medizinische Instrumente aus Sepulkralfunden der römischen Kaiserzeit, added medical instruments from almost 70 different tombs across the Empire to the compendium of known instrumentaria from the Imperial period. As a result of this impressive undertaking, those of us currently examining new data from archaeological sites now have an authoritative typological reference catalog to consult when confronted with a dizzying array of sometimes quasi-melted – and often highly oxidized – medical artifacts. Milne’s familiarity with classical languages and literature made him one of the earliest “crossover” scholars who attempted to reconcile the objects he studied with the primary source literature concerned with the various medical maladies of patients and the procedures used by 11 See above n. 6. 12 Though significant in that it represents the first systematic attempt to create a catalog of ancient medical instruments and related paraphernalia, Bliquez cautions that Vulpes’ work is problematic in that his collections were “contaminated” by objects that were not actually medical in nature. Bliquez 2015, 4. 10 physicians to treat them. 13 However, Milne’s study was restricted to the analysis and categorization of ancient medical objects. It was not until Milne’s contemporary, British physician (and inventor of the modern clinical thermometer) Sir Thomas Allbutt, published Greek Medicine in Rome in 1921 that scholarship became concerned with a broader view of what could now be considered a discrete discipline. Allbutt’s treatise was one of the first attempts to present a survey of Graeco-Roman medicine to a wide readership, and it remained perhaps the most definitive general work on the subject until John Scarborough’s 1969 book Roman Medicine. Since then, scholars of classical literature, Greek and Roman history, and archaeology as well as historians of science have drawn on the works of one another to great effect. As a result, several have become adept at viewing the subject through the myriad lenses of diverse areas of expertise. For example, some of the most prominent scholars of Graeco-Roman medicine today are Ralph Jackson, recently retired from the British Museum; Vivian Nutton, Emeritus Professor at the UCL Centre for the History of Medicine; Ernst Künzl, retired Chief Director of the Roman-Germanic Central Museum of Mainz; and Lawrence Bliquez, Professor Emeritus in the Classics department at the University of Washington. They are examples of the proverbial giants upon whose shoulders a new generation of subject experts now stand. 14 Recent works of the past decade have continued the approach of drawing upon evidence from a variety of academic disciplines to great effect. Books such as Vivian Nutton’s Ancient Medicine, 2 nd edition (2013), Ido Israelowich’s Patients and Healers in the High Roman Empire (2015) and W.V. Harris’s edited volume, Popular Medicine in Antiquity: Explorations (2016) represent the most current efforts to present a comprehensive view of Graeco-Roman medicine 13 Bliquez notes that Milne’s work has the same problems as Vulpes’ vis-à-vis contamination by objects that were not medical in nature. See above n. 12. 14 Jackson, Nutton, Künzl and Bliquez have all published extensively. Their publications that are relevant to this study are referred to throughout. 11 by examining the subject through the combined lenses of primary source literature, epigraphic material and archaeological evidence. 15 Though the understanding we now have of the field is more profound as a result of their work, the existing literature attempting to survey archaeological evidence of Imperial-era, secular medicine relies almost exclusively on evidence that originates in martial or sepulchral contexts as well as that which has been identified in Pompeii and Herculaneum. The omission of much of the material from Rimini, Allianoi, Rhodiapolis and Marcianopolis from the current literature intended to present comprehensive overviews of the Imperial-period medicine, including the titles mentioned above, means that of the six known sites associated with secular civilian medical practices (i.e., sites in civilian contexts identified as loci of medical activities outside of temple sanctuaries or shrines), only two – Pompeii and Herculaneum – are considered in any detail in the broader scholarly discourses concerning Graeco-Roman medicine. Given the scarcity of publications available for the medical material from Allianoi, Rhodiapolis and Marcianopolis, their omission from the most recent literature is perhaps unsurprising. 16 More puzzling is the almost-complete exclusion of the Domus del Chirurgo in Rimini, which has been meticulously documented and comprehensively published by the director of its near 20-year excavation, Professor Jacopo Ortalli. 17 Admittedly, even with the addition of the relatively new discoveries at Rimini, Allianoi, Rhodiapolis and Marcianopolis, the number of specific sites that can be definitely identified as loci where physicians practiced their profession 15 Nutton’s Ancient Medicine, first published in 2004, replaced Scarborough’s 1969 work as the most current survey of the discipline. The second edition was published to include “key discoveries made since the first edition, especially from important texts discovered in recent finds of papyri and manuscripts, making it the most comprehensive and up-to-date survey available” Nutton 2013a, i (Preface). Nutton’s focus on new evidence from textual sources may perhaps be the reason why even here the evidence from Rimini, Allianoi, Rhodiapolis and Marcianopolis is absent. 16 The presentation of the four sites in Chapter 1 includes a discussion of the circumstances surrounding the excavation and publication histories of each site. 17 Ortalli 2000b, 2000c, 2003a, 2005, 2007, 2009. 12 in the secular, civilian sphere is still quite small; outside of these, the majority of archaeological evidence comes to us from tomb finds as well as literary and epigraphic sources. 18 However, within the limited scope of this study, the information from the four sites is proportionally substantial. For example, the number of medically related artifacts identified from Allianoi alone is staggering; the director of its excavations, Professor Daniş Baykan, has ascribed medical functions to almost 350 objects, which is only slightly less than the combined ca. 380 pieces thus far excavated in all of Pompeii and Herculaneum. 19 When we add the ca. 150 instruments recovered from Rimini and the 32-piece instrumentarium discovered at Marcianopolis, we now have a collection that totals well over that from Pompeii and Herculaneum. Furthermore, unlike Pompeii, the medical objects from Rimini and Allianoi come from archaeological contexts that were much more methodically documented. 20 The specific information provided by the medical instruments recovered from these sites is just one component of the contributions that these sites make to the discipline; the following study considers this and the several other aspects of Roman civilian medicine previously mentioned. It is my hope that by considering the significant contributions that the evidence from Rimini, Allianoi, Rhodiapolis and Marcianopolis make to the discipline, I will be building upon – and contributing to – the substantial body of work that has been produced by those scholars who have continued to expand and deepen our understanding of Graeco-Roman medicine over the course of the last 150 years. 18 For medical instrumentaria recovered from burial contexts, see Künzl 1983 and Jackson 1995, 196-200, Jackson and La Niece 1986. For comprehensive catalogs of medically related epigraphy see Samama 2003 (Greek inscriptions) and Alonso 2018 (Latin inscriptions from the Italian peninsula). 19 Baykan 2012a (Allianoi); Bliquez 1994 (Pompeii and Herculaneum). 20 Little is known of the archaeological context of the Marcianopolis instrumentarium. Though few medical instruments were recovered from Rhodiapolis, its contributions are significant in other areas. See Chapter 1 for a detailed discussion of these two sites. 13 Sources and Methodology As previously stated, the primary objectives of this study are to consider the evidence from the sites of Rimini, Allianoi, Rhodiapolis and Marcianopolis and to situate them within the broader context of Roman civic medicine in the Imperial period. In order to accomplish this, it was first necessary to construct reports of the four sites that are as complete as possible; these accounts comprise the first chapter of this study. In the case of the Domus del Chirurgo in Rimini, the process was straightforward. As the site was thoroughly documented and comprehensively published, my presentation of the Domus del Chirurgo in Chapter 1 was accomplished by consolidating the available information in existing publications. This task was made even easier thanks to my own familiarity with the site, which I was able to visit multiple times between 2015 and 2018 and during which I availed myself of the generosity of Professor Ortalli and the staff at the Museo della Città, who graciously gave me access to their expertise and resources. The available published information on the medically related material from Allianoi, Rhodiapolis and Marcianopolis, on the other hand, was insufficient for my purposes. Therefore, the presentations of these sites in Chapter 1 represent a synthesis of the available publications, from which I was able to extrapolate additional information by comparing the published material to available site maps. Some of the information contained in my reports of Rhodiapolis and Marcianopolis was based upon my own surveys and observations, as I visited both sites in the summer of 2019. During these visits, I was able to meet with Professor İsa Kızgut, one of the excavation directors of Rhodiapolis, as well as Professor Alexander Minchev, the archaeologist who excavated the Marcianopolis instrumentarium. 21 Their graciousness and generosity in allowing me to interview them about their respective projects enabled me to add additional 21 Though I made several attempts, I was unfortunately unable to meet with or otherwise communicate with the scholars involved with the excavations at Allianoi. See Chapter 1 of this study for a more detailed account. 14 details to my accounts of these two sites that are not available in existing publications. As far as I have been able to ascertain, the presentations of the medically related material from Allianoi, Rhodiapolis and Marcianopolis contained in this study are the most complete and comprehensive to date. Assembling all the available evidence for the four sites constitutes the first step of this study. In order to appropriately evaluate their contributions to our understanding of Roman civic medicine, I attempt to follow in the methodological footsteps of scholars such as Nutton, Jackson, Bliquez and Israelowich by drawing upon various categories of evidence and disciplines. This entails consulting the extant works of ancient medical authors such as Galen, Celsus and Dioscorides, whose writings help us understand the medical landscape of their time (at least as they perceived it), as well as writers such as Suetonius, Vegetius and the various contributors to the codices of Theodosian and Justinian who, while not directly concerned with documenting the medical paradigms of their era, nevertheless provide information concerning the Roman laws, institutions and individuals that helped to shape civic medicine and influence the practices and organization of its practitioners. Epigraphy is another critical category of evidence considered in this study, and many examples pertaining to the activities of Roman medici (doctors) in the Imperial period are contained in long-standing compendia such as the indispensable Corpus Inscriptionum Latinarum (CIL) and the various catalogs of the Inscriptiones Graecae (IG). However, I am particularly fortunate to be a beneficiary of the efforts of two scholars in particular: Évelyn Samama and Maria Ángeles Alonso. Samama’s 2003 catalog Les Médecins dans le Monde Grec: Sources Épigraphiques sur la Naissance d’un corps Médical is a catalog of all the known 15 examples of Greek epigraphy related to Graeco-Roman physicians and their profession. 22 Alonso’s 2018 Los Médicos en las Inscriptciones Latinas (siglos II a.C.-III d.C.): Aspectos Sociales y Profesionales represents a similar undertaking for the Latin inscriptions of the Italian peninsula. Both works are invaluable resources to the scholar of Graeco-Roman medicine, and I have relied heavily upon these as well as the more traditional corpora of Greek and Latin inscriptions. In evaluating the evidence from the four principal sites addressed in this study, the archaeological material from military valetudinaria, tombs and sites such as Pompeii and Herculaneum provide important comparanda. Likewise, the numerous studies of medical instruments and objects produced by scholars such as Jackson and Bliquez serve as important reference works for the identification of instrument typologies, their functions, and the medical expertise they represent. However, medical implements comprise only one category of evidence available from the four sites under consideration. In some cases, these objects as well as the broader archaeological contexts from which they were recovered provide us with insights into the lives of specific physicians, permitting us to make their acquaintance and speculate to what degree they may have been representative of their profession. Additional lines of inquiry allowed by the available sources include the avenues of education and training that may have been open to aspiring physicians, the forces at work that helped shape the organization and hierarchal structure of the profession, and the nature of medical markets. In the course of investigating these and other aspects of civilian medicine in the Imperial period, I am aided by the substantial 22 Medically related epigraphic evidence discovered after 2003 is of course not included in Samama’s catalog. The inscriptions from Rhodiapolis, which were discovered between 2006 and 2012, are not yet included in any of the authoritative collections of Graeco-Roman epigraphy. See Chapter 1 of this study. 16 body of work available for sites such as valetudinaria, temple complexes, libraries and markets, as well as visual material (e.g., tomb reliefs). Organization and Preview of Chapters The first chapter of this study (“The Archaeological Sites of Ariminum, Allianoi, Rhodiapolis and Marcianopolis”) consists of a presentation of the Domus del Chirurgo in Rimini, Allianoi, Rhodiapolis and Marcianopolis. Each site’s account begins with a brief historical contextualization of the city, followed by a discussion of the relevant evidence from each; a discussion that includes the circumstances surrounding their discovery and excavation. The subsequent three chapters examine various aspects of civilian medicine in the Imperial era, upon which the evidence from the four sites sheds further light. For example, Chapter 2 (“The Intersection of Military and Civilian Medicine”) examines the nature of the relationship between military and civic medicine, and the ways in which medical knowledge – and medical practitioners – may have moved between the civic and martial spheres. Chapter 3 (“The Shaping of Medical Practices, Practitioners, and the Profession”) explores some of the various forces at work that shaped the professional landscape of civilian medicine, forces that include physicians’ professional organizations (collegia) and the nature of the medical economy, while Chapter 4 (“Physicians’ Expertise and the Tools of the Medical Trade”) investigates the various types of medical expertise and surgical technologies that existed for the non-martial inhabitants of the Empire, and examines the ways in which these scenarios may be applicable to the civilian medical landscape more broadly. Given the varied nature of the medically related material from each of the four sites, not every site has relevant evidence to bring to bear on the issues examined in each of the latter three 17 chapter of this study. For example, evidence from Rimini and Marcianopolis is central to Chapter 2’s discussion concerning the relationship between military and civilian medicine, while the nature of the evidence from Rhodiapolis and Allianoi do not – at least at this time – have any bearing on those particular lines of inquiry. Similarly, the material from Allianoi and Rhodiapolis is particularly relevant when it comes to an examination of the forces at work that shaped the medical profession in the civilian sphere, while the material from Marcianopolis has little applicability to these topics and therefore does not make an appearance in Chapter 3. However, the Marcianopolis instrumentarium is central to the discussions in Chapter 4, as is the evidence from Rimini. A number of medical implements recovered from Allianoi are also germane to the discussions of physicians’ expertise in this chapter, while the very limited number of medical instruments recovered from Rhodiapolis (and their deteriorated condition) largely precludes that site from the analyses that comprise this final chapter. Rimini, Allianoi, Rhodiapolis and Marcianopolis each offer us a piece of the puzzle that is the landscape of civilian medicine in the Imperial era in that each has yielded material that can be applied to various lines of inquiry into the field. For example, unlike Rhodiapolis, material from Marcianopolis may tell us little about how physicians may have received their education and training, but it can tell us a great deal about the types of medical procedures that were performed by their owner, which can then be compared with what we know of other practices elsewhere in the Empire, including Rimini and Allianoi. So, while all four sites may not be able to inform all of the topics investigated in the following chapters, each site can – and does – inform some of them. In contemplating the questions I am attempting to pose and (at least partially) answer in this study, I imagine my approach to be similar to examining a landscape by using an 18 incrementally more powerful series of camera lenses; it is with this in mind that I have ordered the chapters in the present manner. Chapter 1 consists of a presentation of the relevant information for the four archaeological sites of Rimini, Allianoi, Rhodiapolis and Marcianopolis. I view this chapter as constituting the foundational layer of this study. It serves as the departure point for the lines of inquiry that I pursue in the subsequent three chapters since it is only in understanding the nature of these sites and the evidence available from them that the topics examined in the subsequent three chapters – the various “views” of the civilian medical landscape – can be adequately explored and understood. I consider Chapter 2, with its focus on the relationship between military and civilian medicine, to be the broadest view of the Roman medical landscape in the Imperial period as it takes into account the circumstances of medicine in two separate spheres of Roman society: the martial and the civic. This chapter examines the nature of the relationship between medicine as it existed for the care of Roman soldiers and that which existed for those in civilian environments, and the ways in which medical knowledge, practices and personnel may have moved between these two spheres. Questions I ask in this chapter include the following: In what ways did military and civilian medicine intersect, and to what degree did these two medical environments overlap? What does the evidence tell us about how medical practices and practitioners in the Roman army may have interacted with, and possibly influenced, those in the civilian world? The examination of these issues begins with a consideration of the available evidence for the military medical corps: how it may have been structured, the roles of military physicians in the army, and what we know of their practices and expertise. I then consider the possible avenues of interaction between military medicine and that which was practiced in civilian contexts by examining various scenarios involving physicians from both spheres. Such scenarios include military 19 physicians who entered civilian practice upon their discharge from the army, bringing the medical expertise acquired in conflict zones with them into civilian environments, civilian physicians who may have temporarily worked in the employ of the Roman army who would then have been able to acquire medical skills more frequently practiced in martial environments, and physicians from both contexts who may have included among their patients both civilians and soldiers. Finally, I consider the relevant material from Marcianopolis and Rimini and examine what light may be shed on these considerations by the evidence from these two sites. The view of the medical landscape both narrows and is magnified somewhat in Chapter 3 as we move from a consideration of both military and civilian medicine together to zeroing in on the dynamics of civilian medicine in the Imperial era. This chapter considers the types of organizational forces that I contend were at work upon medicine in the civilian sphere, beginning with a consideration of actions on the part of the Roman state that may have influenced civic medicine, whether directly or indirectly. For example, what laws and regulations issued by the Imperial administration can be said to have affected the ways in which the profession was organized? Besides direct state or municipal involvement, what were some of the other dynamics that acted upon civilian medicine and its practitioners? In the course of these inquiries, this chapter examines certain laws imposed by the Roman state that, while not specifically intended to impose an organizational structure onto the profession, nevertheless resulted in delineating and reinforcing a hierarchal arrangement within it. For example, the role of the “public physician” is a result of state-imposed laws that were designed to regulate and protect tax revenue. These laws acted indirectly but effectively to create circumstances in which an upper tier in the hierarchy of medical professionals developed, a phenomenon that is examined in detail in Chapter 3. I further examine other laws imposed by the state that exerted a degree of influence 20 over actual medical practices in that they directly proscribed certain procedures and treatments. Additional topics of investigation contained in Chapter 3 include the roles that private benefactors and medical competitions may have had on civic medicine and its practices as well as the ways in which medical knowledge and training could be obtained. Medical education and libraries are of particular interest here, as the evidence from Rhodiapolis has some interesting light to shed on the subject. At the very least, it opens up new avenues of inquiry vis-à-vis the ways in which aspiring physicians may have obtained their education and training. Finally, this chapter investigates the ways in which the basic economic dynamics of supply and demand may have influenced civic medicine, or at least the professional success of some of its practitioners. The economic aspects of a “medical market” are also considered in an examination of the evidence from Allianoi, a town for which medicine seems to have been a significant aspect of its economy. The final chapter of this study zooms in for a close-up perspective on the physicians themselves, the tools of their trade and their expertise. Some of the questions posed here include: What do we know about the design and manufacture of medical instruments from this period? What does the archaeological evidence (i.e., the instruments and the contexts in which they are discovered) tell us about the medical expertise of Roman physicians? What do we know about various types of medical specialization that existed in the Imperial period? And finally, what does the evidence from Rimini, Marcianopolis and Allianoi tell us about the medical expertise of the physicians at these sites specifically, and what conclusions, if any, can we extrapolate from this information regarding civilian medicine in the Imperial period more broadly? The examinations of these questions begin with a discussion of what we know of the instruments themselves: their manufacture, design, and the role that physicians may have played in both. I 21 then go on to examine the significance – and the limitations – of archaeological evidence obtained from sepulchral contexts. This is followed by an assessment of what the literary and epigraphic sources tell us of medical specialization before moving on to an investigation of the same topic through the lens of the evidence from Rimini, Marcianopolis and Allianoi specifically, and what this may indicate concerning the types of medical expertise and specializations that may have been available to Roman civilian patients. It is my intent that by undertaking the present study of these four sites, their significance for our understanding of Roman civic medicine in the Imperial period will begin to be recognized and that they will assume their deserved place within the broader scholarly discourse of the discipline. Though this undertaking is necessarily circumscribed by the limitations of the available evidence, it is my hope that the results of this project represent a step toward a more comprehensive view of Graeco-Roman medicine as a whole – and that it perhaps proposes some intriguing new possibilities for future investigations along the way. 22 Chapter 1: The Archaeological Sites of Ariminum, Allianoi, Rhodiapolis and Marcianopolis The four sites that comprise the primary focus of this study are some of the only existing Imperial-era sites from which we have evidence of secular, civilian medicine in the urban contexts where it was actually practiced. While instrumentaria recovered from sepulchral contexts also provide us with valuable information, the discoveries of evidence related to medical practices in the actual environments in which physicians lived and worked invite us to view civilian medicine of this era through a wider lens. 23 That said, the views provided by the sites of Rimini, Allianoi, Rhodiapolis and Marcianopolis vary greatly. This is largely a result of the accidental and sometimes constrained circumstances under which the discoveries were made and subsequently excavated. The details of these circumstances are included in the presentation of the four archaeological sites that comprise this chapter. Each site’s presentation includes a brief history of the site, an accounting of the circumstances surrounding their discovery and excavation and a summary of the medically related material recovered. When possible, I have also included previously published site plans, which I have modified from their original formats by adding additional information and detail I gained from other publications and/or interviews with the excavation directors. Likewise, the information presented in the descriptions and summaries of the excavation results are amalgamations of information I have gathered from various published sources, interviews, and personal observations from my visits to these sites. The order in which the sites are presented here is not particularly significant, though I chose to begin with the one that was the most comprehensively excavated, published, and conserved, and which is the most accessible to the modern visitor. A beautifully displayed 23 For a discussion of medically related finds in sepulchral context, see Chapter 4 of this study. 23 cultural monument accompanied by didactically rich exhibits, the Domus del Chirurgo is the jewel of modern Rimini’s historical patrimony. It can be easily accessed by any interested visitor wiling to purchase a ticket to the Museo della Città, the city’s primary museum of which the Domus del Chirurgo is now a distinguished part. From Rimini, the sites are presented in general order according to the quantity of known contextual evidence, i.e., the amount of information we have available concerning the medically related material from the site. Rimini, having been thoroughly excavated, documented, and published, is the site for which we have the most complete information. From there we move to Allianoi, Rhodiapolis and finally to Marcianopolis, from which almost no contextual information is available other than the instrumentarium itself. Geographically, Rimini is the westernmost site. From there, we move east across the map to Allianoi and Rhodiapolis in present-day Turkey before veering north to Devnya, Bulgaria to complete a metaphorical – and roughly cartographical – circle (Fig. 1.1). Of these three latter sites, only Rhodiapolis still exists and is able to be visited, though not without considerable planning. The information available for each of these three is varied and, unfortunately and for various reasons, incomplete. But they each nevertheless have a great deal to offer in terms of information, and in these cases we are far better off with some information, however fragmented, than none. Domus del Chirurgo (Rimini, Italy) The Domus del Chirurgo was discovered in 1989 in Piazza di Ferarri, a central square in the resort town of Rimini, an Italian city known primarily in present times for its beaches and nightclubs. Called Ariminum by the Romans, its location on the coast meant that it served as a port for Adriatic shipping. Its position as the terminus of the Via Flaminia, which originated in 24 Rome, and the beginning of the Via Aemelia, which led northwest toward the frontiers of the Empire, ensured that there was a steady stream of people and goods moving through the city for most of its history. 24 Originally founded as a Roman colony around 267 or 268 B.C.E., the region is believed to have been populated as early as the second millennium B.C.E. 25 Though still a colony in the early days of the Roman Republic, the ancient city of Ariminum was well established by the time Julius Caesar came north with his legions with an eye toward adding Gaul to Rome’s expanding territories. Ariminum’s proximity to Rome’s northern border at the time made it a strategic staging area for Julius Caesar’s legions during the years of his Gallic campaigns. 26 In the two centuries following its Gallic conquest, Rome expanded its territories to encompass much of what is now modern Europe, and the political stability of the Empire during this period ensured that much of the Empire, including Ariminum, enjoyed a period of peace and prosperity. By the mid-third century C.E., however, the Roman Empire was in the period of its decline; emperors were being confirmed and subsequently dispatched in dizzying succession, and the political instability resulted in an inability to maintain the integrity of Rome’s far-flung borders. In Ariminum, incursions from hostile tribes in the north had become a more significant threat; it is believed that a particularly violent conflict (possibly with the Alemanni tribe) resulted in a fire that destroyed the northern quarter of the city during the reign of the Roman emperor Gallienus (r. 252-260 C.E.). 27 A hoard of approximately 80 coins recovered from the Domus del Chirurgo, believed to have fallen from one of the second-story rooms when the upper level of the 24 For a study of the region’s settlement history, see Braccesi 2003. 25 Braccesi 2003, 15; Negrelli 2013; Ortalli 2014, 21. 26 Braccesi 2003, 44-5. 27 Maroni and Stoppioni 1997, 41-62; Braccesi 2003, 58; Ortalli 2014. 25 house collapsed, has helped us establish a terminus ante quem for the fire, which the site’s excavation team has placed between 258-260 C.E. 28 As with many such discoveries, the Domus del Chirurgo find was a fortuitous accident. In 1989, an uprooted tree in Rimini’s Piazza di Ferrari required removal and a subsequent repaving of the piazza’s northern corner. During the tree removal, surprised construction workers noticed colorful fresco fragments lodged in the tree’s roots, upon which responsibility for the site was then turned over to a team of archaeologists from the University of Ferrara led by Jacopo Ortalli. Over the course of the subsequent excavations, which were concluded in 2007, Ortalli and his team uncovered a 700-square-meter complex of structures that spanned periods from the Roman Republic to the medieval. It was in the northern sector of the excavation area that the most startling discovery was made: approximately 150 surgical instruments were discovered in a single room of what was a large, two-story domus, which dates to the mid-third century C.E. (Fig. 1.2). 29 The fact that the recovered medical objects represent such an impressive array of high-quality surgical instruments led to the site’s appellation, Domus del Chirurgo, since it was concluded that owner of such an expensive and specialized collection must have been a surgeon of some skill in order to use the instruments effectively, as well as to afford his refined residence. 30 Ortalli and his team determined that the large, single domus inhabited by the surgeon in the third century represents the final phase of modifications of a building that was completed in the mid-second century C.E., which itself was constructed from an older, first-century B.C.E. domus. 31 The unusual trapezoidal shape of the third-century phase of the domus, most evident in 28 Ortalli 1992, 589; Ortalli 2000c, 518; Ortalli 2008, 29-31. 29 Ortalli 2000b, 2000c, 2005, 2007, 2008, 2014. 30 De Carolis 2009a, 2009b, 2015, 2016; Ortalli 2000b, 2000c, 2005, 2007, 2008, 2014; Jackson 2002, 2003, 2009. 31 For discussionsabe of the various phases of the domus’ construction, see Ortalli 2009, 25-6 and 2014, 21-7. 26 the architectural arrangement of the triclinium, was a result of the need to accommodate the pre- existing first-century C.E. road that ran along the northeast side of the property (Fig. 1.3). 32 Otherwise, the domus exhibits all the standard architectural hallmarks of an upper-class residence of the time: the portions of the house’s ground floor that were able to be excavated exposed the remains of a garden, a hypocaust over which a small, private bath complex was likely present, and the aforementioned triclinium. 33 Running through the center of the property along the northeast/southwest axis of the domus is a spacious corridor, serving as a transitional area between the garden and the interior domestic spaces. 34 Remains of mosaics and fresco fragments attest to the fact that the house was richly decorated, featuring fine polychrome and monochrome mosaics and colorful frescos. 35 The most spectacular of the mosaics was discovered on the floor in the same room from which the medical instruments were recovered. The floor of the room, which measures ca. 4 x 4.20 meters, is visually dominated by a magnificent polychrome mosaic depicting the figure of Orpheus, situated in the center of a circular arrangement of rondels in which appear various animals (Fig. 1.4). Interestingly, while there are other high-quality mosaics in most of the rooms, this is the only one that depicts an anthropomorphic figure. It is tempting to symbolically connect this image of Orpheus, who was sometimes associated with Graeco-Roman medicine and its practitioners, with our third-century physician who practiced his profession in this room. However, it would seem as if the mosaic’s existence was a happy, if appropriate, coincidence. An iconographic analysis of the mosaic determined that it dates to the mid-second century C.E., 32 Ortalli 2009, 29. 33 Ortalli 2000c, 2001, 2009, 2014; Fontemaggi and Piolanti 2016, 81-7. 34 Balena and Sassi, 2013, 9-17. 35 Fontemaggi and Piolanti 2016, 81-7. 27 when the original Republican-era domus was expanded to its present size and no doubt decorated in keeping with the tastes - and economic status - of its owner. 36 Adjacent to “Orpheus Room” is a cubiculum (bedroom) that was able to be accessed via a doorway that connected the two rooms; it would appear from the site plan that neither room was accessible from the street. 37 The cubiculum had a single window that opened onto the corridor, which in turn opened onto the garden, allowing for light and air circulation. Interestingly, there was no other doorway to the cubiculum other than that which opened into the “Orpheus Room.” The cubiculum also had a fine mosaic executed in a monochromatic, geometric design. Fragments of carbonized wood and rope recovered from this room have been identified as the remains of a lectus (bed); a bronze, ribbed basin and several oil lamps were also recovered (Fig. 1.5). Architecturally delineated as a separate, two-room space within the larger domus structure, with only a single point of entry via the Orpheus Room, the archaeological finds discovered in these two rooms led Ortalli and his team to conclude that they functioned as a medica taberna, a professional medical clinic within the larger domestic context of the physician’s home. 38 They further hypothesized that the Orpheus Room functioned as the consultation room, whereas the adjacent cubiculum was where the more serious surgical procedures would have taken place, as well as patient recovery. 39 Ortalli’s conclusions concerning the function of these rooms are grounded in solid evidence, discussed in greater detail below. Only able to be partially excavated due to the presence of other structures, the entire house was likely the size of a small city block. 40 It was located in what would have been a 36 Fontemaggi and Piolanti 2016, 85. 37 Ortalli 2009, 25 (Figure 5); Fontemaggi and Piolanti 2016, 81. 38 De Carolis 2009a, 2009b, 2015, 2016; Ortalli 2000b, 2000c, 2005, 2007, 2008, 2009, 2014; Jackson 2002, 2003, 2009; Balena and Sassi 2013; Fontemaggi and Piolanti 2016. 39 Ortalli 2007, 103-04; Angeletti 1992, 216. 40 Ortalli 2000c, 2001, 2003b, 2005, 2007; Dal Maso 2003; Balena and Sassi 2013, 11-30. 28 desirable and prestigious neighborhood at the intersection point of two major streets and just a few blocks from the ancient coastline. In addition to the two-room clinic, other areas of the house that were excavated include a dining room, another room adjacent to the medical clinic that may have been a reception room, and the remains of a latrine. Kitchen and food preparation implements found among the debris from the collapsed second story indicate that a kitchen area and pantry were located on that level. 41 It was in the Orpheus Room that the approximately 150 surgical instruments, many of which were in relatively good (i.e., recognizable) condition, were recovered. This cache represents the largest collection of surgical tools in the world from the Graeco-Roman period in both number and typology. 42 In his assessment of the medical assemblage, Ralph Jackson also identified other instruments that are, as far as we know, quite rare, and some that are completely new. 43 Especially notable and exciting is an instrument referred to as a “Diocles’ Spoon,” used for extracting arrowheads in a way that causes minimal damage. 44 Such a tool had been referred to by Celsus, but an authentic example had never been discovered. 45 While the Diocles’ Spoon is perhaps the most notable of the collection, several others represent rare surgical instruments that could only have been used by a very skilled surgeon. Approximately 40 tools directly associated with bone surgery were recovered, such as drills for trepanation procedures, bone gouges (lenticulars) and bone levers (elevators). 46 Also recovered were at least seven dental forceps that 41 Balena and Sassi 2013, 27; Ortalli 2009, 29. 42 Interview with Dr. Ralph Jackson in the video featured on the Musei di Rimini’s website Domus del Chirurgo – Musei di Rimini. For an inventory of surgical instruments and other medically related objects recovered from Pompeii, see Bliquez 1994. http://www.museicomunalirimini.it/musei/museo_citta/domus_museo_citta/ 43 Jackson 2002, 2003, 2009. 44 De Carolis 2008, 2009a, 2015; Bliquez 2015, 141-43; Jackson 2009b, 89; Ortalli 2009, 33. 45 Celsus, Med. 7.5.2B (= Spencer 1938b, 319); An object belonging to the German collector Theodor Meyer- Steineg, ostensibly from Ephesus, was thought to be an example of a Diocles’ Spoon but was later determined to be a forgery. Künzl 1991, 522-25; Bliquez 2015, 142. 46 Jackson 2009b, 88-9. 29 attest to the surgeon’s practice of dentistry, and instruments associated with the dangerous procedure of extracting stones from the urinary tract. 47 Specialized forceps called staphylagra and staphylocaustes that were used for throat operations and the excision of hemorrhoids were among the collection, as well as over 40 scalpels and scalpel blades, some of which had been identified by Jackson as being heretofore completely unknown types. 48 Other instruments from the collection include 19 spring forceps of varying jaw sizes, specially forged spoons used for debriding wounds, surgical needles and a variety of hooks and probes. 49 Mortars and pestles of varying sizes used to prepare medicines were recovered in-situ in both the Orpheus Room as well as in the corridor. 50 Additional items recovered from the Orpheus Room include small scales and measuring containers used in the preparation of medicines, glass and ceramic medicine jars, some of which were labeled with Greek lettering indicating the various substances once contained within them, and the remains of a rectangular instrument box. 51 An additional interesting object discovered in this room was a foot-shaped vase, believed to have been used as a therapeutic device for foot injuries. 52 Concentrated on the floor along the northeastern wall of the room were the remains of wooden and marble shelves, probably once secured to the wall with wooden fixtures, upon which the instruments and medicine containers were likely arranged. 53 In addition to the remarkable array of medical objects identified in the Orpheus Room, Ortalli and his team also recovered the remains of three weapons that were characteristic of those used by Roman soldiers in the mid-third century, as 47 Jackson 2009b, 87 48 Jackson 2009b, 87-9. 49 Jackson 2009b, 87-9. 50 Ortalli 2000c, 516 and 2009, 32-3. 51 Ortalli 2009, 32-9; The rectangular and cylindrical containers used by ancient physicians to store essential tools are well-documented. For some examples of comparanda see Bliquez 2015, 273-78 and De Carolis 2009b, 53-5. 52 Ortalli 2009, 38; Though rare, other examples of this type of therapeutic treatment do exist. It is believed that the patient would place his foot into the device, which would be filled with a warm, medicated oil. See Nicolaou 1989. 53 Oratlli 2000c, 516; Balena and Sassi 2013, 43. 30 well as a small votive object in the form of an extended hand associated with the cult of Iuppiter Dolichenus. 54 In the adjacent cubiculum, archaeologists found an unusual and interesting graffito that seems to offer a clue regarding the identity of the physician who worked in these rooms. Inscribed on a frescoed wall fragment, believed to have been originally located next to the bed, were the Latin words “[Eut]ych[es] [ho]mo bonus [hic h]abitat. [Hic su]nt miseri].” One of the “miserable ones” presumably a patient, declared in the graffito that Eutyches was a good man, and that he lived here. 55 Epigraphic analyses of the graffito determined that it dates to the mid- third century C.E., contemporary with our physician and the period in which the site was destroyed. 56 This has led the site’s excavators to the tempting and relatively reasonable conclusion that we have a name to associate with the medical practitioner who lived and worked in this extraordinary domus. 57 As a result, the Rimini physician is frequently referred to as “Eutyches” in much of the published secondary literature on the subject, as well as in this study. The construction of a second domus in the Late Antique period over the remains of the southwest section of the Domus del Chirurgo’s rooms and interior courtyard precluded their excavation. Likewise, the entirety of the northwest section of the domus was only able to be partially excavated. Immediately northwest of and adjacent to the cubiculum was the trapezoidal triclinium, in which was recovered a beautiful and unusual decorative element: a small opus sectile panel (ca. 32cm in diameter) made of polychrome glass, depicting three fish. 58 The panel is of Greek origin and dates to the mid-third century C.E. 59 Another decorative element with 54 Ortalli 2000c, 521; Ortalli 2007, 113-14. For a more detailed discussion of these military related items and their significance see Chapter 2 of this study. 55 Ortalli 2007, 115-16; 2009, 37; Balena and Sassi 2013, 43. 56 Donati 2005; Braccesi 2009. 57 De Carolis 2009a, 2009b, 2015, 2016; Ortalli 2000b, 2000c, 2005, 2007, 2008, 2014; Jackson 2002, 2003, 2009. 58 Ortalli 2000c, 519-20 and 2007, 105; Balena and Sassi 2013,48-9. 59 Ortalli 2000c, 520 and 2007, 105. 31 Greek associations was recovered by archaeologists in the excavated northeast portion of the courtyard. A statuary fragment in the form of a foot, together with a portion of its base, was identified by a partial Greek inscription on the base as belonging to a statue of Hermarchus, a fourth- or third-century B.C.E. Epicurean philosopher. 60 Following the fire that destroyed the Domus del Chirurgo and the surrounding neighborhood, the area was almost completely abandoned until the early fifth century, when various emperors began to take up residence in Ravenna, approximately 70km north of Ariminum. 61 From an archaeological standpoint, this proved to be fortuitous; by the time rebuilding began approximately 150 years later, the previous structures had been forgotten. Subsequent structures were built on top of the rubble, thus preserving the remains of the third- century domus, hiding any clues to its existence until an accident of nature uprooted the large tree in Rimini’s Piazza di Ferarri over 1500 years later. Today the modern coastline is almost a full kilometer east of the site. Deposits from the Po river delta, centuries of significant seismic activity in the region as well as the more modern impact of intensive Allied bombing during World War II has altered it considerably. In the third century, the physician’s domus would have occupied a desirable real estate location just a few dozen meters from the waterline, away from the more crowded and chaotic urban center of the town (Fig. 1.6). 62 Today the Domus del Chirurgo, which opened to the public in 2007, is one of Rimini’s primary historical attractions – a beautifully excavated and preserved archaeological site of which the city’s residents are justifiably proud. 60 Ortalli 2007, 109-10. In addition to inscription, the foot and its positioning matches those of other known examples of Hermarchus statues. See Ortalli 2007 111 n. 15. A more detailed discussion of this fragment and its possible significance can be found in Chapter 3 of this study. 61 Ortalli 2003, 111-13; Deliyannis 2010, 46-50. 62 Three particularly destructive earthquakes impacted the city in 1672, 1786 and 1916. See Pivato 2003. 32 Allianoi (Turkey) The ancient Graeco-Roman spa town of Allianoi, located approximately 18 kilometers northeast of Pergamon in western Turkey, is a story of both a tremendously significant archeological gain and an equally significant loss. The site, in which medically related finds were recovered not just from one structure but scattered in substantial numbers throughout the town, is potentially the most significant medical discovery of the Graeco-Roman era. Unfortunately, these finds were recovered as a result of rescue excavations, which are generally conducted when a site is deemed to be at serious risk. Undertaken by an archaeological team from Trakya University led by Ahmet Yaraş and Daniş Baykan, the excavations of Allianoi took place between 1998 and 2006. In this case, the risk was inconvertible; the whole area was slated for submersion upon the completion of the Yortlanı Dam, which became operational in 2010. By February of 2011, Allianoi was completely submerged and now lies completely inaccessible under several meters of water in what is now a reservoir used for agricultural irrigation. 63 The remains of Allianoi date predominately to the second century C.E. Though we know little about the town prior to the Imperial period, the presence of natural thermal springs and a small number of finds indicate that there was a thermal bath complex at the site during the Hellenistic period, though it was almost certainly smaller in scale than the Roman complex. In the first half of the second century CE during the reign of the emperor Hadrian (117-138 CE), the site was lavishly rebuilt, which is consistent with the development of other urban centers in Anatolia at this time, including significant expansion and public works undertaken at Pergamon in the same period. 64 Galen mentions Allianoi in his writings, and the second-century orator and 63 I verified this myself in the summer of 2015, when I traveled to the region. The road that once led to the site now leads into a reservoir. 64 Nutton 2013b, 122. 33 writer Aelius Aristeides claimed to have spent some time in the spa town at the instruction of the god Asklepios. 65 Two inscriptions at Allianoi indicate dedications to the deity, whose sanctuary just outside of the city of Pergamon was one of the most famous healing centers of the ancient world. 66 At some point in the mid-third century, the site was destroyed. It is believed that the town was lost as a result of flooding from the Ilyas River, which ran through the center of the town on an east-west axis, as a layer of riverbed sediment was encountered throughout the site, dating to approximately 250 C.E. 67 Much of the site remained covered, though there is evidence of Byzantine-era inhabitation of the city. 68 The site had been sporadically excavated over the course of the 20 th century, and up until the Yortlanı dam became operational, it was able to be visited by tourists. 69 Despite vigorous protests from both within Turkey and the international community, the plans for the Yortlanı Dam were approved in the mid-1990s, and rescue excavations at Allianoi were begun. 70 While excavations revealed only a portion of the town before they were halted in 2006, eight seasons were enough for excavators to recover a substantial amount of evidence that indicated Allianoi was the site of a robust medical “market,’ a major medical center where sophisticated surgical interventions may have taken place on a systematic basis. 65 Gal. San. Tu. 6.9 (= Green 1951, 261) Aristid. Or. 49.1-7 (= Sacred Tales 3.1-7 in Behr 1968, 241-242). 66 Yaraş and Erten 2008; While the findspots of the inscriptions are indicated in a 2008 publication by Yaraş and Emre Erten by their plan coordinates, the scale of the published plan is so large that one can only approximate the location of their discovery to the nearest city block (See Yaraş and Erten 2008, 84-7). It is presumed from the presence of these objects at Allianoi that there was a temple dedicated to Asklepios, and possibly also to Hygieia and Telesphorus, somewhere in the city, though the specific structure was never identified. In addition to the two dedicatory inscriptions to Asklepios (believed to be altar bases), two statuary fragments, both of which were heads belonging to Asklepios, and two reliefs depicting Telesphorus were also recovered at Allianoi, though their findspots appear to be unpublished (See Aray et al. 2011, 18). 67 Yaraş and Baz 2012, 91. 68 Yaraş 2008. 69 Yaraş 2005a. 70 Baykan 2012a, 161; Nutton 2013b, 122. 34 Unfortunately, very little has been published specifically on the site’s medical findings beyond a catalogue written by Baykan that was published in Turkish in 2012. 71 Baykan’s catalogue lists 348 objects that he believes are medically related, most which were recovered from two areas of the town, one on either side of the river (Fig. 1.7). 72 The first locus was located on the south side of the river, which was the more intensively developed section of the town where most of its inhabitants lived. 73 Baykan notes that few medical objects in this area are in-situ but are rather scattered about the area, both in and outside of various buildings. He describes the instruments as having been recovered in and near three insulae, which he designates as “Insula I,” “Insula II” and “Insula III.” He indicates that near these insulae, medical objects were also recovered from a “transition structure” and “in the south of the East-West street.” 74 Despite the scattered nature of the finds in this first locus - likely as a result of the flooding event that destroyed the town – Baykan notes that the largest and most varied collection of instruments was recovered from Insula I, where they were probably used prior to the flooding event. 75 From the types and spatial distribution of the instruments recovered from the various 71 Though written in Turkish, Baykan does include a 7-page English summary at the end that consists primarily of a listing of instruments, and their corresponding catalogue numbers, that were recovered from a building on the north side of the river. See Baykan 2012a, 161-8. 72 The existing site plan published in Baykan’s 2012 catalogue does not actually indicate the river, the location of which must be inferred from the negative space. Though it was drafted two years prior to the excavation’s conclusion, a larger plan provided by Yaraş in an interim excavation report from the 2004 excavation season does indicate the location of the river’s course in antiquity, which is consistent with the negative space in Baykan’s plan. See Yaraş 2005b, 366. 73 Baykan 2012a, 168. 74 Baykan 2012a, 165. 75 Baykan 2012a, 165. In his review of Baykan’s catalog, Vivian Nutton expresses frustration with the incomplete nature of the published site plans and scant description of the finds – and their locations – from this first locus on the south side of the river. He indicates that additional information he includes in the review, which does not appear in Baykan’s site report, was a result of personal communications with Baykan (Nutton 2013b). Since Nutton indicates that at least one of the insulae, Insula I, was located along the “main street,” one presumes that the east-west street indicated by Baykan and the “main street” indicated by Nutton are one and the same, since the existing site plan only shows one street south of the river that runs on an east-west axis. While the site plan in Baykan’s report in indistinctly scaled, more precise measurements of the excavated section of the street are provided by Yaraş, who indicates that the street is 210 meters in length and 6 meters in width. The size as well as the location of this street suggest that it was likely the decumanus. See Yaraş 2005a, 17. 35 points in this, Baykan concludes that examinations and minor procedures took place in the rooms “facing the street,” while more dangerous surgical interventions were conducted in the rooms situated in the interior of the insulae. 76 Unfortunately, it is difficult to independently assess Baykan’s conclusion because there is no information provided on the site plan for the area of the town south of the river. There is no descriptive or visual information available for the various structures referred to by Baykan, in and near to which the medical artifacts were recovered. 77 For the moment, however, it is impossible to evaluate the distribution pattern of the objects for ourselves, nor are we are able to locate the buildings and spaces where they were found on the general site plan. As with the inscriptions (see n. 66), the best we can do is pinpoint this first locus with its three insula to the approximate blocks, represented by coordinates EXII, EXI, EX, FX and GX. 78 While information concerning the findspots of the medical objects in the locus south of the river is frustratingly vague, we are given more information when it comes to the medical artifacts themselves. The published catalog contains a drawing and a brief description of each object and, in many cases, it also includes citations indicating the comparanda used in his identification of surgical instruments and other types of medical paraphernalia. While I cannot confidently agree with his interpretation for all the 348 objects identified as “medical” in his 76 Baykan 2012a, 165. 77 My attempts to obtain additional information from members of the excavation team, including a more complete and detailed site plan, were unsuccessful. My efforts to access the original site drawings and notes pertaining to this locus, currently in the holdings of the Bergama Museum, were also unsuccessful. A Turkish colleague who attempted to obtain information from the museum on my behalf was told that the museum, in collaboration with some of the archaeologists involved in the rescue excavations at Allianoi, intended to eventually publish the medically related material from the site, and therefore outside scholars could not be granted access to the material. Hopefully, these reported plans for publication will be realized in the near future as they would represent a substantial contribution to the field. 78 In his catalogue, Baykan gives the grid coordinates for each object, though without a more detailed scale it is impossible to locate them precisely. For several of the instruments that he records as having come from this locus, Baykan seems to place the greatest concentration of finds in the blocks indicated by GX and FX on the site plan. Baykan 2012a, 165. 36 compendium, there are enough instruments in the south locus that have been indisputably identified that leaves little doubt that this south locus was the site of a significant medical enterprise (or enterprises) of some sort. 79 At present, there is not enough evidence to either support or refute Baykan’s interpretation concerning the various rooms of the insulae and their medical functions; hopefully future publications containing more detailed plans will be forthcoming. We fair slightly better when it comes to the locus of medical finds that were discovered on the north side of the river by Yaraş, Baykan and their team. Here, we are provided with more information concerning the structures in which the medical objects were found, and there is an attempt to indicate their findspots on the site plan. Unfortunately, the small size and indistinct print of the published plan make the identification of many of the drawings of the objects and their corresponding catalog numbers impossible to read. 80 Nevertheless, the description of this north locus and its finds is more detailed than that provided for the first, giving us a somewhat clearer picture of the archaeological situation in this section of the town on the north side of the river. Unlike the area of Allianoi that lay south of the river, which appears to have been densely settled with residences and shops, the town’s northern section seems to have been primarily dedicated to the thermal spa and associated enterprises that attracted Aristides, and which comprised what was likely Allianoi’s most significant economic sector. The northern section of the town that was closest to the river’s shore is dominated by the large thermal complex, fed by 79 While the number of medically related objects in Allianoi is indeed unprecedented, I suspect that some included in the catalog may be of dubious attribution for various reasons. See detailed discussion in Chapter 4 of this study. 80 Nutton also complains of this issue, noting that the “numbers of the instruments given cannot be read clearly even with the aid of a magnifying glass.” Nutton 2014, 383 n. 53. 37 natural hot springs that bubbled out of the hillside. 81 Immediately northwest of, and adjacent to, the bath complex, excavators partially uncovered a building that consists of a series of small, interconnecting rooms surrounding (on at least two sides) an open, “yard-type structure” (Fig. 1.8). 82 Some of the rooms appear to have opened directly onto what was presumably a street that ran along the south side of the building, while others are accessible only from the interior courtyard. 83 While Baykan makes no mention of the building’s structural relationship to the bath complex, an examination of the site plan seems to indicate that while the southern corner of the building complex shares several walls with the baths, there was no direct access between them. However, this may not have always been the case, as it appears the building with the “yard-type structure” may have existed prior to the enlargement of the bath complex. In his examination of the site plan, Nutton notes that the front of the bath complex appears to have been extended to fill the triangularly shaped space between the two structures. 84 Based on the existing evidence (i.e., the site plan), I agree with Nutton that this is likely. If this is indeed the case, then the bath complex extension would probably have been done during the Hadrianic-era rebuilding of the baths and town, which means that the adjacent building structure with its series of small rooms surrounding a courtyard would have been contemporaneous with the previous bath complex. So while it appears from the plan that there was no direct communication between the two structures 81 Gal. San Tu. 6.9 (= Green 1951, 261); Nutton 2014, 382. 82 Baykan 2012a, 163. 83 Baykan’s general site plan (Baykan 2012a, 194, Fig. 2) does not correspond exactly to the more detailed building plan he provides to indicate the findspot of the medical instruments and related objects (Baykan 2012a, 207, Fig. 22). The former lacks indications of additional walls and structural elements that further delineate additional rooms (or corridors?) that appear on the building plan. The general site plan also lacks indications of openings to the street that appear in the building plan, making it appear as if there was no external access to the building. Regarding the general site plan’s depiction of the building’s interior rooms, there appears to be openings between several of the rooms that do not exist on the more detailed building plan (e.g., an opening that appears to connect rooms b4 and b5 on the general plan is replaced with a solid wall on the building plan). Without access to more detailed and carefully rendered plans, it is impossible to know with precision how these rooms were related to each other. 84 Nutton 2014, 383. 38 following the extension of the front portion of the bath complex, direct access between the two may have existed prior to the mid-second century. It is in the group of rooms in the southeast corner of the building, immediately adjacent to the west wall of the bath complex, where the most numerous and intriguing groups of surgical instruments and related medical paraphernalia were discovered. The majority of the instruments from this complex were recovered from four rooms designated B4, B5, B7 and C1. In each of these four rooms, the instruments were grouped together by type, i.e., each room contained instruments that would have been used in a specific procedure or on a particular part of the body. 85 For example, the surgical instruments recovered from room B4 are associated with uvulectomies and hemorrhoidectomies, such as specialized forceps for crushing and then removing uvulas or hemorrhoids, spatula probes (which were also used as tongue depressors), tube probes, and rectal specula. 86 Fragments of a male catheter was also recovered from this room, indicating that certain urological issues may also have been addressed here. 87 Immediately adjacent to and east of room B4 is room B5, from which excavators recovered instruments associated with eye surgery. Among the recovered instruments were identified needle cauterizers of the type generally associated with cataract surgery, as well as a needle grip, eye scalpels, eyelid hooks and small eye spatulas with both flat and pointed ends. 88 To the east of room B5 and separated by what appears to be a short interior corridor, room B7 was found to contain instruments used in urological interventions, particularly 85 While some of the objects included in Baykan’s catalogue have been ascribed functions that are questionable and difficult to substantiate, his interpretation of the surgical instruments and related medical material recovered from these specific rooms is more certain, with well-documented examples of comparanda. Lawrence Bliquez’s 2015 compendium of examples of known surgical and parasurgical tools from the Graeco-Roman world is by far the most comprehensive and authoritative on the subject, and provides a much-needed update of John Milne’s 1907 Surgical Instrument’s in Greek and Roman Times. 86 Baykan 2012a, 163-4. 87 Baykan 2012a, 134 no. 252; Bliquez 2015, 224. 88 Baykan 2012a, 164. 39 lithotomy surgeries, which were performed to remove stones from the bladder, kidneys, or urinary tract. The inventory of surgical instruments identified in this room include additional catheter fragments, specially shaped spoon probes, fine scalpels and bone crushers, which were presumably used for accessing and crushing larger stones prior to removal with a spoon probe or spatula. 89 Immediately adjacent to room B7 and sharing its north wall is the fourth room, which was designated C1. It was in this room that excavators recovered a variety of suture forceps and needles that would have been used to suture wounds. 90 A variety of medical instruments were recovered from several rooms immediately south of, and adjacent to, rooms B4, B5 and B7. These rooms, which are not given numbers on the building plan, appear to have opened onto the street or alley that appears to have run along the southern side of the building complex, eventually running into one of the walls on the western side the bath complex. Additional instruments were found in some of the northern rooms of the complex, located on the opposite site of the courtyard, as well as in the central courtyard itself. 91 Baykan states that one of the northern rooms contained a cupping vessel, while a cauterizing lancet was recovered from a second room to the east of the first. 92 He further indicates that among the instruments found in the courtyard closest to these two northern rooms were identified a pair of hemostatic forceps and the blade of a small, bronze bone saw. 93 While the findspots of these remaining instruments are documented in the building plan, the illegibility of their assigned catalogue numbers prevents us from identifying their type and function. However, the presence of ca. 65 medical instruments in this building complex, 89 Baykan 2012a, 164. 90 Baykan 2012a, 164-5. 91 I suspect that the instruments found in the central courtyard were likely deposited there by the flood that is thought to have destroyed the town, which may have swept them out of their original locations in the various rooms surrounding the courtyard. 92 Baykan 2012a, 165. 93 Baykan 2012a, 165. Bliquez 2015, 184 n. 433. 40 approximately half of which can be positively identified from the available published material, represents a substantial addition to the available evidence concerning civilian medicine in the Imperial era. The fact that the site was submerged because of the dam project before the building complex could be fully excavated is an extraordinary loss for the field of Graeco-Roman medicine. The fact that the entirety of this beautiful ancient spa town is now completely inaccessible is a loss to all (Figs. 1.9, 1.10). Rhodiapolis (Turkey) Around the same period that medicine in Allianoi was flourishing, another city to the south, Rhodiapolis, also had a robust medical culture. Located in the Antalya province of Turkey near the modern town of Kumluca, Rhodiapolis had a reputation for being a place of medical learning, which was attributed to one of its most famous citizens, Heraclitus of Rhodiapolis. Heraclitus was a second-century physician and philosopher, called the “Homer in the field of medical poetry” by his fellow citizens, who dedicated a gilded statue to Askepios and Hygieia on his behalf in recognition of his service and substantial public donations to the city. 94 The same inscriptions that conferred such a distinguished title on Heraclitus by his grateful fellow citizens also lists a number of his accomplishments, contributions and accolades, which included his donation of a temple dedicated to Asklepios and Hygieia as well as copies of 60 of his medical texts. 95 Little is known about Rhodiapolis prior to the Roman period, though archaeological surveys indicated that it existed as a settlement since at least the eighth century B.C.E. and 94 Oliver 1975, 126; Samama 2003, 397-8. The inscription covered the plinth on which the statue, now missing, is believed to have stood. See Oliver 1975, 125. 95 For the text of the Rhodiapolis inscriptions pertaining to Heraclitus, see Īplikçioğlu 2014. 41 continued to be occupied through the Classical and Hellenistic periods. Situated on a rocky hill approximately 300 meters above sea level, the location’s height, and unobstructed view of the wide plains of the Kumluca valley that surround it made it an attractive site to establish first a settlement, then a city. Indeed, the presence of the vast tracts of agriculturally fertile farmland in the surrounding region, much of which is still in use today, were likely what drew the first settlers to the region, and the small rocky mountain upon which they chose to establish their settlement was likely chosen for its ideal defensible position. The lure of these two factors were enough for people to maintain and continue to develop the settlement until it became a city of some note, despite the lack of a convenient fresh water source. 96 By the Hellenistic period, Rhodiapolis had constructed its theater, the architectural hallmark of any self-respecting Greek city. 97 However, it was in the late-first/early second centuries C.E. that we see its most dramatic phase of construction, during which it experienced its most “brilliant period of urbanism” that transformed it into a “Roman city model” (Fig. 1.11). 98 As visible as the current ruins of the city are on top of the mountain, the ancient site would have certainly been known to the locals who farmed the plains of the Kumluca valley throughout the region’s various historical epochs. However, it wasn’t until the mid-19 th century 96 To resolve the issue of access to fresh water, the Rhodiapolitains engineered a remarkable system of water catchment. The topography necessitated extensive terracing on which all the city’s structures – public and private – were built. Within each terrace level at least one (but often several) massive water cisterns were constructed, the ceilings of which functioned as the foundation layer for many of the city’s courtyards and open public spaces. Today, several of these cisterns are now visible and their presence necessitates that extreme care be taken when exploring the site, since what appears to be a flat, open square or courtyard may indeed just be a (now very precarious) covering of a chasm that could be up to 20 meters deep. During my investigation of the site in 2019, I saw at least two open cisterns that had fully mature fig trees growing inside of them; the tops of the trees were still at least 3 meters below ground level. 97 Çevik et all 2010, 33. 98 This “building boom” that began in the late-first century through the Hadrianic era is typical of urban development in western Anatolia during this period and has been well-documented in various studies of Graeco- Roman cities in this region. Examples include Bean 1978, Radt 1998, Hoffman 1998, Nutton 2013b, Matthews 2014 and Çevik 2015. 42 that Rhodiapolis was first mentioned in western literature. 99 The first formal study of the site was published in 1889 by researchers from the Austrian Academy of Sciences, who were attracted by the site’s impressive second-century tomb of Opramoas. 100 Standing approximately 30 feet high, the massive funerary monument is located in the center of the ancient city, just outside of the stage of the theater (Fig. 1.12). 101 Covered with inscriptions, one of which is considered to be one of the longest Greek inscriptions in all of Anatolia (TAM II 905), the structure is an epigrapher’s dream; the Austrian team first published its inscriptions in 1889, but it has remained a focal point for studies of ancient Greek epigraphy for well over a century. 102 While Opramoas’ loquacious monument may have been considered to be the primary feature of Rhodiapolis by many scholars for more than a century, recent archaeological investigations by a team from Antalya’s Akdeniz University, under the direction of faculty members Dr. İsa Kızgut and Dr. Nevzat Çevik, revealed another, truly remarkable facet of Rhodiapolis. Over the course of six seasons, investigations revealed what the archaeologists believe to be an entire medical precinct located immediately southwest of the theater, flanking the south side of the decumanus, as well as three additional inscriptions associated with Heraclitus. 103 Unfortunately, the available published material on the medical complex consists of only general summaries that were published upon the conclusion of each excavation season as well as an epigraphic analysis published in 2014 by epigraphist Bülent Īplikçioğlu. 104 The project was abruptly concluded following the 2012 season due to a controversial restoration 99 Rhodiapolis gets a brief mention in the rather charming travelogue published by British surveyors T.A.B. Spratt and Edward Jones in 1847. Spratt and Jones 1847, 165-67. 100 Peterson and Von Luschan 1889. 101 Observations from a visit to the site that I made in June, 2019. 102 Petersen and Von Luschan 1889, 75-137; While the Oprmoas monument has been the subject of many publications, one of the most recent and comprehensive is Christina Kokkinia’s Die Opramoas-Inschrift von Rhodiapolis: Euergetismus und soziale Elite in Lykien, published in 2000. 103 Çevik et al. 2007, 2008, 2009, 2010; Kızgut et al. 2010; Kızgut 2011, 2012, 2013; Īplikçioğlu 2009, 2014. 104 Çevik et al. 2007, 2008, 2009, 2010; Kızgut et al. 2010; Kızgut 2011, 2012, 2013; Īplikçioğlu 2009, 2014. 43 project undertaken at the site by the municipality of Kumluca, after which the Akdeniz team withdrew from the project and abandoned their plans to publish detailed site reports on, and analyses of, their extraordinary discovery. 105 The information presented in this study has been compiled using both the available published material and my own notes from a meeting with Professor Kızgut, who graciously agreed to speak with me in Antalya on June 3, 2019 regarding his work at the site. 106 A total of five inscriptions pertaining to Heraclitus have now been recovered from Rhodiapolis. Two of them, TAM II 906 and TAM II 910, were identified in the first part of the 20 th century and first published in 1944 as part of the Tituli Asiae Minoris (TAM) catalogue. 107 The three additional inscriptions came to light during the Akdeniz team’s excavations, which also revealed a fragment that belonged to TAM II 906. Fortunately, the new inscriptions have since been published; however, their discovery is too recent for them to have been included in any of the comprehensive epigraphic compendiums such as the Tituli Asiae Minoris or the Inscriptiones Graecae ad Res Romanas Pertinentes (IGR or IGRR). Therefore, these more recent epigraphic discoveries will be referred to in this study by their project inventory numbers: Inv. 557, Inv. 776, and Inv. 846. 108 The additional fragment identified as a missing section of TAM II 906 was designated Inv. 927 and will be referred to as such in this study. 109 105 Yavuz 2017, 18 April; Conversation with İsa Kızgut on June 1, 2019. 106 This is likewise the case with the included site plan presented in this study. The estimated find spot locations that appear on the site plan were either deduced by me from the available published texts or from my meeting with Professor Kızgut since no findspots of any of the artifacts or inscriptions were included on the published site plans. The scale of the included site plan was also added by me. I determined the approximate scale of the plan using the measurements given for the room designated by the excavators as a library. Kızgut et al. 2010, 86. 107 TAM II 906 = IGRR III 732; TAM II 910 = IGRR 733; Also see Samama 2003, 398-8; Cohn-Haft 1956, n. 63; Oliver 1975, 125-6. 108 Īplikçioğlu 2014. 109 Īplikçioğlu 2014, 242. 44 The inscriptions that record the public beneficence of Heraclitus also note that, in addition to donating his medical texts to the city of Rhodiapolis, Heraclitus also gifted copies to the cities of Alexandria, Rhodes and Athens, from which he also received honors. (TAM II 910 and Inv. 846). Another inscription records that “Heraclitus of Rhodiapolis” dedicated a temple to Asklepios and Hygieia and further reveals that in addition to being a philosopher and physician, he was also a priest of the Asklepios (TAM II 906). While Rhodiapolis has been the subject of several epigraphic surveys, no systematic excavations of the site had been undertaken until the Akdeniz team began their work. When they conducted their initial survey work in 2005, they found that the site had been severely impacted by several centuries of looting; in more recent times, it was clear that looters had resorted to dynamiting certain sections of the city. 110 While the destructive capacity of dynamite used in an archaeological site is obvious, in this case the damage was further compounded by the fact that the city was constructed on a series of artificial terraces that had been carved out of the steep incline of the mountain’s slope. In some cases, the explosions caused the collapse of entire terraces in the southern section of the site. 111 Further complicating the archaeology of the site was the intensive use of spolia from Imperial-era structures during the Byzantine period. Despite these complications, the excavations revealed several new monuments and structures in the city, including the medical complex that can now be attributed to Heraclitus. 112 Measuring approximately 1500 square meters, the complex was likely built on at least two levels and includes a small temple dedicated to Asklepios and Hygieia attached to the 110 The results of the 2005 surveys are unpublished. 111 Professor Kızgut had informed me of the looting damage in the course of our communications. When I visited the site I was able to see for myself that much of the terracing below the acropolis and city center to the south was indeed collapsed, making certain sections of the site very precarious and unsafe to explore. 112 Çevik et al. 2007, 2008, 2009, 2010, Kızgut 2011, 2012, 2013, Kızgut et al. 2010. 45 western side of a large building, which consists of an open courtyard with a series of small rooms on its east and west sides (Fig. 1.13). 113 The temple was identified by its architecture and by the discovery of statuary fragments belonging to images of Asklepios and Hygieia inside the building (Fig. 1.14). 114 The temple entrance is arranged at a right angle to that of the adjacent building complex. The entrance to the latter is signaled by the remains of a monumental triple portico on the north side of the courtyard, and which opened to the south side of the decumanus (Fig. 1.15). Opposite the entrance on the south end of the courtyard stand the remains of a round building that the excavators first referred to as a “temple” but which they now believe may have been the funerary monument of Heraclitus, set within an exedra that forms the south wall of the complex. 115 In the southwest corner of the complex, immediately adjacent to the exedra, Kızgut and his team identified a building that they believe is a library, which is the “only example of its kind in Lycia.” 116 The summary report from the 2009 season states that “the north and south walls of the library were divided symmetrically into three niches (that were) coated with a plaster layer…and faced with thin marble panels.” 117 The published reports do not provide insight as to how this room came to be identified as a library, though it was presumably deduced based on the epigraphic evidence as well as the presence of the regularly spaces niches in the walls, which are 113 Professor Kızgut related to me that in the course of excavating these rooms they noted the remains of stairs and beam holes, indicating that there would have been at least one additional level. Conversation with İsa Kızgut, June 1, 2019. 114 The statuary fragments, which are not mentioned in the published reports, consisted of a shoulder piece belonging to an image of Hygieia that was identified by the distinctive himation arrangement, and a portion of the head of Asklepios. These fragments are currently in storage at the Antalya Museum and unable to be accessed. Conversation with İsa Kızgut on June 1, 2019. Several of the inscriptions that mention the temple were discovered “near” the structure. See Īplikçioğlu 2014. 115 Çevik et al. 2008, 67; Çevik et al. 2010, 44; Kızgut agrees with Īplikçioğlu, who makes a convincing argument for the identification of the “round temple” as Heraclitus’ funerary monument based on the epigraphic evidence and a connection with a similar honorary inscription recovered from the Asklepieion in Athens (Īplikçioğlu 2014, 235; Conversation with İsa Kızgut, June 1, 2019). The parallels Īplikçioğlu draws between the Athens and Rhodiapolis inscriptions, and the competitive rivalry between the Epicurean and Stoic schools that he believes they represent, is first introduced by James Oliver in his 1975 article “The Empress Plotina and the Sacred Thymelic Synod.” 116 Kızgut et al. 2010, 88; Çevik et al. 2010, 44. 117 Kızgut et al. 2010, 88. 46 also recorded in imperial libraries, such as those in the Forum of Trajan, the baths of Caracalla in Rome and the library of Hadrian in Athens. Furthermore, it seems to have been a somewhat common practice for libraries to be placed in buildings or porticos adjacent to temples, such as the twin libraries associated with the temple of Apollo on the Palatine Hill in Rome, or that which was within the colonnade surrounding the Temple of Athena in Pergamon. 118 Admittedly, these examples are of a considerably larger scale; the putative library in Rhodiapolis is somewhat smaller, measuring ca. 6.95 x 5.03 meters. 119 However, there is certainly precedent for libraries within complexes associated with temples, and we know from the epigraphic evidence that there was definitely a library in Rhodiapolis, so while the attribution given to this room by the excavators is not irrefutable, neither is it unreasonable. During the seasons of 2008, 2009 and 2010 the series of small rooms on both sides of the courtyard were fully excavated. 120 During excavations of five of the small rooms along the west side of the courtyard, the remains of eight medical implements, made of iron and bronze, were recovered. 121 From these fragments, which were in very fragile and poor condition, Kızgut concluded that they represented five spoons/spatula probes, two scalpels and one cupping vessel. 122 Excavators theorized that these rooms functioned as treatment rooms in which physicians would examine patients and/or conduct surgeries. 123 Without additional evidence, 118 Casson 2001, 81-4, 91, 114-15. 119 Kızgut et al. 2010, 86. 120 Kızgut et al. 2010, 88; Kızgut 2011, 94-5; Çevik et al. 2010, 44. Much of the work undertaken by the Akdeniz team in their final two seasons (2011 and 2012) consisted of meticulous and beautifully executed restorations, using the original materials recovered from the various structures of the city to rebuild/reinforce them. See Kızgut 2012 and 2013. 121 Kızgut 2011, 94; Conversation with İsa Kızgut on June 1, 2019. 122 Conversation with İsa Kızgut on June 1, 2019. In precisely which of these rooms the fragments were found was not recorded. According to Professor Kızgut, the fragments were in such poor condition that the archaeologists decided not to compile artifact reports on them. This was an odd decision, given that their interpretation of the rooms’ function is in part based upon the discovery of these objects within them. At present, the remains of these objects are in the storage holdings of the Antalya Museum, and are considered too fragile to be restored or displayed. I was told it would not be possible for me to access them. 123 Kızgut 2011, 94-5. 47 such a suggestion is speculative. If this complex did indeed function as a site of medical training, it is tempting to speculate that these rooms were in fact treatment rooms, where patients seeking medical intervention for various illness or injuries could come for treatment, where physicians in training could gain practical experience, or perhaps where medical demonstrations may have taken place. Despite the presence of the temple, it is unlikely this entire complex functioned as a sacred precinct, i.e., a miniature version of the Asklpeieion in Pergamon. The presence of surgical instruments within the sacred precinct of an Asklepieion would be highly unusual, and it is unlikely that they were votive in function as no other health-related votive objects were recovered in the vicinity. 124 Furthermore, the two sets of rooms that line the east and west sides of the courtyard “do not easily fit within the standard plan of sacred abata.” 125 The temple and the building complex with its courtyard, library and rooms were deliberately constructed on perpendicular axes to each other, each with its own separate entrance. Architecturally speaking, there is no communication between one building the other; the shared wall between them has no opening. Moving between the two structures could only be done by crossing the liminal, “neutral” space of the portico, into which both entrances open. The temple is adjacent to the rest of the building complex, but noticeably outside of it. Given the evident systematic plan of the complex, it is unlikely that this arrangement was done out of architectural or topographical necessity; there is nothing “ad-hoc” about its design or construction. There is every indication that the temple’s placement and its spatial relationship to the rest of the complex was deliberate. Future excavations may provide more information concerning these two structures and their relationship to each other, however, based on the available evidence at the moment I suggest it is 124 In fact, per Professor Kızgut no medical or health-related votive objects were identified anywhere in the entire site. Conversation with İsa Kızgut on June 1, 2019. 125 Nutton 2014, 382. 48 likely that the building complex with its central courtyard, rooms, library and what was possibly the funerary monument of the complex’s founder was a “secular” space, a center of medical learning and perhaps treatment. Just outside of this center visitors would find the temple of Asklepios and Hygieia, related to but spatially distinct from the rest of the complex. Though there has yet to be a systematic survey of the known tombs in Rhodiapolis, Kızgut notes that there are more tombs than one would normally expect to find in a town of this size, and that an unusual number of them are burials belonging to individuals who were from cities that were far from Rhodiapolis. 126 While either circumstance could have a variety of explanations, Kızgut believes that these individuals may have come to Rhodapolis to be treated for illness, and were eventually buried among the local citizens. Some may have died of their illnesses, others may have chosen to stay on in the city after they recovered, and still other individuals among these “foreign” burials may have come to study and train as physicians. Pending a thorough investigation of the Rhodiapolis tombs, this remains a highly speculative, though very intriguing, hypothesis. If Heraclitus’ contributions to the city did indeed establish it as a medical center known as far away as Alexandria and Athens, then it seems likely that both patients and aspiring physicians would have traveled there to seek treatment or training. In either case, the influx of people wealthy enough to travel and stay in the city for extended period of time would have had a positive economic impact on the city’s coffers. In his analysis of inscription Inv. 776, Īplikçioğlu concluded that it dates to the late-third/early-fourth century, approximately 200 years after Heraclitus died at the venerable age of 87. 127 The plinth on which the inscription was incised was found “near” the round structure on the south side of the courtyard, further evidence 126 Conversation with İsa Kızgut on June 1, 2019. 127 Īplikçioğlu 2014, 244. 49 that the round structure may have been the funerary monument of Heraclitus. 128 That Rhodiapolis’ philanthropic physician was apparently still well-known and beloved by the citizens two centuries after his death suggests that his legacy continued to confer prestige and possibly economic benefits to the city. The excavations of Rhodiapolis by the team from Akdeniz University came to a conclusion after the 2012 season following the municipality of Kumluca’s decision to develop the site for tourism by building a visitor’s center and undertaking dramatic restorations of some of the ancient structures. The restoration work in particular proved to be controversial, and all work was suspended pending legal reviews. 129 I have been informed by Professor Kızgut that the controversial restoration methods, undertaken by the Kumluca municipality, have been suspended. Akdeniz University was once again granted permission to continue excavation at Rhodipolis, and plans have been made to re-commence excavations of the medical complex at Rhodiapolis once funding for the project is secured. 130 Marcianopolis (Bulgaria) Of the four medically related archaeological sites addressed in this study, it is the material from Marcianopolis that is the most difficult to contextualize. Founded during the reign of Trajan, what remains of the ancient Roman city of Marcianopolis lies under the modern Bulgarian town of Devnya, 30 kilometers west of the Black Sea port city of Varna (ancient Odessos). 131 In the mid-1970s, a cache of 32 surgical and pharmacological objects was recovered from a room in 128 Çevik et al. 2009, 77-8. 129 Yavuz 2017, 18 April. 130 Email communication with İsa Kızgut on October 16, 2019. 131 For sources on the history and topography of Marcianopolis, see below n. 114. 50 what excavators believed was a domus, which was destroyed by fire in the mid-fifth century C.E. 132 The unfortunate circumstances surrounding their discovery were such that we have little more information other than the objects themselves. Nevertheless, there is much to be gained in a closer examination of this extraordinary set of finds, a sophisticated array of instruments that could only have belonged to a highly skilled surgeon. The Marcianopolis assemblage is second only to those of Allianoi and Rimini in terms of the number of objects found in a single collection from the Imperial era. The city’s tumultuous military history is, I believe, a contributing factor to the presence of such an impressive instrumentarium and is therefore worth briefly summarizing. To the modern eye, the small, nondescript Devnya may seem an unlikely place for an ancient city of historic and archaeological importance. A working-class town of approximately 8000 inhabitants situated in the Devnya River Valley, the land surrounding it is dedicated to agriculture and a number of stone quarries that dot the hills on either side of the Devnya river valley. 133 As nondescript as its modern successor may be today, however, Marcianopolis was once an important Roman city that was eventually designated the capital of Moesia Secunda during Diocletian’s reorganization of the eastern provinces. 134 Ancient sources indicate that the city was named for Emperor Trajan’s sister, Ulpia Marciana Augusta and its founding coincides with Trajan’s successful campaigns against the Dacians and Rome’s interest in securing the region. 135 Trajan’s decision to establish the city was in all likelihood due to its strategic location. 132 Minchev 1980, 1982, 2016. 133 Denya Municipality information website: http://www.guide-bulgaria.com/NE/Varna/Devnya accessed May 23, 2019. 134 Angelov 2004; Dumanov 2015, 91; 135 The third-century historian Dexippus records the origins of Marcianopolis’ name, as does the fourth century historian Ammianus Marcellinus (Exerpta de stategematibus 4F 25J; Amm. Marc. 27.4.12 and 31.5.4.). For the works of Dexippus see FGrHist 100 T5, s.v. “Dexippus”; For translations and analyses of this and other fragments of Dexippus’ Scythica from the Excerpta Constantiniana, see Davenport and Mallan 2013 and Martin and Grusková 2014. 51 Marcianopolis was located along an important route that connected the port at Odessos to the interior and which ran along the northern flank of the Haemus Mountains, roughly parallel to the Via Militaris to the south of the mountain range (Fig. 1.16). 136 Despite the increasing threats to the region from the Gothic tribes to the north, numismatic evidence suggests that Marcianopolis reached its peak of economic and cultural prosperity during the Severan period (193-235 CE). 137 By the middle of the third century, however, Marcianopolis was besieged several times during the same turbulence that led to the destruction of the Rimini site. 138 Its fortunes rose once again as a result of its designation as Moesia Secunda’s capitol at the end of the third century, and experienced another economic and political boost during Constantine’s reign (306-337 CE). Located along the shortest fortified road that connected the Danube to the emperor’s new capital of Constantinople, Marcianopolis grew in prosperity and prestige. In 332 CE, the city temporarily gained an imperial resident when the emperor came to Marcianopolis to receive the reports from his son, Constantine II during the latter’s campaigns against the Gothic armies that continued to threaten the Empire’s northeastern borders. 139 Events of the fourth century would see a continued rise in Marcianopolis’ importance as an imperial seat; during his first campaigns against the Goths (366-369 CE), Emperor Valens (364-378 CE) made Marcianopolis the temporary capital of the eastern Empire and the base of the Roman army, deeming the city the most suitable for his army’s winter quarters. 140 During these years, the early sixth-century Greek historian Zosimus refers to Marcianopolis as “the 136 Lozanov 2015, 83-4. 137 Angelov 2004, 2; Varbinov 2012. 138 Wolfram 1988. 139 Kulikowski, M. 2006. 140 Amm. Marc. 27.5.5-6; Phot. 9.7-8; The late-fourth/early-fifth century historian Philostorigus similarly refers to Marcianopolis as the emperor’s temporary base. Philostorigus’ original, 12-volume Ecclesiastical History is lost, but portions of it were reproduced in the works of Photius, who was appointed Patriarch of Constantinople in 853. 52 largest city in Thrace.” 141 However, by the end of the fourth century the decline of the Empire’s political and military strength in the region resulted in the increased intensity of foreign attacks. When Atilla led his Huns in a sweeping invasion of the Empire’s northeastern territories in 447 CE, Marcianopolis was largely destroyed. 142 Though perhaps not as long-lived as many other Roman cities, during the ca. 350 years of its existence Marcianopolis was center-stage during the martial dynamics of the Empire’s northeastern frontier, with an almost constant flow of soldiers and commerce through its territory. Like Rimini, the movement of military units heading toward or returning from the frontier regions meant that there were likely a number or soldiers – and ex- soldiers – among its residents. For a physician skilled in the types of surgical interventions used to treat combat injuries, Marcianopolis would have undoubtedly made an attractive place to establish a practice. While literary and epigraphic evidence gives us at least a broad historical portrait of Marcianopolis’ history from its founding in the early second century to its destruction in the mid- fifth, archaeological evidence from the ancient city is disappointingly sparse. Indeed, only the “House of Antiope” and several streets in its immediate vicinity were subject to intentional and methodical archaeological investigations, led by Dr. Alexander Minchev of the Varna Regional Museum of History in the period between 1976 and 1986. 143 The 21-room, late-third century villa urbana is the only remnant of ancient Marcianopolis that has been systematically excavated and preserved, and is now the primary feature of the Museum of Roman Mosaics, Devnya’s small archaeological museum. 144 While the House of Antiope is itself completely unrelated to the 141 Zos. 4.10.3. 142 Angelov 2004, 2; Minchev 2016, 232; For a concise summary of the Gothic and Hunnic invasions of the Balkan territories in Late Antiquity, see Heather 2007. 143 Minchev 2002. The name of the site is derived from the subject of one of its series of spectacular floor mosaics, which I saw for myself during a visit to Devnya on June 5, 2019. 144 Minchev 2000; http://archaeologyinbulgaria.com/museum-of-roman-mosaics-devnya-bulgaria/ (accessed 4/2/19); http://www.museology.bg/en/museums/i159/museum-of-mosaics-devnya.html#.XTY52i3MwUs (accessed 4/2/19). 53 cache of medical instruments, its excavation is the reason for Minchev’s fortuitous presence in Devnya when, during the construction of a petrol station elsewhere in the city, the remains of what Minchev believes was a domus was revealed. 145 The construction crew alerted Minchev to their discovery, after which Minchev and his team excavated what turned out to be a medical instrumentarium, which at the time was the largest single collection of such objects ever discovered from the Roman period. 146 Minchev and his team were given only two days to excavate the objects, after which construction work would resume. The petrol station was to be dedicated to a local Soviet dignitary, and the ribbon-cutting ceremony that was to be held to inaugurate the new building would not be postponed. 147 In the course of their hurried recovery of the objects, which were found together under a mound of dirt that measured approximately half a meter in diameter, the archaeologists noted that they were partially melted as a result of exposure to intense heat. 148 Minchev noticed that the 6-8 centimeter stratum immediately covering the instruments was comprised of ash and charred wood, a burn layer that was consistent with what he and his team observed during the course of their formal excavation of the “House of Antiope” in another area 145 The instruments themselves are documented in Minchev’s three publications on the collection (Minchev 1980, 1982, 2016), while the circumstances surrounding their discovery and excavation were related to me by Alexander Minchev, who graciously agreed to meet with me on June 4, 2019 to discuss his work at the site. 146 The total number of medically related objects recovered from Pompeii and Herculanean does exceed the number in the Marcianopolis collection. However, if any of them were recovered in numbers equivalent to or greater than 32 from a single in-situ assemblage, such a discovery was never recorded (see Bliquez 1994). The number of objects discovered in a medical instrumentarium from the Roman period did not surpass that of the Marcianopolis collection until the discovery of the Domus del Chirurgo in Rimini . 147 Communication with Alexander Minchev on June 4, 2019. 148 Minchev 1983, 144. I was able to confirm their condition for myself during a visit to the Varna Regional Museum of History in the company of Professor Minchev on June 4, 2019. Despite the heat damage, many of the implements were nevertheless clearly recognizable, and I left confident that Minchev’s and Kirova’s identification of the objects were indeed accurate. 54 of the city. 149 This was the carbonized layer that resulted from the Huns’ 447 CE invasion, which resulted in a massive fire and the subsequent destruction of Marcianopolis. 150 Minchev’s priority was the safe recovery of the objects, which turned out to be a collection of 32 surgical and pharmacological objects, the variety of which indicate that they had just rescued the instrumentarium of “an experienced physician who practiced in the city and used his very sophisticated and advanced medical knowledge in the first half of the fifth c. AD.” 151 At the time of his initial publication on the objects, Minchev had categorized them into seven distinct categories, which represented a wide range of medical procedures that included ophthalmology, gynecology, surgery and pharmacology. 152 In a much more recent publication, several more decades of experience and an increase in the number of quality publications on comparanda allowed Minchev to further refine his assessment of the instruments’ functions, and they have now been re-evaluated and identified as falling into one of 11 distinct categories: scalpels, probes, hooks, needles, forceps, bone levers, specula, lithotomy extractors, trepanning instruments, objects used in the making and mixing of medicines, and several “unidentified” tools whose poor condition precluded precise identification. 153 An additional study of the instruments, which are now held in the collections of the Varna Regional Museum of History, by Nadejda Kirova substantiates Minchev’s interpretation of most of the surgical instruments, the details of which are addressed in Chapters 2 and 4 of this study. 154 Given that the excavations of the House of Antiope by Minchev and his team represent the only incidence of a deliberate archaeological investigation of ancient Marcianopolis, it is 149 Communication with Alexander Minchev on June 4, 2019. 150 Minchev 2000, 251. 151 Minchev 2016, 233. 152 Minchev 1983, 144-47. 153 Minchev 2016, 232-33. 154 Kirova 2002. 55 hardly surprising that what additional evidence of the city’s Roman history does exist comes to us as a result of accidental discoveries made in the course of modern construction projects. What is surprising, however, is that a relatively disproportionate number of these inadvertent discoveries turned out to have associations with either medical practices or medical cult. An example of such a discovery occurred during the construction of a water-pumping station in Devnya. 155 The station was designed to exploit a natural, spring-fed water source in the town, but once the project began the Soviet engineers quickly discovered that they were hardly the first to do so. In 1989, during the course of construction, crews uncovered the remains of what Minchev believes was a temple dedicated to Asklepios – and possibly also to Telesphorus and Hygieia. 156 The temple, which Minchev concluded was constructed during the mid-to-late second-century, had been erected “very close” to a bath complex, which was supplied by the same subterranean water source that was the reason for the modern station’s construction. 157 Amidst the architectural remains of the temple/bath complex, construction crews recovered a fragment of a statue of Asklepios that was “almost life-sized,” and which is believed to date to the second/third century C.E. 158 Unfortunately, there is little published information concerning this discovery beyond a few sentences in one of Minchev’s articles. 159 From our communications, it seems that no 155 Communication with A. Minchev on June 4, 2019. This was also communicated to me by Dr. Vassil Tenekedjiev of the Varna Regional Museum of History via email on March 11, 2021. 156 Minchev 2016, 231-32. I am grateful to Dr. Tenekedjiev for confirming the year in which the discovery was made. Personal communication with V. Tenekedjiev on March 11, 2021. 157 Minchev 2016, 231. 158 Devnya, Museum of Mosaics, Inv. 341; Minchev 2016, 231-32; I am grateful to the Museum of Mosaics in Devnya for confirming that the statuary fragment is in their holdings and for providing its inventory number. I am indebted to Dr. Tenekedjiev for liaising on my behalf with the personnel at the Museum of Mosaics in Devnya to obtain that information, as well as for providing me with its second/third century date. Personal communication with V. Tenekedjiev on March 9 and March 11, 2021. 159 Minchev 2016, 231-32; Dr. Tenekedjiev made me aware of a brief, 1999 publication by Anastas Angelov, the former director of Devnya’s Museum of Mosaics, titled Марцианопол. История и археология (Marcianopolis: History and Archaeology) that mentions the statuary fragment. The book was published in Bulgarian, and as of the time of this writing I have been unable to obtain a copy. Communication with V. Tenekedjiev on March 9, 2021. 56 archaeological investigation was permitted at this particular site, and the architectural structures identified as a “temple” and “bath complex” were never properly studied, nor indeed even recorded, before they were covered up by the new structure of the water pumping station. 160 As such, it is impossible to say whether or not the Asklepios statuary fragment recovered by the construction crew came from a structure that was a temple or a section of a bath complex. 161 Numismatic evidence from Marcianopolis suggests that there was a temple dedicated to Asklepios, and possibly also to Hygieia and Telesphoros (son of Asklepios and the god of convalescence/recuperation) somewhere in the city, as there are several dozen examples of coins minted in Marcianopolis bearing the images of those three deities. 162 Without further investigation the exact location of the Asklepian temple in Marcianopolis, or indeed its existence, cannot be definitively confirmed. 163 However, if the structures revealed by the pumping station’s construction were indeed the remains of a temple and an adjacent bath complex, the configuration would be consistent with similar complexes in cities throughout the Graeco-Roman world. 164 In those baths that lacked such a temple, the link between bathing and the divine representations of health was frequently maintained in the form of the imagery; Asklepios and his daughter Hygieia are the most common images of deities found in Roman bath complexes in the Imperial period. 165 In his detailed description of a Roman 160 Minchev 2016, 232-33; Communication with Alexander Minchev on June 4, 2019. 161 Devnya, Museum of Mosaics, Inv. 341. I am very grateful to the Museum of Mosaics in Devnya for providing this information, and to Dr. Vassil Tenekedjiev at the Varna Regional Museum of History for his help in identifying the location of the statuary fragment. 162 Aparaschivei 2012c, 30; For multiple examples of coins with images of Asklepios, Hygieia and/or Telesphoros from the Imperial period minted in Marcianopolis, Nikola Moushmov's 1912 catalogue Ancient Coins of the Balkan Peninsula and the Coins of the Bulgarian Monarchs remains the most comprehensive compendium to date. While the original publication was written in Old Bulgarian, a modern translation is available on the numismatic reference website WildWinds (see http://www.wildwinds.com/coins/moushmov/index.html). 163 The identification of a bath complex at this site is more certain, since the presence of a natural spring would have made it a likely location for such a structure. 164 Jackson 1999; Fagan 1993 and 2002; Yegül 2010. 165 Manderscheid 1988, 120. 57 bath, the second-century rhetorician Lucian mentions statues of Asklepios and Hygieia as prominent aspects of the complex’s decorative elements. 166 Indeed, of all the colossal sculptures known to have been installed in the baths of Caracalla in Rome in the third century, it was the statue of Asklepios that was the largest. Though only the head remains, it is 49cm in height, which indicates that the enormous, gilded statue would have stood approximately 4 meters tall. 167 Another set of medically related discoveries from Marcianopolis have come to us in the form of burial goods from three separate tombs, which were also discovered accidently at various times in the 20 th century during the course of building projects. These burial discoveries revealed evidence of medici (or, in two of the instances, perhaps pharmacists) who were in residence in Marcianopolis during the late-second and third centuries C.E. 168 The first tomb, built in the Thracian-style (i.e., an earthen tumulus covering a stone sarcophagus) and dating to the early third-century C.E., contained instruments common to both doctors and pharmacists in the Imperial period: a bronze measuring spoon (ligula); a bronze, spoon-shaped probe (cyathiscomele); a small, rectangular plate made of green stone that was used to prepare medicines, and a small bronze box that was identified as a collyrium, commonly used to contain eye medications. 169 The second burial, also in the Thracian style, was dated to the first half of the third century C.E. and contained contents similar to the first: a bronze spoon probe, a small plate of the same green stone found in the first tomb, a small bonze pail (generally referred to in primary 166 Lucian Hippias, 5 (from Fagan 1993, 154). 167 Rome, Museo Nazionale Romano nelle Terme di Diocleziano, la Sala del Planetario, Inv. 11614. See Gensheimer 2018, 86 and Marvin 1983, 363-64. 168 Minchev 1981, 119; 1982,143-44. 169 Minchev 1983, 143. Collyria are quite well-documented components of the instrumentaria of both physicians and pharmacists, eye diseases being one of the most frequently mentioned complaints in primary sources of the period. Gal. Compositione Pharmacorum iv.1550. See Summerton 2015, Baker 2011 and Jackson 1996. 58 sources by the broader term situla) commonly used to store ointments, and a small glass bottle (balsamarium). This bottle could have functioned in a number of ways but, when considered together with the other objects, seems likely to have been another medicine container. 170 The third burial from Devnya dates to the late-second, early-third century C.E. and contained objects indicative of a surgical profession. In addition to several vessels made of clay, bronze or glass, the surgical instruments recovered included scalpel handles, two blunt dissectors, two epilation forceps (vulsella) that were used to treat trichiasis, a spoon-probe, a flat probe (spathomele), a simple probe (specillum), and a small probe that may have been used to examine the eye. 171 All the instruments were fashioned from a high-quality bronze, and three of them (one of the forceps and the two blunt dissectors) have gold and silver inlays. 172 While Minchev has published a total of three articles on the subject of the medical implements from Marcianopolis, the somewhat disorganized and chaotic circumstances under which objects were recovered at various times during the 20 th century have resulted in an unfortunate lack of contextual information, including basic site plans. There is neither a plan of the site itself from which the instrumentarium was recovered, nor is there a general plan that depicts the known Roman sites in Devnya and their spatial relationship to each other. 173 In fact, the most recent comprehensive plan of Devnya in existence that depicts any Roman features in 170 Minchev 1983, 143. 171 In the case of scalpels from this period, it is not uncommon to find only the handles remaining. In the Imperial period such instruments were generally fashioned with handles made of a copper alloy while the blades were forged from iron or steel. Bliquez 2015, 72. 172 Minchev 1983, 143-44. 173 These known sites comprise the House of Antiope, the domus from which the instrumentarium was recovered, the possible temple/bath complex in which the statue of Asklepios was discovered, the various know tombs in the city, including the three in which medical/pharmacological instruments were found, and the remains of the Roman city walls and amphitheater. I confirmed the lack of specific site or general plans in the course of my discussions and correspondence with Alexander Minchev as well as with the current director of Devnya’s archaeological museum, Dr. Ivan Sutev, during my visit to Devnya on June 5, 2019. Communications with Minchev on June 4, 2019 and June 6, 2019 and with Sutev on June 5, 2019. 59 the city’s layout at all was drafted by the 19 th -century Austrian military cartographer Heinrich Hartl in 1898. Published in 1906, the map depicts only the extant Roman walls around the city’s perimeter (Fig. 1.17). 174 While Hartl’s map may be of historical interest, a century of industrialization in the region, not to mention the changes to Devnya’s urban landscape brought about by two world wars and 44 years of de-facto Soviet control, have rendered it all but useless for the current study. 175 The lack of contextual data concerning such a remarkable set of medical discoveries at Marcianopolis is not only frustrating, but also limiting. Without more information concerning the archaeological context of the instrumentarium, for example, it is impossible to confirm whether the room in which the collection was found was indeed even part of a domus. While there are known examples of medicae tabernae situated within the broader context of a residential domus such as the Domus del Chirurgo in Rimini and the similarly named “Casa del Chirurgo” in Pompeii, there are also examples of such clinics occupying one or two rooms in commercial spaces that are distinct from any known domestic context. 176 In the case of Marcianoplis, unfortunately, we cannot even guess as to whether the owner of the remarkable collection of sophisticated surgical implements practiced his craft in a residential or commercial quarter of the city. 174 Plan of Marcianopolis by Heinrich Hartl, drafted in 1898. Kalinka 1906, 360. 175 In my communications with Minchev during the summer of 2019, he had agreed to try to sketch a map of the location of where the instrumentarium and the statue of Asklepios were recovered, though he expressed discomfort with the technology required to scan documents and sending them as digital files. Unfortunately this never came about. In a subsequent e-mail I suggested that perhaps he could just send me the street addresses of the petrol station and the water pumping station, which I could use to create a basic map of the sites’ locations and their geographic relationships to each other as well as the other known Roman structures (e.g., the “House of Antiope” and the remains of the amphitheater) in Devnya. Unfortunately, I never received this information. As of the time of this writing I have been unsuccessful in my attempts to reach him via e-mail, so for the moment the exact locations of these sites remain unknown. 176 Jackson 1988, 66; Bon et al. 1997; For the various identified locations of medical practices at Pompeii and Herculaneum, see Bliquez 1994. 60 Despite the lack of contextual information for the Marcianopolis collection, we can nevertheless be relatively confident in drawing at least a few conclusions. For example, the instruments themselves – their typologies and functions – allow a degree of inference concerning the expertise of the owner, which is addressed in detail in Chapter 4 of this study. Furthermore, the circumstances in which they were found (i.e., under a substantial burn layer) allow us to imagine, at least broadly, the circumstances in which they came to be lost. Similar to the event that led to the burial and subsequent preservation of the Domus del Chirurgo in Rimini, the calamity that befell the owner of the Marcianopolis collection must have happened so swiftly that the owner was unable to retrieve and escape with what was a very valuable - and inherently portable – set of instruments. Had there been enough time to flee to safety, it is unlikely that the owner would have done so without the tools that not only represented a significant investment, but which also would have allowed him to continue making a living by practicing his profession. Like Rimini’s excavator, Jacopo Ortalli, Minchev believes it is likely that the owner of the collection of instruments at Marcianopolis was either killed or captured. If by chance he had survived, then the circumstances following the invasion - which likely included the continued presence of the invaders, at least for a time - would have made returning to retrieve the instruments too dangerous of an enterprise to undertake. 177 Minchev, like Ortalli, readily concedes that his conclusion regarding the fate of the physician is merely speculative and must remain so. However, while we will never know the exact circumstances of the physicians’ ultimate fate, the nature of the instruments themselves are the best argument in support of the inability – rather than the unwillingness – to recover them. Of the extant surgical tools from the Roman period, Ralph Jackson notes that “the single most 177 Conversation with Minchev, June 3, 2019. 61 striking feature of surviving instruments is their quality. Some are exquisitely decorated and some are plain, but almost without exception they are precision tools developed for a specific task or range of tasks.” 178 As such, surgical instruments were valuable objects, not just because of the high-quality bronze or iron from which they were made, but also because of the high degree of skill needed to craft them. Even the simplest tool in a surgeon’s instrumentarium would still have been highly valued, and not easily or carelessly left behind. Though we unfortunately lack definitive information concerning the archaeological context of the Marcianopolis instrumentarium, the nature of the instruments, as well as the town’s proximity to the Empire’s military activities in the region invite a consideration the relationship that civilian medicine in towns such as Marcianopolis, Rimini and other similarly located towns in the Empire may have had with military medicine. Could the medici of such towns, located as they were in regions where Roman soldiers were routinely present, have been intersection points between military and civilian medicine, enabling knowledge and technology to be shared between the two spheres? The sites of Rimini and Marcianopolis in particular have the potential to shed some light on this particular line of inquiry, the investigation of which comprises the following chapter. 178 Jackson 1988, 113. 62 Chapter 2: The Intersection of Military and Civilian Medicine The nature of the relationship between military and civilian medicine in the Roman Empire has historically been a somewhat murky issue. This is, in part, due to the fact that the corpus of contemporary studies concerning Graeco-Roman medicine has largely neglected the civilian sphere in favor of martial or sacred sanctuary contexts. This is an understandable circumstance when one considers that, until recently, the relative dearth of evidence for civilian medicine has precluded an equal treatment of the subject in contemporary scholarship. Another factor contributing to the scant attention paid to the relationship between military and civilian medicine thus far is the geographically far-flung and typologically disparate nature of that evidence which is known to us. Some of the evidence presented in the following discussion has been researched and considered based on a variety of studies that exhibit great depth in terms of the subject matter but are nevertheless restricted geographically in that they are confined to specific regional areas of the Empire. Other studies limited by specific categories of evidence (e.g., surgical instruments, epigraphic evidence, etc.) or the particular nature of the archaeological sites themselves. Specificity in terms of geographic regions, categories of evidence, or discrete archaeological sites, while a perfectly reasonable method of delineating the necessary parameters of a study, does not generally allow for the proverbial casting of a wide net. In this regard I consider myself to be the fortunate beneficiary of a formidable body of work produced by an equally formidable cadre of scholars who have, region by region and category by category, wrestled the existing evidence for Graeco-Roman medicine into collections of coherent investigations, compendiums, and catalogs over the last several decades. Among these studies are a series of reports on Marcianopolis and the Domus del Chirurgo in Rimini, both of which I 63 suggest represent scenarios in which military medical expertise, technology and personnel filtered into civilian contexts. It is the aforementioned body of work that allows me to make the following attempt to examine the ways in which military and civilian medicine may have intersected, as well as the nature of those junctures. For example, the instrument typologies represented by at least two of the four civilian sites presented in this study, Marcianopolis and Rimini, can leave no doubt that the physicians who worked with them were familiar with treating the types of injuries that typically resulted from combat. 179 And while Marcianopolis occasionally functioned as a de facto military base at various points from the third century C.E. onwards, neither of these sites can be associated with permanently stationed military units. Furthermore, both sets of instrumentaria were recovered from domus contexts in civilian neighborhoods. So we are therefore left with at least two certainties: 1) It is clear from their typologies that the physicians who owned or used the surgical instruments recovered from Rimini and Marcianopolis were familiar with wounds of the types sustained in combat situations (e.g., military or gladiator conflicts); and 2) these physicians were working in civilian contexts. 180 In this, the archaeological evidence corroborates what scholars have long suspected but which has yet to be thoroughly explored: medical knowledge gained by doctors treating soldiers did eventually make its way to civilian, urban environments. But how? By what means were medical knowledge and technologies, particularly those most closely associated with the mitigation of the types of 179 Totaling only eight, the medical instruments recovered from Rhodiapolis are neither comparatively significant in quantity, nor are they indicative of trauma-specific surgeries. The evidence for civic medicine at Rhodiapolis is of a different, but no less valuable, nature. While a significantly higher number of instruments were recovered from Allianoi, I am not convinced that any of them had functions representing the unique types of procedures generally associated with traumatic injuries but were more universal nature, used to mitigate conditions that were common to both soldiers and civilians (e.g., lithotomy tools for the removal of bladder or kidney stones). 180 For examples of studies on and indices for using instrument typologies to identify various categories of medical expertise, see Jackson 1995 and Bliquez 1988, 1994 and 2015. 64 traumatic injuries that commonly resulted from battle, transmitted from the valetudinaria of the Roman frontier camps to the urban, civilian centers of the Empire where everyday Romans lived far from conflict zones? In antiquity, information was communicated (or, in the case of medicine, taught) either via direct verbal contact, or through the exchange of written missives and texts, both of which depended on the vast but painstakingly slow human networks that facilitated trade and transportation throughout the Empire. In our present age of advanced communication technologies, in which almost incalculable quantities of information (or misinformation) can travel halfway around the globe in milliseconds, it is at times difficult to grasp the comparatively rudimentary and laborious ways in which information was dispatched and received in antiquity. But prior to the modern era, the relative sophistication and connectedness of the Roman Empire, especially because of the great network of Roman roads and lack of piracy in shipping, are perhaps without rival for the majority of human history. 181 Information may have moved slowly from our modern perspective, but it moved, often with remarkable efficiency. And while our evidence is too limited to create a definitive, Empire-wide map of the progression of medical innovations between the martial and civilian spheres, we can identify some points of contact, so to speak, where the surgical techniques developed and practiced by military surgeons to address traumatic injuries were communicated to the civilian sector. Geographically, the earliest intersection points would have been located in those liminal spaces where permanent (or at least long-term) military camps coincided, both spatially and culturally, with local civilian 181 For a compelling, and (in my opinion) thoroughly convincing, study of the ways in which ideas and information were transmitted throughout the Empire by way of various types of networks (e.g., economic, social, etc.), see Collar 2013. In particular, her chapter on the spread of the cult of Iuppiter Dolichenus and its relationship to the movement of military units is a sophisticated analysis of the distribution of evidence using Proximal Point Analysis (PPA) and has fascinating implications for the transmission of medical technology and knowledge in the Imperial period. Such a study, while yet to be undertaken, would be a significant contribution to the field. 65 populations. But the overlap of military and civilian medicine could hardly have been restricted to the frontiers. The mobility of men and materials in the Empire meant that physicians and the expertise they carried traveled, and their interactions with doctors and patients in the civilian sphere represents another point of intersection where the barrier between the military and civilian worlds becomes porous. This chapter is an examination of some of these junctures. Military Medicine At present, we have little evidence for any sort of organization or standardization of civilian medical care at the state or municipal level prior to the second century C.E. By contrast, the systematization of the army medical corps dates to the end of the first century B.C.E. – beginning of the first century C.E., when Augustus (27 B.C.E. – 14 C.E.) instituted a series of reforms intended to formally establish and organize a professional standing army for the Empire under the imperial system. 182 That a medical infrastructure for the Roman army was organized and sponsored by the state with no equivalent provisions made for civilians is hardly surprising. The support of the Roman army is what ensured the security of the Imperial government and the Empire’s borders, and the army’s maintenance was the government’s greatest expense. Additionally, the close living quarters and geographical mobility inherent in army life made the military forts – and the towns that often grew up near major military bases to service the commercial needs of the soldiers - particularly vulnerable to outbreaks and the rapid spread of disease. Some outbreaks reached epidemic, even pandemic, proportions, affecting soldier and civilian alike. Soldiers may have been a small fraction of the population as a whole, but the 182 Cass. Dio. 54.25.5 and 55.24.5-9 (= Cary 1917, 349 and 458-9); Suet. Aug. 49.1-3 (= Rolfe 1913, 204-4). 66 security and well-being of that whole was dependent upon them; their welfare was very much in the state interest. The high degree of organization and state support of the army, as well as a vast network of Roman roads, meant that legions were able to be deployed with relative ease throughout the Empire, often traversing great swaths of the Empire’s territory as legions and units moved from one frontier to another. Just as local populations would have come into contact with the diverse languages and cultures of the soldiers, so too would they have come into contact with the various technologies employed by engineers, architects, and physicians of the military units. The connectivity and scale of the army’s geographic reach meant that the movement of military units served as a conduit of both people and ideas. Ido Israelowich notes that the well-developed network of the army “enabled a swift and consistent transmission of medical ideas and practices.” 183 This was particularly true of surgical technology and techniques, since military surgeons had far more consistent experience in the mitigation of traumatic injuries than most of their civilian counterparts. Since the beginning of its establishment, Rome’s professional army was perhaps the most significant arena in which medicine was practiced. Its relatively advanced organization and consistency in physician training meant that medical knowledge could be developed and improved upon, while the army’s geographic mobility meant that this knowledge could – and would – eventually be transmitted to the civilian sphere in a variety of different ways. 184 In order to understand in what ways military and civilian medicine intersected, it is helpful to briefly examine what we know of Rome’s military medical corps, its organization and 183 Israelowich 2012, 87. 184 For an excellent summation of evidence demonstrating the degree of connectivity that existed in the Roman army, and therefore the degree to which medical knowledge and materials could be transmitted throughout the army’s medical service, see Israelowich 2015, 100-02. For 67 how military physicians were trained, so that we may better understand both the nature of the evidence for the ways in which medicine in the Roman army came to influence its practices in civilian contexts. Fortunately, there is a reasonably substantial corpus of archaeological, epigraphic and literary evidence that attests to the medical service of the Empire’s army. 185 Such evidence suggests that those who served in a medical capacity were likely categorized as distinctly as those in other branches of the army. 186 For example, though the title medicus appears with the greatest frequency in the epigraphic evidence pertaining to the military medical corps, it is likely that Q. Marcius Artemidorus, a medicus castorum who dedicated an alter to Iuppiter Dolichenus, held a higher rank than M. Naevius Harmodius, a medicus cohortis with the tenth castra praetoria. 187 Both would have held a higher rank than the “soldier physician” T. Aurelius Numerius, who was a miles medicus with the legio XXII Primigenia Pia Felix. 188 In the Digesta, Tarruntenus Paternus lists a number of categories of physicians who were considered immunes, military personnel who were exempted from certain duties as a result of their positions and the special responsibilities that those entailed. 189 Examples of other types of titles among the medical personnel of the Roman army include medicus legionis, medicus dulplicarius, medicus alarum, optio valetudinarium (the officer in charge of running the hospital), and medicus ordinarius. 190 While there are still some questions as to what certain positions actually entailed, 185 Studies of such evidence include Wilmanns 1995a and 1995b, Israelowich 2016, Davies 1969, Baker 2002 and 2004, Nutton 2013a,174-90 and Bader 2014. 186 See in particular Wilmanns’ 1987 study “Zur Rangordung der römischen Militärärzte während der mittleren Kaiserzeit.” 187 CIL VI 31172 (= Alonso 2018, 226 no. 73); AE 1952, 143 (= Alonso 2018, 232 no. 92); The altar dedicated by Q. Marcius Artemidorus was originally located in Rome’s castra priora equitum singularum, the barracks that housed part of the emperor’s cavalry bodyguard, suggesting that medicus was either a full member of the prestigious equites singulares Augusti or, at minimum, closely affiliated with them. Also see Alonso 2018, 159 and Israelowich 2015, 104; A Roman military cohorte was a unit made up of 500-1000 men. There were ten cohortes in a legion. OCD:341, s.v. “cohors.” 188 CIL III 14347,5. (From Alonso 2018, 169 n. 123 and Israelowich 2015, 104 n. 147). 189 Dig. 50.6.7. 190 Epigraphic examples of such titles include: CIL V 4367 (medicus legionis; from Alonso 2018, 285 no. 304), AE 1995, 1350 (medicus dulplicarius; from Alonso 2018, 164 n.101), CIL XI 3007 (medicus alarum; from Alonso 68 and who could hold them, such literary and epigraphic sources seem to indicate that a medical hierarchy existed within the military’s medical service that paralleled that of the fighting branches. In terms of authority and status, at least some physicians in the army enjoyed a privileged position. In his description of the military medical corps of the second century, Vegetius ascribes military medical practitioners with a high degree of professionalism as well as influence. In addition to the more obvious roles of caring for sick and injured soldiers, their purview extended to other aspects of the lives of the soldiers in their care. 191 The medici of the Roman army were consulted on decisions concerning the soldiers’ daily food and exercise regimens, and - much like today – they had the final say over whether or not a soldier who had been medically discharged was eligible to be reinstated. 192 They were even involved in decisions pertaining to the construction and placement of the camps themselves, since the layout of the camp and the characteristics of its surrounding environment were considered critical contributing factors in maintaining the health of its inhabitants. 193 Legal sources attest to their distinguished status in the eyes of Roman law. Military physicians were exempted from the compulsory munera civilia (civic duties) as they were already in service of the state by virtue of the nature of their profession. 194 Though there seemed to be a variety of titles and responsibilities among personnel in the army’s medical corps (see below), the most frequently documented practitioners in the entire medical corps were the medici themselves, trained soldiers who could serve medical functions 2018, 275 no. 265), CIL VI 175 (optio valetudinarium; from Davies 1989, 212 n. 16), CIL VIII 18314 (medicus ordinarius from Davies 1989, 214 n. 25). 191 Veg. Mil. 3.2 (= Milner 1996, 65-6). 192 Cod. Iust. 12.35.6. 193 Veg. Mil. 3.2 (= Milner 1996, 65-6); Vitr. De arch. 1.4. 194 Dig. 4.6.33 69 both in the forts and during campaigns. Whether medical personnel were officers or common enlisted soldiers is unclear, though it is generally assumed that either category of soldier could be included in the medical corps, with the most experienced surgeons holding ranks that were equivalent to those of senior military officers. 195 Those who were occupied primarily with dressing wounds were caspsarii, while the categories of medical specialists included the medicus chirurgus (surgeon), medicus ocularius (eye specialist) and medicus clinicus (what we may term a “general practitioner” today). Evidently, poisonous snakes were such a common problem among the legions that there was even a category of specialist called a marsus, a physician who specialized in the treatment of poisonous snake and insect bites. 196 How army doctors were trained, and to what degree such training may have been “standardized” across the entire military medical service, is still unclear. A late-second century C.E. inscription from Lambaesis (present-day Algeria) not only lists the hospital staff of the legio III Augusta along with their various titles and ranks, but also makes it clear that the army provided training to members of their medical service. 197 While we lack enough evidence to draw definitive conclusions, it is safe to presume at least some consistency in the types of training and knowledge an army doctor was expected to have. For example, they would have been expected to know how to address the types of wounds caused by projectile points such as arrows and spearheads, and how to surgically remove those objects from tissue or bone if necessary. Any doctor who was not already in possession of these skills upon entering the army would, thanks to the nature and frequency of military conflict in the Imperial era, have had plenty of opportunities to learn them. 195 Jackson 1988, 134. 196 Jackson 1988, 134; Scheidel, 2007, 430-31; Davies 1989, 209-231. 197 CIL VIII 2553 and AE 1906, 9 70 While medical treatises by Hippocrates and other, later writers were known to have circulated throughout the ancient world, developing effective surgical skills required more than book-learning. This would have been especially true of the more anatomically invasive interventions, such as amputation, trepanation procedures or the safe extraction of metal projectile points embedded in bone. The prohibition against human dissection in the Roman period meant that gaining precise anatomical knowledge was a challenge, with most physicians having to rely on drawings or animal dissections. 198 Surgeons who had the best chance of developing the necessary skills were those who treated soldiers, effectively gaining their anatomical knowledge and traumatic injury expertise “on the job.” Even in the Greek Classical and Hellenistic periods, when there was no prohibition against cadaver dissection for the purposes of medical training, Hippocrates advised aspiring surgeons wishing to gain experience in wound-related surgery to “serve in the army and accompany it abroad; for in this way he would become experienced in this practice.” 199 Approximately 500 years later, Celsus echoes the same sentiment when he laments that most physicians are only able study a human’s internal anatomy after the subject is already deceased, which teaches them nothing about “what our viscera are like when we are alive.” But soldiers or gladiators, he continues, are sometimes so grievously wounded that “some or other 198 Gal. De anat. admin. I.2.221-224 (= Singer 1956, 3-4). Curiously, while various contemporary authors refer to the practice of human dissection in the Roman world as being taboo, none offer any speculation as to why it was so. Susan Mattern, who wrote two biographies on Galen, mentions only that the physician from Pergamon lived in “a world in which the dissection of human corpses was taboo and rarely practiced.” (Mattern 2013, 43). Charles Singer, in his published translation of Galen’s On Anatomical Procedures (De anatomicis Administrationibus) speculates that the reason was neither philosophical nor religious but was rather a result of the “fear and disgust aroused by a dead body,” and that medical men such as Galen refrained from writing about their results of human dissection for fear of offending his readership. Such things, continues Singer, “can hardly be spoken of outside the professional circle.” (Singer 1956, xxii). I suspect that this is more a reflection of Singer’s own mid-20 th century sensibilities than a reticence on Galen’s part, as the latter is straightforward and exceptionally detailed in describing even the most invasive and brutal of procedures (such as animal vivisection), and who in any case states in the introduction of his anatomical treatise that he intends it to be an informative texts for other physicians. (Gal. De anat. admin. I.1.215- 216) 199 Hippoc. Medic. 14.IX.220L (= Potter 1995, 315). Also see Salazar 2000, 73 and Aparaschivei 2012b, 100. 71 interior part is exposed in one man or another” and the physician who attends such patients will learn far more about human anatomy than those who only study the dead. It is foolish, he goes on to admonish, for a physician to suppose that the internal composition of a body when it is dead is the same as it is in life. 200 In other words, if a doctor in the Roman Imperial period was serious about gaining real knowledge of human anatomy and a command of the surgical arts, he needed live subjects to study – preferably ones who could present him with a wide variety of gruesome injuries. Of course, such injuries also resulted from gladiatorial spectacles, and the opportunities that such games presented for physicians to learn both anatomy and surgical skills were undoubtedly some of the reasons why some physicians such as Galen sought to treat gladiators at various times throughout their careers. However, it seems that such a role could not be volunteered for but rather had to be earned; Galen’s appointment to the role of physician to the gladiators of Pergamon was something that he was required to win, competing against other physicians in a series of public contests in order to demonstrate a pre-existing knowledge of anatomy. 201 The anatomical knowledge that secured Galen his position as a gladiator physician was something of which he was openly proud, and which he felt made his expertise superior to that of most of his colleagues. Never one to resist self-promotion, Galen boasts of his extensive education and training, made possible by his family’s social standing and wealth. 202 As wealthy property holders and members of the aristocratic elite of Pergamon, Galen’s social status enabled him to spare “no effort or expense” in undertaking training. 203 For example, comparatively few 200 Celsus Med. Proe. 43 (= Spencer 1935, 25-6). 201 Mattern 2013, 81-4. For a study of the performative aspects of his anatomical investigations, see Gleason 2009. 202 For a detailed description and timeline of Galen’s studies as well as references to his writings in which such details can be found, see Mattern 2013, particularly Chapter 2. 203 Mattern 2013, 54. 72 doctors could seek out – as Galen did – the type of anatomical and surgical training offered at the famous medical school in Alexandria. At this institution, anatomical demonstrations apparently did include dissecting human cadavers, the school’s centuries of medical tradition as a Ptolemaic Greek institution evidently superseding the newer Roman aversion to such practices. 204 And unlike Galen, most physicians would not have been able to travel to seek out instruction from students of Quintus, an anatomist who was “distinguished and pre-eminent in the time of Hadrian,” and famous for his “anatomical perspicacity.” 205 Obtaining training by such means would have been virtually impossible for an aspiring physician who needed to make a living. The public medical competitions through which Galen won his appointment as Pergamon’s gladiator physician suggests that the owners of gladiator ludii were unwilling to allow doctors-in-training to practice on their expensive human property. In order to secure such a position, it would seem that anatomical knowledge and the commensurate surgical skills necessary to treat combat injuries were pre-requisites for the job. In other words, if other cities in the Empire regarded the treatment of gladiators as seriously as Pergamon, obtaining trauma surgery expertise in this way may not have been a practical or even viable option for doctors looking to acquire the surgical skills necessary to mitigate combat injuries. Thus, for a medicus seeking to acquire such skills, service in the army’s medical corps was the most obvious option. In fact, if Galen is to be believed, then I suggest that the prestige and compensation resulting from an appointment as a physician for gladiators was such that the prospect of such an opportunity may well have been one of the motivating factors to obtain such skills in the first place. 204 Gal. De anat. admin. 1.2.220 (= Singer 1956, 3); 205 Gal. De anat. admin. 14.1.231 (= Duckworth 1962, 183); Mattern 2013, 54. 73 Unlike many professional specializations within the army that would have had few applications outside of a military context, military doctors would have the opportunity to gain a skill set that could give them distinct professional advantages in the civilian world, even in cities or towns where gladiator games were rare or non-existent. For an ambitious civilian medicus, a stint in the army could be an astute career move; moves of this type would ensure a steady flow of military-trained physicians returning to practice in civilian environments. As in the case of fighting units, we have no reason to believe that the hierarchal structure and allocations of responsibilities were not standardized across the whole of the Roman army. But, to what degree the army’s actual medical practices were similarly standardized is a matter of some debate. Baker argues convincingly that the practices of the medici of a Roman military unit would have been influenced by their immediate environment, both in terms of the types of illnesses their patients might encounter, as well as successful wound mitigation techniques learned from practitioners from the local civilian population. 206 Her position is particularly logical when it comes to the treatment of disease. Different environments mean different diseases, as well as different medicinal substances (e.g., plants and even minerals with therapeutic properties) and techniques to treat them. Local knowledge as well as medicines would likely have been included in the camp physician’s metaphorical “toolbox,” particularly when confronted with an unknown illness. This type of locally acquired, region-specific knowledge would also have been a professional benefit for military medical personnel, who could then transmit this knowledge to other civilian spheres either by passing it on to their civilian counterparts and/or apprentices, or by applying this diverse knowledge during their subsequent civilian practices. 206 Baker 2004a, 24-5. 74 However, the possible reliance on local medical knowledge and materials for particular ailments hardly precludes the existence and implementation of certain standards of medical practices and materials across the military. Indeed, evidence suggests that when it came to certain substances that were considered by Roman army doctors to be beneficial, the army would go to great lengths to procure them, however inconveniently located a camp might be. For example, at a legionary fortress in Carpow (eastern Scotland), an amphora of wine infused with horehound, an herb native to continental Europe, was recovered during excavations. 207 Recommended by Dioscorides as a treatment for coughs and asthma, the horehound-infused wine could only have been obtained deliberately, either specifically requested by a camp doctor, or included as part of a standard shipment of supplies. 208 Another example is found in an inscription found near Budapest, Hungary, which reveals that an estimated 678 liters of medicated wine was sent to the legionary fortress of Aquincum (modern Budapest, Hungary) in barrels from several different customs zones, all stamped “duty free” as they were intended for the “hospital of legio II Adiutrix.” 209 In either case, it is clear that while Roman military doctors may have availed themselves of local knowledge and materials on occasion, they also adhered to certain “canonical” treatments, which they apparently had reason to assume the army would expend the resources to procure for them. Indeed, it seems that such supplies were considered a priority by the unit commanders, and that the tendency of the army’s medical staff to rely on certain standard treatments and materials was accommodated by the Roman administrative 207 Wright 1963, no. 51. 208 Dsc. 3.105.1 (= Beck 2017, 228), 5.48 (= Beck 2017, 351); Pliny also mentions horehound and records it as something of an all-purpose substance used to treat, among other conditions, coughs, constipation, gangrene, jaundice, “maladies of the male genitals” and hangnails. Plin. NH 20.89 (= Jones 1951, 141-3). 209 Immune in ra[tionem] val[etudinarii] leg[ionis] II Adi[utricis]. AE 1933, 120; Davies 1989, 219; Israelowich 2015, 103. 75 system. 210 As consistent policies, procedures and materials existed for all other branches of the Roman army, there is no reason to believe the medical service would have been excepted. Despite Baker’s assertion to the contrary, evidence also indicates that state-approved standards existed for military medicine not only for the organization of medical corps staff but also in terms of certain treatments and materials. This standardized approach may have also extended to training. While it is generally accepted that certain surgical skills were acquired on the job, a basic corpus of knowledge and medical protocol was likely expected of military physicians. For example, Ralph Jackson suggests that the works of Celsus, who devoted several chapters of his De Medicina to the treatment of injuries caused by projectiles such as arrows, lead balls and spear points, were made available, along with the texts of other medical authorities, to newly commissioned military doctors as a type of military medical manual. 211 In a letter to his parents, a third-century physician from Alexandria named Marcus implies that he had access to such a medical manual upon entering military service, since he did not feel the need to bring his own medical books with him and instead left them at home. 212 These two approaches to military medical practices – applying a uniform “standard” of medical care vs. relying on local expertise and resources care need not be mutually exclusive. If, as Jackson suggests, military physicians were provided with the canonical texts of the time to 210 In his first-century C.E. authoritative treatise on the duties of a general, Onasander specifies that medical supplies should be placed in the middle of the column whenever the legion was on the march, so that they could be both optimally protected and easily accessed. Onasander, Strategikos 6.6 (= Oldfather 1928, 399); Israelowich notes that the very existence of a sepasiarius, who was responsible for medical ointments, “suggests that the production, distribution, and codification of use of materia medica were administered on an imperial level.” Israelowich 2015, 104. 211 Jackson 1988, 128-29; Celsus Med. 5.26. 212 Jackson 1988, 129. In a letter to his parents, Marcus asks that they “shake the dust off my medical books, shake it off and remove them from the window, where I left them on my departure.” P. Ross. – Georg., 3.1.17-19 (translation from Davies 1969, 94.) 76 study and consult, it does not preclude the possibility that they could also learn of treatments for a variety of illnesses and injuries thought to be effective by people from local areas. Indeed, the latter seems highly probable, given that urban colonial centers grew up in close proximity to military encampments (e.g., Pompeii, Ostia, Paestum, Mainz, Lyon, Timgad, etc.). The interdependent nature of the relationship between military camps and the civilian settlements that grew up around them (canabae) have been well-studied, and there is no reason why the army’s well-documented use of local knowledge and resources would not also have included medicine. 213 Such scenarios are not only reasonable, but also highly probable. It seems reasonable to presume that army medical staff, accustomed to dynamic or even volatile situations and environments – and no doubt keenly aware of the responsibilities and expectations placed upon them – would have exploited every perceived advantage in the execution of their duties. In order to maximize the chance of a positive outcome, it is reasonable to suggest that a shrewd army medicus would adopt a two-pronged approach to his trade by combining canonical standards of care with local medical knowledge and resources that were proven to be effective. The number of distinct specialists that comprised the medical corps, their apparent adherence to at least some standardized medical practices and the formal organization of their ranks in the earliest years of the Principate stands in sharp contrast to the lack of evidence for any sort of comparable medical system in the civilian sector. As wealthy and powerful as the Roman Empire was in the second century, its resources were finite. Even if the Imperial will for implementing a comparable medical model for the Empire’s civilian population had existed (and 213 While she makes no mention of medicine specifically, Penelope Allison’s studies of several military camps and their adjacent civilian settlements in the Germanic provinces offers a very thorough treatment of the archaeological evidence for military/civilian interactions: Allison 2013. C. R. Whitaker’s socio-economic study of the Roman frontiers is very useful for understanding the mutual reliance that existed between military camps and the local civilian population: Whitaker, 1994. Patricia Baker’s study of medical care for the Roman army along the western frontier in the Imperial era is probably the most complete to date on the topic. See Baker 2004a. 77 there is no evidence to suggest that it did), effecting such a system would have been economically and logistically impractical - if not impossible. In addition to the expense to the state, such regularization would have required at least some sort formalized training and assessment paradigm that applied to all civilian medical practitioners throughout the Empire, something that would not exist in civilian medical training until the 19 th century. 214 However, the establishment of a formal system of medical care for the Empire’s soldiers likely had some bearing on the types of medicine practiced in the civilian sphere, even if there was no comprehensive state effort to implement a comparable model. From a strictly clinical perspective, effective treatments and surgical techniques developed by army surgeons, who were routinely provided with medical training opportunities in the form of traumatic injuries, would eventually make their way into the medical repertoire of at least some civilian practitioners. In terms of organizational structure, the military medical service provided an example to municipal authorities and civilian physicians in the second century, when civilian physicians had come to be counted among the various professionals found on municipal payrolls. 215 An obvious way in which military medicine would come to affect the civilian population is that the establishment of a medical corps meant an overall increase in the number of trained physicians. While the existing evidence does not allow us to definitively conclude how many army medici there were at any given time, we can arrive at some general estimates. In Rome, we know that in the early third century C.E. four medici were assigned to each cohortes vigilium, which equates to one doctor for every 250 men. 216 This seems to have been a relatively standard 214 For a discussion of physician education and training, see Chapter 3 of this study. 215 Nutton 1992, 5-7; 2013, 249-50. 216 CIL VI 1059 (= Alonso 2018, 227-8 no. 77 and Korpela 1987, 204 no.271-272, 274-275); The dedicatory inscription includes the four names of the medici cohortis II vigilum among a number of the cohort’s other members. Firefighter cohorts of this period were comprised of 1000 men. CIL VI 1063-1064 (from Alonso 2018, 171 n. 135). 78 ratio, since it appears that large warships with a crew of 200-250 men also carried at least one medicus duplicarius. 217 However, while medici are consistently documented as being part of military auxiliary formations, and even in irregular numeri, there is presently no evidence that there was more than one medicus for each unit. 218 Estimating conservatively, we can presume at least one medical specialist for every 500 men in most units, meaning that an entire legion would have had at least 10 men in their medical corps who bore the title medicus. 219 As noted, a number of different medical specialists were attested to in epigraphical and textual evidence that went by different titles – presumably these would have been attached to at least the larger units. Demographic studies of the Roman army during the Imperial period estimate that it was comprised of anywhere from 300,000 to 400,000 soldiers. 220 At any given time, the Roman military may therefore have had in its employ up to 1000 medical staff. 221 Retired Military Physicians in Civilian Practice Just like the professional soldiers in the fighting units of the Roman army, physicians who survived their military service and completed their contract of service would eventually retire. Also like their soldier counterparts, these discharged professionals would assume – or 217 There are a number of epigraphic examples that mention medici duplicarii who were assigned to the larger warships. These include CIL VI 3117, 3124, 3128, 3910, CIL X 3441-3444, 3484, 3642, 3664, CIL XIV 237 (from Alonso 2018, 165 n. 105 and Nutton 1970, 66-7). Also see Davies 1989, 214. 218 Epigraphic evidence of inscriptions concerning the medici of the Roman army has been well-studied and catalogued. While not exhaustive, examples of such studies include Scarborough 1969 (Chapter 6), Davies 1969 and 1970, Baker 2001 and 2004, Southern 2007, 233-37, Bader 2014 and Israelowich 2016. The most comprehensive treatment to date is Juliane Wilmanns’ 1995 book Der Sanitätsdienst im Römischen Reich: eine sozialgeschichtliche Studie zum römischen Militärsanitätswesen nebst einer Prosopographie des Sanitätspersonals in which she reviews almost 100 different epigraphic examples for medical personnel in almost 70 Roman military sites. See in particular her table on pages 251-254 that lists known doctors and other medical personnel according to their unit types (e.g., cohortes praetoriae, equites singulares Augusti, legionen, numeri, etc.) For a study of medici in the Roman navy, see Nutton 1970. 219 Schiedel 2007, 431; Davies 1989, 212-15; Wilmanns 1995b, 68-70. 220 Demographic studies of the Roman army include Gilliver 2007, Southern 2007, Goldsworthy 2003 and Campbell 1984. 221 Schiedel 2007, 431. 79 resume – civilian lives. For some, this may have meant taking up professional roles in areas other than medicine, but for others the transition from treating soldiers to treating civilians would have been a relatively natural one, made easier – and presumably more lucrative – now that they were in possession of surgical skills many of their civilian colleagues would have lacked. While acknowledging that such a phenomenon may be a possibility, Baker argues against this model asserting that “there is not much to support the idea of doctors working after their service in the army except for the statement by the Hippocratic writer (On the Physician 9.219L) saying that doctors should join the army to gain more surgical experience.” 222 Current available evidence indicates otherwise. For example, the material recovered from the Domus del Chirurgo paints a vivid picture of a physician who in all likelihood had prior military experience and then went on to establish a lucrative civilian practice. 223 Likewise, the range of surgical tools represented in the instrumentarium of the Marcianopolis physician also suggests someone familiar with the types of wounds most commonly suffered by soldiers and gladiators. 224 In both cases, the regions in which these physicians lived would have brought them into close contact with soldiers and civilians simultaneously; it stands to reason that at least some of the successful physicians in these types of environments would have seen the value in being adept at treating both soldiers and civilians. Furthermore, the custom of military doctors eventually settling into successful civilian practices in urban centers was evidently common enough that by the early third century C.E. an imperial ruling was issued to clarify the legal benefits to which military physicians were entitled once they left the army and practiced their profession in the civilian sphere. 225 Both 222 Baker 2004a, 52. 223 A summary of the evidence from the Domus del Chirurgo is presented in Chapter 1 of this study. For a detailed discussion of this evidence and why it indicates that the Rimini physician had served in the army, see Chapter 4 of this study. 224 For a detailed discussion of the evidence from Marcianopolis, see Chapter 4 of this study. 225 Cod. Iust. 10.53.1. 80 Galen and the late-first century Imperial physician Statilius Crito Titus temporarily served as military physicians at the request of the emperors Marcus Aurelius and Trajan, respectively. 226 Given the military presence in the region, and Marcianopolis’ location along one of the province’s primary traffic routes, the city would have been both convenient and attractively located for a newly discharged military medicus with an eye toward establishing himself as a civilian practitioner. Rimini, likewise situated at one of the crossroads of the land and sea routes that facilitated the movement of people and goods throughout the Empire, would have been similarly appealing. Yet these two examples, while part of a very small group of sites from which we have archaeological evidence of civilian medical practices that could have been established by military-trained surgeons, can hardly be considered unique. Cities and towns similarly situated throughout the Empire would have been regarded as favorable locations for retired military physicians interested in applying their skills in civilian environments. In addition to the archaeological evidence indicating that the Rimini physician and possibly the Marcianopolis physician served in the Roman military, there are a number of literary and epigraphic sources that attest to the practice of military medici establishing themselves as civilian practitioners following their service in the army (see following discussion). That civic authorities would wish to lure army-trained surgeons to their cities and towns is hardly surprising when one considers that the general caliber of such surgeons was high, particularly when it came to trauma surgery. Roy Davies notes that military medical officers and their techniques were generally held in high esteem, observing that Galen, one of the second century’s most authoritative medical voices, recommends a variety of surgical intervention 226 Gal. Libr. Propr. 2.18 (= Singer 1997, 7-8); Mattern 2008, 3; 2013, 187-98; OCD 1396, s.v. “Statilius Crito Titus”; Also see Nutton 2014, 385-6. 81 techniques and treatments that were all quoted from army surgeons. 227 For example, in one of his treatises on pharmacology The Composition of Drugs According to Places (De Copositione Medicamentorum Secundum Locos), Galen cites “Antignonus, a distinguished doctor in camp” for a headache recipe. He also credits Axius, an eye specialist (medicus ocularius ) who served in the classis Britannica (British fleet), with inventing an eye-salve. 228 Celsus likewise credits military physicians with developing a number of his recommended wound mitigation techniques, such as staunching blood flow in certain type of wounds, using fibulae to close wounds that were unable to be stitched, and discovering a compound called barbarum, which was made from the bark of certain types of trees that had demonstrable styptic effects. 229 Some techniques recommended by Celsus, such as the secondary amputation method employed by Roman army surgeons in the event that gangrene set in the wake of a rushed, emergency amputation, were still employed in the early 20 th century by surgeons during World War I. 230 Approximately 30 km away from Marcianopolis in the neighboring city of Odessos, we have evidence of a second-century C.E. physician of high status who established himself in the civilian sphere following military service. His tomb relief depicts the deceased, Asklepiades, son of Apellas, seated with his wife and slaves above a collection of battle items that comprised the fundamental equipment of a Roman soldier: the shield (clypeus), chest armor (lorica), helmet (galea), leg armor (greaves) and a sword (gladius, Fig. 2.1). 231 The accompanying inscription, in addition to informing us of his theophoric name and his profession, also lists a number of high- ranking administrative and religious offices held during his lifetime. Asklepiades was an 227 Davies 1989, 215. Also see Israelowich 2015, 105-6. 228 Gal. Comp. Med. Loc. 12.557 and 12.12.786 (Kühn). 229 Celsus Med. 5.26.21-4. 230 Celsus, Med. 7.33.1-2 (= Spencer 1938b, 471); Davies 1989, 217; McCallum 2008, 64; Iraelowich 2016, 226. 231 IGBulg. I 2 150 (AE 1937 99); Samama 2003, 193 (no. 94); Aparschivei 2012b, 108; Minchev 2016. Nutton 1977, 224 (no. 79). 82 archiatros, or head of the city’s collegium medicorum; he was, essentially, the city of Odessos’ official chief physician. Judging from the military imagery on his tomb, it would seem that at least some of his highly esteemed expertise was gained from his experience, at some point, as an army medicus. The establishment of the Imperial army meant that, eventually over time, skilled physicians with a greater degree of surgical expertise than most of their civilian counterparts returned to civilian life upon their retirement. While some medici could and did spend their entire careers in the army if they so chose, they were not bound by the usual enlistment terms of 20 or 25 years and could, and apparently sometimes did, serve well past the retirement age for a regular soldier. A second-century C.E. tomb inscription from the camp of the Legio III Augusta at Roman Lambaesis (present-day Algeria) records the death of the medicus C. Papirius Aelianus, who was apparently in active service when he died at the age of 85. 232 While C. Papirius Aelianus’s lengthy period of service is remarkable, it seems military medical personnel may have been able to serve for significantly shorter terms of service as well. An example of this may possibly be found in the burial inscription of Marcus Valerius Longinus, who served as a medicus in the Seventh Legion before he was made a member of the city council of Drobeta (Turnu Severin, Romania), a position he held until his death at the age of 23. 233 The physician Numisius evidently also served a shorter term of service since he appealed to Emperor Caracalla concerning the potential loss of his tax immunity in his civilian life while he served with the Second Adiutrix Legion. 234 Numisius would not have had to make this request if he had been 232 CIL VIII 18314. See Davies 1989, 214. 233 “d. m. | M. Val. M. f. | Longinu[s] | med. leg. | VII Cl. | ornat. ornament decu[r] | a splendid. | ordin. M. H. D. | vix. An. XXIII | M. Victorious | …anio et Victoria | [Ge]mina | fil. Pien[t] | p.” CIL III 14219,9 (from Nutton 2013a, 185); There is a second possibility related to this individual’s circumstances, a discussion of which is addressed further on in this chapter. 234 Cod. Iust. 10.53.1; Nutton 2013a, 185. 83 serving a normal soldier’s contract, since soldiers were automatically exempt from civic liturgies. 235 Since physicians seemed to be able to engage in military service with shorter contract terms than regular soldiers, it therefore seems reasonable to suggest that the retirement rate of physicians was likely higher than that of their combatant counterparts. That same abbreviated service obligation also would have meant that many of these men would, upon their discharge from the army, find themselves with enough professionally productive years ahead of them that a second career would have not only been possible, but likely also necessary. While we have some evidence that perhaps some of the higher ranking military medici may have been of a high socio-economic status, there is no indication that this was true for all of the medical professionals in the military. 236 Wealthy, highly educated physicians such as Numisius and Callimorphus, the physician/historian who recorded the Parthian wars of the mid-second century, were hardly representative of all military medical personnel. 237 For most, finding employment at the conclusion of their service would likely have been an economic imperative. At various points in its several centuries of history, the Roman army frequently experienced precipitous turnover in personnel; the loss of fighting men due to death and injury has always been an occupational hazard of waging war. By contrast, the comparatively brief service commitments required of military medici meant that when it came to losing personnel from its medical service as a result of retirement, the army’s loss was the civilians’ gain. The stream of retired military physicians who set up practices in civilian, urban environments meant that their expertise was now available to the broader population of the city or town in which they 235 Dig. 50.4.3 (from Israelowich 2015, 104 n.145); Immunity from civic liturgies was furthermore granted to veterans for some time following their discharge from the army. 236 The socio-economic status of Graeco-Roman physicians varied widely, as attested to in a variety of studies on the subject. See Nutton 1992, Pleket 1995; Jackson 2009a; 2013, 248-58; 237 Cod. Iust. 10.53.1. 84 settled – or at least to the segment of the population who could afford it. And though medical specialists may have represented a tiny percentage (< 0.3%) of the total army, it is likely that they would have successfully survived their service and retired to civilian life at a comparatively higher rate. 238 Physicians, of course, were no less susceptible than soldiers when it came to the disease outbreaks that could beleaguer Roman military camps, but on the whole, they still likely enjoyed higher survival rates. Because while we cannot rule out the possibility that they could also serve as soldiers in battle when necessary, it is reasonable to assume that efforts were made to keep them removed from conflict as much as possible since their skills would be needed to treat their unit’s casualties. Taking all this into consideration, we then have the rough outlines of the following probable scenario: beginning in the early first century C.E., the establishment of a state- administered medical corps within the newly created professional army meant there was now a reasonably standardized system for the training of an increasing number of physicians - training that included the surgical skills necessary to mitigate severe injuries. Acquiring those skills required consistent and repeated exposure to patients who suffered from traumatic wounds - circumstances that the Roman army was uniquely disposed to provide. With shorter service requirements and a lower mortality rate than their fighting unit counterparts, army medical personnel could then retire from military life armed with a type of expertise uncommon in civilian doctors with no military experience. With more productive professional years ahead of them, a marketable skill set and the possibility of financially favorable tax exemptions, establishing a practice in a city or town large enough to sustain one would have been an attractive and likely successful course of action for a newly discharged military medicus. We 238 These are my own calculations based on the data cited in fn. 35 and 36. 85 have an example of this in one Marcus Ulpius Telesphorus, a medicus first of the ala Indiana in Germany and then of ala III Aturum in Mauritainia Tingitana before he retired to become a “salaried medical health officer” in the “splendid city of Ferentium.” 239 A skilled surgeon who went on to establish a successful practice in civilian life had the potential not only to use his expertise in service of his patients directly, but to be a potential vector for the transmission of that expertise to other physicians in his city or town. In this way, the military medical corps would eventually impact civilian medicine in two critical ways: first, as retiring military doctors began practicing in civilian communities, their civilian patients would now have access to a degree of expertise that would have been previously unavailable, particularly when it came to surgery. Second, military physicians entering into – or returning to – civilian life brought their hard-earned knowledge with them. This second circumstance is perhaps even more significant than the first, since efficacious medical knowledge that is shared among practitioners can have an exponential, rather than merely linear, impact on the population they serve. Unfortunately, it is difficult to decisively quantify this impact, at least given the current limitations of our evidence. Yet it seems unlikely that the increasingly sophisticated professionalization we see among civilian medical practitioners in the second and third centuries is completely unrelated to the establishment of a rigorously trained military medical service at the beginning of the first. 239 D.M. | M. Ulpio.| M. fil. Sporo |medico alar | Indianae et | tertiae Astorum | et salariario | civitati[s] splendidissimae | Ferentiensium | Ulpius Protog[e]nes | lib. p. b. m. f. CIL XI, 3007 = ILS 2542 (=Alonso 2018, 275 no. 265). 86 Civilian Physicians in the Employ of the Roman Army Thus far, we have examined only one point of overlap between military and civilian medicine in the Imperial era. While the medici of the Roman army taking their experience and expertise into the civilian sector at the conclusion of their service is perhaps the most obvious paradigm by which the medical knowledge gained in the martial sphere came to be transmitted to and practiced in civilian environments, it is not the only one. Along the frontiers of the Empire, Roman civilian settlements that sprang up next to or near the castra on the frontiers, called canabae, were spaces in which soldiers and civilians interacted on a daily basis and in which the two worlds not only overlapped but also became enmeshed and mutually interdependent. On individual and family levels, soldiers would either marry local women and establish households, or bring their already established families with them. The resulting socio-cultural dynamic, as well as the ways in which the army’s never-ending need for supplies drove the local economy, have been the subjects of some admirably detailed studies. 240 The army’s needs were hardly limited to supplies; labor and expertise were also necessary resources for which the army routinely turned to the local civilian population. In some cases, it appears that this included medicine, thus opening a new avenue by which medical knowledge and practices could be exchanged, with civilian physicians working for the military on an ad-hoc basis when officially commissioned army physicians were in short supply. According to Dan Aparaschivei, evidence from Novae, a Roman legionary fortress and accompanying town approximately 220 km east of Marcianopolis, demonstrates that at least one civilian physician worked at Novae’s valetudinarium. As evidence, Aparaschivei points to a second-century dedicatory inscription to Asklepios and Hygieia made by a medicus named 240 Examples include Allison 2013, Scheidel 2007, Kehne 2007, Whittaker 1994, 98-131, Hanel 2007 and Campbell 1994, 140-80. 87 Aelius Macedo. 241 Similar known inscriptions made by military doctors generally indicate their legion, auxiliary or naval unit, just like their soldier counterparts. 242 According to Aparaschivei, the fact that such notations were lacking from this particular inscription suggests that Aelius Macedo was not a military physician but rather a civilian working in the valetudinarium, treating ill and injured soldiers alongside the hospital’s military medici. A second inscription from Novae, dating to the early third century C.E., similarly lacks any military unit designations, and Aparaschivei notes that there are other such inscriptions from different military hospitals throughout the Empire. 243 I concur with Aparaschivei that the lack of military designations on the inscriptions constitutes a reasonable argumentum ex silentio that these individuals were civilian doctors working in military contexts, particularly in light of the army’s well-documented practice of exploiting local labor and supply resources to meet its needs. 244 Formally commissioned military doctors are well-attested in epigraphic evidence from Roman army settlements that span much of the Empire’s frontiers. 245 Such evidence reveals that military physicians, like their infantry counterparts, belonged to specific units (e.g., legion, auxiliary fortress or naval unit) and held various ranks within the medical service. 246 The body of epigraphic evidence concerning military doctors is detailed enough that we can recognize a degree of uniformity in the way that the physicians’ military designations are presented. Indeed, such inscriptions follow the same 241 Aparaschivei 2010, 4; 2012, 107-08. The inscription (AÉ 1998, 1134) reads: Aescla- | po et Hy- | giae Ae<l>(ius) | Macedo || med(icus) PS.S.P. For the Greek inscription, see Kolendo 1998, 64. 242 Wilmanns 1995a and 1995b. 243 Ἀσκλη[πι]- | ῷ θεῷ σω[τῆ]- | ρη ․․․ | Α̣ὐ̣ρ̣(ήλιος)(?) | Διό[δω]- | ρος. IGLNovae, 176. For similar examples, see AÉ 1929, 215 and AÉ 1969-1970, 502. From Aparaschivei 2010, 144. 244 Kehne 2007; Whittaker 1994, 98-131; Hanel 2007. 245 See above n. 218. 246 For tables of the epigraphic evidence for military physicians indicating their titles/ranks and military units, see Wilmanns 1995b 251-254 (specific names of physicians and their military units) and Bader 2014, 56-7 (title/rank of physicians and other medical personnel and the type of their corresponding incorporation). 88 formula often used by regular soldiers, in that the identifying military designations almost always follow the name of the physician. An example from Rome dating to the late-first century C.E. reads “In honor of Asklepios and the good health of his fellow soldiers, Sextus Titius Alexander, doctor of the fifth cohort of praetorians, made this offering in the consulship of [Domitian] Augustus for the eighth time…”. 247 Building upon such evidence, scholars have been able to assemble a relatively clear picture of the organizational structure of the army’s medical corps, including the various titles, ranks and responsibilities that could be held by a commissioned medicus. 248 Though the absence of such information on the inscriptions from Novae may not constitute definitive proof that civilian physicians were in the employ of the Roman army, such an arrangement seems likely in a conflict environment where the dynamics of personnel, as well as the volume of patients requiring treatment, were likely to have been particularly volatile. If those responsible for running the castra requisitioned supplies from the local population, why would they not turn to the same source for additional personnel when the situation demanded it? 249 In those cities that were either near garrisoned soldiers or even (if they were unlucky) battle zones, it is likely that civilian physicians were temporarily employed – or even commandeered – by the army when necessary. 250 Alternately it is possible that an enterprising physician, either unable or unwilling to enlist, would have seen a nearby military hospital as a good source of both expertise and income. 247 CIL 6.20 (from Campbell 1994, 104). 248 Examples of the various titles/ranks of doctors in the Roman army’s medical corps that occur in epigraphic evidence most frequently include medicus legionis, medicus cohortis, medicus alae, medicus duplicarius, medicus castrensis, medicus castrorum, medicus miles, medicus ordinarius and medicus ordinarius legionis. See Wilmanns 1995b. 249 For examples of local civilians/supply provisioning army garrisons, see Adams 1995. 250 While there is no direct evidence for this practice in the Imperial Roman era, several such incidences are recorded in Greek antiquity. Salazar 2000, 69; Samama 2003, 456 (no. 367); Samama 2003, 231 (no. 126). 89 Military units stationed in or near large cities – such as Rome – that had a large enough civilian population to support a variety of medical specialists, would have been able to access certain types of medical expertise without committing to hiring a full-time specialist, consulting with these civilian specialists on an “as-needed” basis. Such seems to be the case with Ti. Claudius Claudianus, a medicus clinicus, specializing in internal ailments who served as a civilian consulting physician of Rome’s cohors IV praetoria. 251 Military Physicians Treating Civilians A scenario in which a civilian doctor could be employed by the army when extra medical help was needed invites a consideration of the opposite scenario: military physicians who treated the civilian population of a castrum or canaba. In theory, encouraging military physicians to treat both soldiers’ families (in the case of a permanent military settlement) and the local townspeople would have been a good administrative policy. Such practices would have presumably generated goodwill among the soldiers and local civilians, particularly as the latter group was frequently called upon to provide such supplies as could not be obtained otherwise. 252 The degree to which military physicians practiced their profession for the benefit of civilians is likely unknowable in terms of the entire Empire; in any case, such interactions would have almost certainly varied greatly from place to place. While Romans may not have understood the exact mechanism of contagious diseases, they certainly understood the concept, and it was well-understood that diseases did not distinguish between soldiers and civilians. Any disease that threatened the civilian populations of a canaba was an equal threat to soldiers; using 251 CIL VI 2532. Baker 2004a, 45; Davies 1989, 214; Aparaschivei 2012b, 108. 252 Evidence for the provisioning of Roman military garrisons from local sources is well documented. Examples include Adams 1995, Tab. Vindol. II no 180 (see commentary: http://vindolanda.csad.ox.ac.uk/4DLink2/4DACTION/WebRequestQuery) 90 whatever means at their disposal to maintain a healthy civilian population in areas where soldiers were garrisoned would have been understood by the authorities to be in the army’s best interest. Policies that prevented regular soldiers on active duty from taking on civilian jobs were no doubt implemented in order to eliminate the possibility of a soldier being distracted from his military duties. 253 In the case of the military medici, however, treating soldiers’ families and the civilians of their settlement would have been a logical measure for maintaining a healthy fighting force. While our material evidence for such practices is admittedly indirect, what there is suggests that such practices may indeed have been undertaken by certain members of the army’s medical service, and in at least one case was gratefully received by the civilian community. An example of such circumstantial evidence is the burial inscription belonging to Valerius Longinus, the young physician who served in the army before becoming a civilian city council member in his hometown of Drobeta. 254 He was awarded an ornamenta decurionalia for medical services rendered to the city. 255 Ido Israelowich cites this particular inscription as an example of a retired army doctor who went on to established himself in civilian practice once his service was concluded, and this is certainly a distinct possibility. 256 However, a different scenario is also possible: though the inscription does not explicitly state that Longinus was on active duty at the time, his young age at the time of his death suggests that, even given the shorter service 253 A passage in the Digesta seems to indicate that allowing regular soldiers from holding jobs outside of the military while in active service was strongly discouraged: “Paternus has also written that [a general] who is mindful that he commands armed troops ought to grant leave very sparingly, ought not to… dispatch a soldier on his own private business or out fishing or hunting. For in the disciplina Augusti provision is made in these words: ‘Even though I know that it is not inappropriate for soldiers to be employed on jobs as craftsmen, I nonetheless fear that if I should permit any such thing to be done for my convenience or yours, limits tolerable to me would not be imposed on this practice.Even though I know that it is not inappropriate for soldiers to be employed on jobs as craftsmen, I nonetheless fear that if I should permit any such thing to be done for my convenience or yours, limits tolerable to me would not be imposed on this practice.” Dig. 49.16.12 (= Watson 2011, 410). 254 See above n. 233. 255 CIL III 14216, 9. 256 Israelowich 2015, 106. 91 requirements for the army’s medical personnel, he may not have yet completed his service contract. It is possible that in the case of Longinus we may have an active-duty member of the military’s medical corps who provided medical aid to the city of Drobeta in response to some sort of medical crisis for which he was formally honored by the city authorities. Though the nature of his service to the city is not specified, the public nature of the monument suggests that it was hardly clandestine; any professional services provided to the city of Drobeta by the army medicus would almost certainly have been done with the approval of the local military leadership. While we do not yet have enough evidence to know exactly what the Imperial administration’s official position was on their military doctors treating civilians, scenarios such as the ones discussed above seem likely. Baker notes that the wives and families of soldiers would have needed medical care at times, and that rendering such care to the local population could have been “a means for maintaining good relations between military and civilian groups. It could also be a method for a military doctor to learn more about the ailments of women and children, a skill that could be used by doctors who wished to practice civilian medicine after their service in the army was completed.” 257 Given the symbiotic nature of the military and civilian supply networks and economies in the frontier regions, it is easy to imagine that military authorities would have preferred to maintain good relationships with their civilian neighbors; allowing members of their medical corps to serve the local community would have been an easy and relatively inexpensive way to do so. 257 Baker 2004a, 52. It is after making this point, however, that Baker goes on to suggest that “there is not much to support the idea of doctors working after their service in the army except for the statement by the Hippocratic writer (On the Physician 9.219L) saying that doctors should join the army to gain more surgical experience,” a position I dispute in this chapter. 92 A set of second-century inscriptions from Heraclea Pontica offers an additional example of a physician who treated both soldiers and civilians, possibly simultaneously. A dedicatory inscription to Asklepios by Marcius Xenocrates indicates that he was a physician of the evocati. 258 The same Marcius Xenocrates was honored by an association of actors in Heraclea Pontica in recognition of his medical services. 259 It is unclear whether the physician Xenocrates was a retired military physician who set up a practice at Heraclea Pontica, or if he was a civilian physician who, at some point in his career, had been hired by the army to treat soldiers. 260 Regardless, it is clear that Xenocrates was a physician who treated both soldiers and civilians. Archaeological Evidence: Marcianopolis While the epigraphic and literary evidence discussed above suggests several paradigms by which military medicine extended into the civilian sphere, on its own it remains somewhat circumstantial in nature. However, when considered alongside the material evidence from Marcianopolis and especially Rimini, we have a strong case for a scenario in which at least some army physicians of the Imperial era, upon their completion of military service, went on to establish civilian practices. By doing so, they would have brought their expertise to the civilian world, where they could both benefit patients and transmit knowledge to civilian practitioners, in addition to possibly increasing their income potential. A number of instruments in the Marcianopolis instrumentarium suggests a practitioner who had specific expertise in traumatic injuries. For example, Alexander Minchev and his team 258 Inscriptions from Heraclea Pontica, no. 7 (Jonnes and Ameling 1994, 4-6); Evocati is the term used to describe soldiers who had fulfilled their service requirement but then voluntarily re-enlisted. 259 Inscriptions from Heraclea Pontica, no. 2 (Jonnes and Ameling 1994, 9). 260 A third possibility is that Xenocrates was an active duty military physician who simultaneously treated civilians. However, since Heraclea Pontica is not known to be a site where Roman military units were stationed during the Imperial period, this seems unlikely. See OCD:662, s.v. “Heraclea Pontica.” 93 identified a trepanation bow and its accompanying ruler (used to precisely define and cut the circular hole in the skull in order to relieve intracranial pressure), bone lever and extraction forceps, all of which were used to treat the types of injuries sustained in military conflicts. 261 Of particular note among the surgically related instruments is a specially modified speculum. In most aspects, it is a standard example of a rectal speculum generally used in the treatment of hemorrhoids. However, the insertion ends appear to have been deliberately fabricated to render them shorter than normal, a circumstance that led Minchev to suggest that this alteration indicates the tool may have been used to extract arrowheads or other foreign objects from wounds. 262 Instruments such as those described above were neither simple to fabricate nor inexpensive to acquire. There would be little reason for a physician to invest in such tools if he did not have the expertise to use them as well as opportunity enough to justify the expense. Perhaps fortunately for a fifth-century physician in Marcianopolis, if not for the inhabitants, such opportunities are likely to have presented themselves frequently. The city’s location and relative importance made it a target for the Gothic armies that threatened the Empire’s northeastern borders from the third century onwards. While injured civilians could well have sought the Marcianopolis’ physician’s services following attacks on the city, the fact that the city was also used at various times as a temporary base for the legions necessary to protect the region’s border meant that, in all likelihood, the Marcianopolis physician would have also treated soldiers, either those who were billeted in the city or those who were sent back from the front for treatment. Indeed, soldiers may have been the physician’s primary patients, for though it is believed the instruments were recovered from a domus, there is no way to know whether or not the physician 261 Minchev 2016, 232-3. 262 Minchev 2015, 232; For a more detailed discussion of this instrument, see Chapter 4 of this study. 94 was an active-duty member of the army’s medical service or a civilian physician at the time of the city’s destruction in the mid-fifth century. At that point, Marcianopolis could be considered a Roman city that was also – at least at times – a de facto legionary base and had been for approximately 150 years. 263 Any clear distinction between the “military” and “civilian” nature of the city had ceased to exist by the early fourth-century, when the emperors began using it as a staging ground for their northern campaigns. 264 While soldiers and civilians injured during the various conflicts of the third, fourth and fifth centuries would have provided a substantial client base for any medicus with expertise in trauma surgery, there would have been other sources of patients who needed such skills. The precarious and somewhat dangerous nature of urban living was acerbically satirized by Juvenal, who, writing in the late-first/early second century, describes the types of accidents that could befall the inhabitants of a large Roman city. 265 While few Roman cities ever approached the scale of Rome, we can safely assume that any urban environment came with a few inherent dangers when it came to injuries. Construction works, the transportation of heavy goods and the volatility of the animals – and people – used to achieve such tasks are just a few examples of circumstances that could easily result in injury or death. At no point in human history has the daily act of living not had at least some potential for physical harm. In the Graeco-Roman world, however, such risks were disproportionately assumed by the poorer classes, who would have been hard-pressed to pay for the services of a skilled surgeon, even if one existed in their city or town. As such, it is not surprising that the majority of evidence we have for sophisticated 263 Kulikowski, M. 2006. 264 Amm. Marc. 27.5.5-6; Phot. 9.7-8; See Chapter 1 of this study. 265 Juv. Satire III 95 surgical procedures – such as those represented by the Marcianopolis and Rimini instrumentaria – seem to have at least some connection to military contexts. It is unlikely that the hazards of civilian daily life would have been enough, on their own, to sustain a successful surgical practice in any but the largest of the Empire’s cities. However, most Roman cities and large towns during the Imperial period shared a common feature that would have been another source of potential clientele for a skilled surgeon: the amphitheater. Those injured in the gladiator games that took place in the amphitheaters of the Roman Empire would have required the same type of injury mitigation as soldiers, and the same skill set on the part of the practitioner. In his writings, Galen describes working in such a capacity in his native Pergamon, following the completion of his medical training in Alexandria. 266 Today, while very little of the amphitheater of Marcianopolis remains, the barest outlines are still visible underneath a thick growth of shrubs and trees. It is unlikely that the Marcianopolis physician whose instrumentarium was recovered by Minchev’s team himself treated gladiators, since such contests had all but disappeared by the beginning of the fifth century. However, for the majority of Marcianopolis’ existence, the staging of gladiator games in the city’s amphitheater, in addition to the presence of soldiers returning from combat and the occasional civilian who ran afoul of the dangers of urban life, would have ensured that a physician experienced in treating traumatic wounds would have had ample opportunity to utilize his skills. While the surgery-specific instruments recovered from Marcianopolis leave no doubt that their owner had surgical expertise, other instruments paint a portrait of a medicus who also treated women. Whether the Marcianopolis physician may have first trained as a military 266 Hired by the archierus of Pergamon to treat the city’s gladiators, Galen served in this capacity from ca. 157/158- 161/162 C.E. Gal. Comp. Med. Gen. 3.2 (= XIII 599-600 Kühn). Also see Scarborough 1971 and Carter 2004, 42-4. 96 surgeon (or was a civilian surgeon who treated soldiers) and then gained additional skills that served female patients or vice-versa is something we will likely never know. However, it is apparent that by the time of the city’s destruction in the mid-fifth century our physician not only treated women, but evidently did so with enough skill that he invested in (or somehow otherwise acquired) gynecological instruments that were both sophisticated and expensive. 267 Also among the instruments and medically related objects from Marcianopolis are examples of more general medical tools that had a variety of uses. These include needles commonly used in treating ophthalmic issues, scalpels, forceps, several different types of probes and spatulas of the types generally used to treat hemorrhoids and bladder/kidney stones. 268 These instruments, as well as the various conditions they were used to treat, are more universal in that both soldiers and civilians suffered from these conditions equally, and examples of these medical tools are common in both military and civilian contexts. 269 Given the degree to which the military and civilian spheres co-existed in Marcianopolis at various points in its history, it seems reasonable to suggest that at least some physicians practicing in the city would be able to address traumatic injuries as well as treat the more common health concerns of the civilian population. The composition of the Marcianopolis instrumentarium not only suggests a physician who may have brought military medical knowledge to bear in a civilian context, but also one who had acquired a relatively sophisticated degree of expertise in obstetrics and gynecology, making this a compelling, if still somewhat speculative, example of the ways in which martial and civic medicine may have intersected in the person of this fifth-century medicus. 267 For a detailed discussion of the gynecological instruments in the Marcianopolis collection see Chapter 4. 268 Minchev 2016, 232-3. 269 For a more detailed discussion of such objects, both from the Marcianopolis collection and elsewhere, see Chapter 4 of this study. 97 Archaeological Evidence: Rimini Though it pre-dates the Marcianopolis site by almost 200 years, evidence from the Domus del Chirurgo in Rimini attests to a scenario that bears several striking similarities to that of the Marcianopolis physician, along with several notable differences. Both sites reveal scenarios in which physicians who may had military medical expertise established successful practices in civilian contexts. In both cases, the circumstances that led to the sites’ state of preservation were destruction events of such magnitude that the owners were unable to flee with their valuable instruments, nor did they ever return to recover whatever they could from the debris, suggesting that neither man may have not survived the attacks on their cities. Both collections are among the largest and most significant of their type. And yet, while the 32 objects from the Marcianopolis cache represents one of the largest in-situ collections from the Roman world, the Rimini collection is five times as large. The approximately 150 distinct surgical, parasurgical and pharmacological items recovered from the Domus del Chirurgo represent an unprecedented discovery in terms of both its size and composition. Furthermore, some items from the Rimini instrumentarium represent the first material evidence of instruments previously known to us only from primary source literature, such as the example of the “Diocles’ spoon,” which was used to extract arrowheads or spear points while minimizing additional tissue damage (Fig. 2.2). 270 This innovative instrument was designed to counteract the vicious design of barbed arrowheads and spear points. Such arrow and spear points were deliberately crafted with barbed edges so that they would cause almost as much damage during the extraction process as they did at the point 270 For a thorough discussion of this extraordinary object and its mention in various ancient literary sources, see De Carolis, 2015. A discussion of additional objects in the Rimini collection, including those that are the first known evidence of their type, can be found in Chapter 4 of this study. 98 of the initial injury. The design of the “Diocles’ spoon” effectively covered the barbed portions of a projectile point, allowing the object to be more smoothly removed from the body, minimizing further tissue damage. 271 The typology of instruments and objects in both collections attests to physicians who had not only an extraordinary degree of surgical expertise specific to addressing traumatic injuries, but also the knowledge and skills to treat more common conditions that seemed to plague Romans, regardless of their profession or socio-economic status. Instrument types in the Marcianopolis and Rimini collections indicate that the physicians who owned them regularly treated patients who suffered from conditions such as trichiasis (an eye condition in which the eyelashes grow inwards, potentially causing injury to the cornea), hernias, hemorrhoids and kidney or bladder stones. Both doctors also had among their instrumentaria tools with which they would perform tooth extractions, uvulectomies and tonsillectomies. However, it appears that only the Marcianopolis physician included gynecology and obstetrics as part of his medical repertoire. The instrumentarium of Rimini’s Eutyches, while containing remarkable instruments that attest to an astonishingly sophisticated knowledge of surgery, had a notable absence of tools related to gynecological conditions or childbirth. While we may never know why this particular physician eschewed expanding his practice to include the treatment of conditions specific to women, it may merely be that he had neither the interest nor the need. The extent of his instrument collection and the size and quality of his domus indicate that he had a very robust and economically successful practice; clearly enough of Rimini’s citizens required (and were able to pay for) his surgical skills that he may have simply seen no need to venture outside of his scope 271 See Chapter 4 of this study for a more detailed discussion of the Diocles’ Spoon 99 of expertise. And Eutyches’ surgical expertise, as evidenced by the range of tools recovered from the Domus del Chirurgo, was extensive. It is in part this surgical expertise represented by the Rimini instrumentarium that led Jacopo Ortalli to suggest that the Rimini surgeon had martial affiliations – a hypothesis with which I agree. 272 The breadth of surgical procedures the Rimini medicus performed indicate a considerable amount of experience treating traumatic injuries of the type typically resulting from military conflict or gladiator competitions. 273 Based on this and other evidence (discussed below), Ortalli concluded that the Rimini physician may have once been a medicus with the Roman army before retiring from active service to the refined domus in which he established a civilian practice. In addition to the Diocles’ spoon, the Rimini instrumentarium contains over 40 different scalpels and scalpel blades representing at least 10 distinct typologies, a range that would have enabled the surgeon to perform procedures that required large incisions through difficult-to- penetrate tissue such as tendons and muscle in order to extract projectile points, as well as highly delicate eye operations to remove pterygium growths on the cornea. 274 A total of 19 spring forceps of varying sizes were identified in the collection that were used to grasp and then remove foreign objects from wounds, repair skin and blood vessels, hold open the edges of a wound or incision so that surgical procedures could be performed, and clamp down veins or arteries during procedures in order to prevent excessive blood loss. 275 272 Ortalli 2007, 113-4. 273 The entire collection of medical instruments from Rimini were evaluated Jackson in consultation with Bliquez. Both scholars are considered to be two of the field’s foremost experts on Graeco-Roman surgical instruments and their identification, methods of manufacture and use. The conclusions reached by Ortalli, Stefano De Carolis and myself with regard to the Rimini’s physician’s expertise and military affiliations are predicated in part on Jackson’s identification of the instruments, which was corroborated by Bliquez and De Carolis and in which I have the utmost confidence. See Jackson 2009b, De Carolis 2009a, 2009b, 2015 and Bliquez 2015. 274 Jackson 2009b, 88. 275 Jackson 2009b, 88. 100 Approximately 40 instruments in the Rimini collection were identified as having functions specific to bone surgery. These include two folding handles that attached to the bow drills used in trepanation procedures, three sequestrum forceps that were designed to remove detached or partially detached cranial bone fragments, nine bone levers used to manipulate fractured or dislocated bones back into their proper place, twelve bone chisels, three surgical gouges (also for use in trepanation procedures) and a bone saw, which would have been employed during amputation procedures. 276 Like the Marcianopolis physician, it is possible that a medicus in possession of the skills necessary to treat traumatic injuries may possibly have earned part of his income by treating gladiators. Among Ariminum’s public buildings was included a large amphitheater. Constructed in the second-century, very little of the structure remains today – an unfortunate result of the significant damage it sustained during the Second World War. With an estimated capacity of approximately 10,000 spectators, Rimini’s amphitheater would have been one of the largest in the Italian peninsula outside of Rome. 277 Unfortunately, the structure has never been extensively excavated and what remains is in very poor condition; we know little about the types of events that took place there, or the frequency with which they may have been held. However, the instability of the third-century (particularly in areas of the Empire that, like Rimini, were vulnerable to Gothic incursions) makes it unlikely that expensive gladiatorial games were a frequent occurrence in ancient Ariminum in this period, but this is merely speculative. 278 Regardless, it is entirely within the realm of possibility that any injuries that may have been 276 Jackson 2009b, 88-9. 277 Ortalli 2003, 106. 278 There has been very little archaeological study of Rimini’s amphitheater, of which only a portion of the foundation is visible to the modern visitor. What remains of the non-visible portion of the structure lies underneath modern buildings. 101 sustained by gladiators during Eutyches’ medical tenure at Rimini could have been addressed by the physician, whose skill set would have been ideally suited to the types of injuries inflicted in the arena. In all probability, revenue from treating gladiator patients (if indeed they existed) would not have been sufficient to enable Eutyches to achieve the level of economic success evidenced by his domus and the various objects discovered within it. Since there is no evidence that he regularly counted the city’s women among his patients and his economic status is unlikely to have been maintained by exclusively treating victims of the gladiator games, the array of specialized instruments suggests that he may have had a steady stream of patients perhaps resulting from the frequent military skirmishes along the Empire’s northeastern frontiers, which, at this period in Rome’s history, were alarmingly porous. Military units of the third century found themselves along battle lines as far south as Ravenna – a situation that would have been unthinkable a century earlier. The fourth-century historian Eutropius writes that in 254 “the Germans came as far as Ravenna,” while Jerome reports that 10 years later plundering tribes of Germans and Alans also came as far south as Ravenna. 279 Rimini’s location at the end of the Via Flaminia (coming from Rome) and the beginning of the Via Aemelia, which led northwest toward the frontiers of the Empire, meant that any military units moving between Rome and the frontiers would have passed through Eutyches’ city. Furthermore, approximately 50km north of ancient Ariminum was located the military port of Classe (outside of Ravenna), where the Empire’s Adriatic fleet was stationed. Many of the soldiers and sailors returning to Rome via land after arriving in Classe would also have passed through Rimini, coming south along the Via Popilia, which connected the two cities. 280 Those soldiers who sustained injuries but survived long enough to retreat to Ariminum may well have sought the services of one of their own, for it 279 Eutr., Breviarium 9.7; Jer., Chronicon a.2277. From Deliyannis 2010, 36. 280 Deliyannis 2010, 26-31. 102 is likely that, whatever his status at the time of the site’s destruction, the Rimini physician had served extensively with the Roman army. The number and nature of the surgical instruments recovered by Ortalli and his team are in and of themselves strongly suggestive of a physician with military training. However, in the case of the Domus del Chirurgo, we are not restricted to just the evidence that the instrumentarium provides in order to suggest a military background for the Rimini physician. In addition to the medical equipment in the Orpheus Room, archaeologists recovered a votive object in the form of a small bronze hand, a devotional object that also seems to connect the physician with a period of service as a member of the army’s medical corps. 281 Approximately 12 cm high and 4 cm in diameter, the hand is “opened upwards and characterized by the presence of a round element, perhaps an egg or a ball of incense, at the top of the middle and index fingers, and a crested snake wrapped around the wrist and running along the thumb.” 282 Such votives are associated with the cult of Iuppiter Dolichenus, a divinity originating in northern Syria and especially popular among Roman soldiers from the second century onwards (Fig. 2.3). 283 Evidence for worship of this particular deity is well documented in the Romagna area of the Italian peninsula as well as in Rimini itself. 284 A shrine to the soldiers’ deity was discovered in the ancient forum of Ariminum, located approximately 200 meters south of the Domus del Chirurgo. Two inscriptions discovered in the context of this shrine may offer additional evidence that our surgeon – and at least one other man in his household - were devotees of Iuppiter 281 Ortalli 2000c, 520-21; 2007, 113-14. 282 Ortalli 2007, 113. Translation mine. 283 Ortalli 2007, 114. For studies of the cult of Iuppiter Dolichenus, its particular association with the Roman army and its diffusion throughout the Empire between the second and fourth centuries, see Spiedel 1978, Stroll 2007, Pahl 2010, Collar 2011, 2013, Sanzi 2013 and Leisser 2015. The definitive inventory of votive inscriptions and objects related to the cult of Iuppiter Dolichenus is the Corpus Cultus Iovis Dolichenus (CCID) by M. Hörig, 1987. 284 Cenerini 2000, 65-9. 103 Dolichenus. The inscriptions are from two third-century marble altars, similar in form and lettering style. Both inscriptions are dedications to Iuppiter Optimus Maximus Dolichenus that were recovered in 1897. 285 The first is a votum pro salute made by T. Flavius Galata Eutyches for his freedman Amarantus (Fig. 2.4). 286 The second inscription is also a votum pro salute, this time made by the freedman T. Flavius Amarantus for the health of his son, T. Flavius Viator. 287 Though it is impossible to say with certainty that the “Eutyches” mentioned in the graffito of the cubiculum made by a grateful patient is the same “T. Flavius Galata Eutyches” who demonstrates such concern for the health of his freedman Amarantus, it is tempting to imagine that this is the case. In both instances, there is a strong association with the military cult of Iuppiter Dolichenus. Interestingly, both also connect this particular deity with health. While pro salute votives are common to the temples and shrines of a great number of Graeco-Roman deities, in the case of Iuppiter Dolichenus the majority of inscriptions indicating supplications for well-being and health are generally couched in the context of being victorious in battle. 288 For the army, the god’s association with victory was so strong that images of Iuppiter Dolichenus were frequently depicted alongside the feminine personification of Victoria and appeared on military standards. 289 If the T. Flavius Galata Eutyches from the Dolichenum in Ariminum’s forum is indeed the same person as the skilled medicus of the Domus del Chirurgo, it is tempting to postulate that it was his military service that acquainted him with the soldiers’ god, and it was this familiarity that impelled him to turn to a military deity instead of Asklepios, the most 285 Horig 1987, 296-97. 286 CIL XI, 6788. Donati 1981, 170-171; Hörig 1987, 296 n. 458; Cenerini 2000, 65; Ortalli 2009, 38. 287 CIL XI, 6789; Donati 1981, 170-171; Hörig 1987, 297 n. 459; Cenerini 2000, 65; Ortalli 2009, 38. 288 Hörig 1987. 289 Speidel 1978, 38. 104 obvious choice for a medicus, when seeking assurances of health for his freedman and, judging by the votive hand from the medica taberna, perhaps also for his patients. To date, there is no known evidence specifically referring to civilian physicians who were devotees of Iuppiter Dolichenus. 290 However, if the T. Flavius Galata Eutyches from the votive inscription recovered from the Dolichenum in Rimini is in fact the same person as the military- trained surgeon whose domus and medica taberna were discovered approximately 200 meters away, he is the second known example of a military physician who ascribed health-preserving powers to a deity more usually associated with victory in battle. Epigraphic evidence from a temple dedicated to Iuppiter Dolichenus, located on the Caelian hill in Rome, indicates that a medical officer of the equites singulars Augusti, Quintus Marcus Artemidorus, was also a devotee of the god. 291 As far as their spiritual lives were concerned (or, in most cases, at least the public side of their spiritual lives) most ancient medici for whom we have evidence of cultic associations were, unsurprisingly, devotees of Asklepios. And yet we now know of at least two cases in which a medicus openly associated himself with a deity known to have been particularly venerated by soldiers. In considering the various ways in which a Roman doctor would count himself among the worshippers of a soldier’s god, the possibility that he himself was, at least at some point in his career, in military service himself is extremely plausible. In the case of Artemidorus, he makes his military service clear in his votive inscription. In the case of Eutyches, the presumption that he had a military career prior to settling in Rimini is admittedly less unequivocal, but nevertheless seems extremely likely. Though the 290 There are ca. 640 known, extant inscriptions related to the cult, none of which can be ascribed specifically to civilian medici. However, Monika Hörig records three votive inscriptions by soldiers that appeal to Jupiter Dolichenus, Asklepios and Hygieia together. Hörig 1987, 92 n. 126, 108 n. 158, 378 n. 624. 291 CIL VI, 31172. Iovi Dolicheno pro salute n[umeri] eq[uitum] sing[ularium] Aug[usti], Q[uintus] Marcius Artemidorus, medicus castrorum aram posuit. Also see Speidel 1978, 14. 105 domus was clearly large and exhibited evidence of a variety of religious and philosophical decorative motifs throughout what remains of the complex, the intimate nature of the votive hand – a small, private object - suggests an affiliation of a more personal nature. It was recovered among the surgical instruments and other associated medical objects in the Orpheus Room, making it the only object with a religious association that did not also have a practical, medical function located in a room that was clearly the nexus of the physician’s professional life. Also notable is the absence of any similar, purely devotional objects related to the cult of Asklepios, which one would generally expect to find in such a context. This suggests two possible scenarios: either Eutyches himself attributed the power to effect favorable outcomes of his medical interventions to Iuppiter Dolichenus, or his patients did – perhaps it was both. Whatever his own personal beliefs, the composition of the instrumentarium suggests that Eutyches did a brisk business treating soldiers in his civilian life. Placing such an object in view may have been done deliberately with the intention of instilling confidence in a nervous patient. Regardless, the portrait we construct by considering the votive object among the collection of medical implements in the context of the medica taberna is that of a unique confluence: the professional life of a doctor and the spiritual life of a soldier. A third set of objects discovered within the Orpheus room suggests that the Rimini physician may have gained more than medical skills and a religious affiliation from his association with the Roman army. The remains of three distinct weapons - all typical of those considered to be “offensive” weapons used by Roman soldiers in the third century – were found among the physician’s medical implements. Like the surgical tools that remained, what remained of the weapons were just the components made of iron, as the wooden elements (in this case shafts that would have been fashioned from dense, strong wood such as ash), were destroyed in 106 the fire. However, the metal pieces were sufficient for Ortalli and his team to identify them as the iron shank of a pilum (javelin), the iron, triangular-shaped tip of a spear, and finally another, smaller triangular-shaped lance tip that would also have been affixed to a wooden shaft (Fig. 2.5). 292 Ortalli offers two possible explanations for the presence of the weapons in the Orpheus rooms. He suggests that they could have belonged to the dominus of the house (i.e., the physician) as “trophies” reminding him of his time of service in the military. The second explanation Ortalli offers is that the weapons were possibly used in the conflict that eventually destroyed the Domus del Chirurgo, as well as the majority of the northern quarter of the city. 293 That the conflict itself raged immediately around – if not actually in – the Domus del Chirurgo seems likely; an iron ax head, typical of those used by the Germanic tribes in the third century, was recovered in the vicinity of the ruins of a domus located approximately 100 meters east of the surgeon’s house. 294 However, I suspect that the first scenario suggested by Ortalli – that the weapons belonged to the owner of the house and were placed there deliberately prior to the fire – is the more likely. It is also the one that even more firmly connects the physician with a military career, thus further supporting the notion that this particular site is another juncture in which military medical practices filtered into the civilian sphere. While the presence of the ax head several houses away suggests that the invading army did indeed come directly to this quarter, the three weapons in the Orpheus Room do not fit a typical pattern of weapons scattered during battle. First, there is no other known instance anywhere in the neighborhood of more than one 292 Ortalli 2000, 521. For a discussion of the characteristics of such weapons that allow them to be identified as those used by the Roman army (vs. opposing armies) as well as their approximate dates, see Chapter 3 in Goldworthy 2003, specifically the section titled “Equipment” beginning on page 118. 293 Ortalli 2000, 521. 294 Ortalli 2000, 521; 2014, 28. Also see Mazzeo Saracino 2005, 28-29 and Biondani 2005, 311, n. 18, fig. 310. 107 weapon, Roman or Germanic, recovered from the same findspot. One would expect weapons discarded in the heat of battle to be randomly scattered, rather than collected in a group. Furthermore, the organization of the medical implements within the same room suggests that they were arranged in an orderly fashion at the time of the building’s collapse. 295 Had an altercation taken place within the relatively small confines of the Orpheus Room, as Ortalli’s second hypothetical scenario suggests, one would expect that the organized arrangement of so many small objects would have been significantly disturbed. Finally, the three weapons in question - a lance, spear, and a javelin – are all “long-range” weapons, meaning that they would require some distance between opponents in order to be used effectively, making them a poor choice in an urban context, where narrow streets and the dense arrangement of structures would force combatants into close to proximity to one another. Taking these factors into account, I consider it highly probable that the soldiers’ weapons recovered from the Orpheus Room were placed there deliberately by the owner, a reminder of his time in military service and, like the Iuppiter Dolichenus votive, perhaps served as a tangible reference to the milieu in which he gained his considerable professional expertise. Given the peripatetic nature of military life, it is almost certain that Rimini was not the surgeon’s native city. 296 Wherever Eutyches’ prior professional experience in the army may have taken him in the Empire, his decision to eventually settle in Rimini may have been driven both by the steady stream of available clientele in the soldiers that routinely traveled through the city, as well as its elements of eastern character. The city’s location meant that it not only frequently 295 Ortalli notes that the fire that swept through the district was of such a great intensity that it provoked “an almost immediate collapse of the structure…” and that the objects recovered from the site were organized in such a way that it is clear that “…at the moment of its collapse the building was in its original arrangement.” Ortalli 2009, 22. Referring specifically to the surgical instruments, Jackson draws a similar conclusion, noting that the fact that the instruments were recovered in the groupings in which they were stored was a stroke of luck, as the groupings allowed for the identification of certain instruments’ functions. Jackson 2009b, 87. 296 Ortalli makes a convincing case for Eutyches’ origins in the Greek east. See Ortalli, 2007. 108 hosted military units moving between Rome and the Empire’s frontiers, but that it was also part of the vast network of land and sea routes along which the Empire’s wealth was transported. Rimini’s harbor was frequented by ships bearing sought-after eastern luxuries, and the city’s economy was dynamic and robust as a result. The frequent movement of people and goods through the city from throughout the Empire meant that it was a provincial town with a cosmopolitan aspect, and archaeological evidence from the Imperial period suggests that the city had a large number of inhabitants that hailed from eastern regions of the Empire. 297 And yet while ancient Ariminum may be unique in that it has presented us with such an extraordinary site, the town itself was hardly so. Though the Domus del Chirurgo in Rimini had yielded what is (thus far) a unique example of a physician who likely had prior military experience eventually established a successful practice in a civilian context, I suspect that this site may be a representative example of such a scenario rather than a distinct occurrence. First, the likelihood that this site is the only one in the Empire is extremely improbable; Ariminum was a typical example of a medium-sized Roman town, the likes of which could be found throughout the Empire in the third century, serving as crossroads for the numerous land and sea routes that comprised the Empire’s vast transportation network. There is nothing to suggest that it was unusual in terms of either its demographic or economic characteristics that would cause it to be the location of the one, exceptional circumstance in which a military physician settled and established a practice in a civilian environment. In other words, there is no reason to assume that Eutyches was a unique case. In fact, I propose that what we may have in the site of the Domus del Chirurgo is a representative example of a situation that was, if not common, certainly not unique. That is, I suggest that the evidence from Rimini, and to a lesser degree also that of 297 Del Maso 2003, 151. 109 Marcianopolis, attests to a possible scenario in which military physicians, upon their discharge from the army, could and did go on to settle and practice in civilian environments, bringing their expertise and technology with them. From there, such knowledge would have dispersed into other regions of the Empire, along the same networks that facilitated the effective distribution of people, goods, and ideas for much of the Imperial age. 110 Chapter 3: The Shaping of Medical Practices, Practitioners, and the Profession While there is no evidence that a comparable medical infrastructure of the type implemented for soldiers was ever instituted for civilians by the Roman state, the medical profession and its practices in the civilian world were perhaps not as ad hoc and as haphazard as the absence of such a state-supported system might suggest. The lack of significant government intervention in civilian medicine does not mean that there was no government intervention. Furthermore, governments, whether state or municipal, are not the only forces at work when it comes to shaping the medical landscape of a community or nation. In the absence of the overarching and all-encompassing governmental regulations of medicine that exist in many countries today, other dynamics will generally fill some of the void, serving as catalysts for at least a measure of professional organization and self-regulation. This chapter examines some of those dynamics, both external and internal, that acted upon medicine in the civilian sphere and subsequently helped to shape the landscape of the civic medicine and the physicians who moved within it. This chapter begins with a discussion of certain laws pertaining to medical practices and practitioners that were implemented by the Roman state. These laws, while not intended to impose any sort of structural or professional organization on the profession directly, nevertheless resulted in influencing the stratification of the profession. For example, tax laws imposed in the second century C.E. directly affected the office of the “public physician,” resulting in increased professional competition and a degree of hierarchal organization within the profession. 298 Likewise, laws enacted with the intent of prohibiting certain medical practices had the effect of 298 The second-century C.E. tax laws were implemented to modify a previous set of laws that were codified in the first-century B.C.E. A detailed discussion of these will be presented further on in this chapter. 111 delineating, albeit in a very limited manner, the conduct of law-abiding Roman medici by proscribing certain types of practices. The resulting intensification of competition amongst physicians for the privileges and status associated with the office of a public physician directly affected the second area of influence that acted upon civilian medicine: the self-regulation, at least of a sort, within the medical profession itself. The increasing competition for the coveted state and municipally conferred privileges and status gave rise to a more pronounced and formalized hierarchy within the medical profession. Those doctors with status and credibility – though not necessarily competence and skill, as Galen derisively noted – could serve as either facilitators or obstacles when it came to the success and upward mobility of their younger, less-experienced and/or simply less powerful colleagues. 299 One of the most prominent examples of this is the increasing importance of physicians’ collegia (guilds) in the second, third and especially the fourth centuries. 300 Access to – or exclusion from – membership in a city’s medical collegium could, at least in some instances, determine the degree of success, both financial and social, a physician might achieve in his profession. 301 This chapter investigates the evidence for these physicians’ collegia as well as formal medical competitions, focusing on the roles that these institutions may have played in shaping the dynamics of both the medical profession and the careers of individual doctors. The training and education of physicians is a third force that acted to influence individual medical careers and the profession in general. The establishment and support of medical 299 Galen complained frequently of charlatanry in his profession, and often accused unskilled practitioners of taking up the profession in order to claim benefits and privileges. Gal. PHP 9.5.4 (= DeLacy 1981, 564); Gal. De praecogn. 1.1-4 (= Nutton 1979, 69). 300 Collegia in the Roman world were legally recognized confraternities or professional clubs (OCD, 338 s.v. “clubs, Roman”). Also see Diosono 2007 and Nutton 1977, 207-10. For a study of the increasing importance of collegia from the second-century C.E. onwards, see Patterson 1994. 301 Verboven 2007, 20-2; Scarborough 1969, 131-2; Nutton 2013a, 257; Jackson 1988, 58-9. 112 educational and training opportunities, and the degree to which they were accessible, often relied on the financial and intellectual engagement of those in the profession. As such, the education and training of physicians could be said to be another area in which the profession itself had a hand in its own self-regulation and organization. If the Roman state had little to do with administering healthcare in the civilian sphere of society, it seems that it likewise took little direct interest in the education of physicians. 302 However, this does not mean that sponsored medical education – of a sort – was not available. While the medical library at the Mouseion in Alexandria was famous throughout the ancient world, it may not have been unique. It seems that medical collections existed in the libraries of at least several cities beyond that of the famed Egyptian institution, established via donations made by guilds or individuals. Some of these institutions may have offered educational opportunities beyond access to texts, such as public anatomical demonstrations. Therefore, much of this discussion will focus on medical libraries, their collections, how they were established/supported and what types of educational resources and activities may have been available in these milieux. The evidence from Rhodiapolis raises the possibility that at least some other cities besides Alexandria may have had educational and training opportunities for aspiring physicians that went beyond simply access to medical texts in the collections of those cities’ libraries. A fourth area of influence that also contributed to the development of a degree of organizational and hierarchal structure within civilian medicine is perhaps one of the most basic and fundamental of societal forces: the economic law of supply and demand. 303 Fortunately for 302 There is an exception to this in the mid-fourth century. See discussion on page 142 of this study. 303 Despite the various debates concerning the nature of the Roman economy and the applicability of various modern economic models, William Harris notes that basic conceptual terms such as “supply” and “demand,” like “capital” and “labor,” are “nonetheless indispensable in any intelligent analysis of that economy,” hence my unhesitating use of these terms in my own discussions here in this study. (Harris 2018, 213). 113 those physicians who were born without the inherent advantages of social status and wealth, this is also the sphere in which the individual medicus would have had the greatest degree of agency. While neither infallible nor absolute, there is certainly a degree of legitimacy to the truism that the more competent a physician is, the more opportunities he will have for success. In this I believe we are on relatively safe ground in assuming that ancient Romans were like any other humans in this regard. It seems likely that an ill or injured patient would want to be treated by a physician who had an established record of success, or at least a physician who was perceived as having such a record of successes and, therefore, was of good or excellent reputation. It is possible that both the Marcianopolis and Rimini surgeons, who were both highly skilled and financially successful, may perhaps be examples and beneficiaries of this sort of medical “free- market,” which in this study is defined simply as a market in which the basic laws of supply and demand drives the buying and selling of goods and services. 304 Without entering into the current debate surrounding the nature of the Roman economy as a whole – a vast topic outside of the scope of this project – in the context of this study I intend that the term “free-market economy” as it pertains to the economy of the medical market connotes a paradigm in which physicians and their patients were free to choose and invest in goods and/or services according to their own personal circumstances and desires without interference from any regulatory authority. 305 In other words, patients could choose their practitioners and their treatments, and physicians could 304 The term “free-market” as I define it here is taken the Encyclopedia Britannica, which defines the concept as “an unregulated system of economic exchange, in which taxes, quality controls, quotas, tariffs, and other forms of centralized economic interventions by government either do not exist or are minimal.” (Encyclopedia Britannica s.v. “Free market.” https://www.britannica.com/topic/free-market. Accessed March 19, 2021); For a discussion of the evidence attesting to the skill and expertise of the Rimini and Marcianopolis physicians, see Chapter 4 of this study. 305 This is consistent with the term “market economy” as described by economic historian Peter Temin, who defines it as “an economy where most resources are allocated by prices that are free to move in response to changes in underlying conditions.” (Temin 2001, 170). Temin argues that the various Roman markets “were not tied together as tightly as markets often are today, but they still functioned as a comprehensive Mediterranean market” (Temin 2013, 10). Such a model does not preclude the involvement of the Roman state in the regulation of certain types of markets and the imposition of taxes, which are often present in market economies (Temin 2001, 180). 114 choose to purchase their supplies, without regulatory interference; the costs of such services and goods would likewise be free from price-fixing by the authorities and could adjust without restriction according to demand. I suggest that we can be reasonably confident with this model as it applies to Roman civic medicine, since whatever the nature of the broader Imperial economy (a question that is still very much a point of debate), it has been convincingly argued by economic historian Peter Temin and others that there were nevertheless many individual markets for products and services that remained free of significant interference from Imperial or municipal authorities. 306 Such markets were therefore able to respond to the basic economic forces of supply and demand. Thus far, we have no evidence to indicate that medicine in the civic sphere cannot be included in this category of market. 307 The potential for personal success that a skilled medicus might enjoy regardless of his social status or professional connections is one example of how the basic law of supply and demand may have been at work in the landscape of civic medicine, but it is not the only one. It is my hypothesis that the evidence from Allianoi could point to the existence of a robust economic market that consisted not only of the economic, supply/demand dynamic between physicians and their patients, but also a market of goods in which the demand created by doctors for materials essential to their craft was met by various craftsmen and/or merchants, who either produced or procured such materials. The manufacture of surgical instruments, for example, was a highly complex and difficult process that required a level of craftsmanship found only in the workshops 306 Summaries of the various aspects of the debate concerning the nature of the Roman economy as a whole include Scheidel 2012, Flohr and Wilson 2016 and Wilson and Bowman 2018.; That individual market economies for goods and services in the Imperial era functioned as free markets has been convincingly argued in a number of studies on the subject. Examples include Temin 2001, 2012, 2013, Driel-Murray 2016 and Ruffing 2016. 307 This is in contrast to medicine in the martial sphere, since in that context medicine was much more strictly regulated in the sense that soldiers had little choice when it came to choosing a practitioner. See Chapter 2 of this study. 115 of the most skilled metallurgists. 308 The presence of over 300 instruments at Allianoi represents a market for such objects that was substantial enough to produce or otherwise procure them. Likewise, the procurement of medicines in their finished form, as well as the raw ingredients used in such substances, seemed to be a substantial industry that drew upon resources across the Empire’s vast trade and distribution networks – and even beyond. 309 In the final section of this chapter I propose that Allianoi may be an example of a place in which medically related products made their way through such networks and arrived in the town in order to supply the demand generated by the physicians and their patients. Before launching into a discussion of these four categories of influence that shaped civilian medicine, its practitioners, and their practices, I would like to briefly address the subject of how a “physician” was defined in the eyes of Roman law. While there may have been no known, state-imposed standards to which physicians had to adhere in order to work as such, by the late-second century there seems to have been an attempt by the Imperial authorities to more clearly delineate who could be considered a medicus and, more importantly for tax purposes, who could not. Ulpian’s partial definition of a legitimate doctor indicates that there must have been some dubious claims to the title, which he seeks to clarify: “Some will perhaps regard as doctors those also who offer a cure for a particular part of the body or a particular ill, as, for instance, an ear doctor, a throat doctor or a dentist. But one must not include people who make incantations or imprecations or, to use the common expression of imposters, exorcisms. For these are not 308 Bliquez 2015, 14-16; Jackson 1997; Jakielski and Notis 2000. 309 In his Natural Histories, Pliny the Elder records herbs that were believed to have medicinal qualities being imported from regions as far-flung as Britain and Ethiopia (Plin. HN 27.1.2). The far-ranging voyages to acquire cinnamon, whose antibacterial properties made it a preferred substance to address infection, is one such example. An analysis of Pliny’s account of the spice suggests that it originated in the regions now represented by southern Sudan and southern Ethiopia. (Plin. HN 12.42; Miller 1969, 153; For an analysis of the “Cinnamon Route” in the Roman period, see Haw 2017). The first-century C.E. pharmacologist and botanist Diocorides’ 5-volume De Materia Medica, a work that influenced pharmacology well into the 17 th century, records medicinal substances from regions of the Empire and beyond that correspond with the modern countries of Egypt, Syria, Spain, India and Armenia, to a name a few (Riddle 1985, 3); Also see Miller 1969, Scarborough and Nutton 1982, Scarborough 1982. 116 branches of medicine, even though people exist who forcibly assert that such people have helped them.” 310 Ulpian’s efforts were motivated by legal concerns rather than by an interest in the ancient version of medical quality controls standards, since a physician who could be judged to be a proper professional was entitled to sue for fees. 311 Nevertheless, the state’s efforts to define who may be considered a medicus offers us insights as to how Romans, or at least Roman government, differentiated between those who were considered to be legitimate professionals and those who were not. Aside from the exclusion of those whose methods the state viewed as illegitimate, there is little else to suggest the Imperial authorities were concerned with setting professional standards for those whom it allowed to define themselves as medici. Therefore, the organization, hierarchal delineation, and formalized structure of the medical landscape – such as they were – that did exist by the late-fourth and early fifth century C.E. came about as a consequence of other forces and dynamics at work from the state and municipal authorities. The profession itself, and basic economic principles, are discussed further on in this chapter. The Imperial administration’s most significant contribution to this amalgam of forces was a second-century law that effectively created the highest level of an emerging medical hierarchy: the office of the “public physician.” Tax Laws and the Office of the “Public Physician” As far as any state involvement is concerned, the influence exerted by the Roman Imperial and municipal authorities on the civilian medical profession seems to have been largely a by-product of the government’s desire to safeguard other interests, such as its tax revenue. The well-being 310 Dig. 50.13.3. (Translation by Watson 1985, vol. 2). 311 Nutton 1977, 53-4. 117 and health of the population was of interest to the state inasmuch as a healthy population was a stable and economically productive one. Roman authorities were aware of the undiscerning nature of a contagious disease, and to the economic impact of epidemics or injuries. By the middle of the first century B.C.E., Roman authorities evidently saw enough value in physicians’ contributions to the well-being of the population that Julius Caesar encouraged Greek doctors to emigrate to Rome by offering them citizenship. 312 A few decades later, a grateful Augustus granted physicians tax-exempt status in honor of his physician Antonius Musa, whom he believed had saved his life. 313 For the majority of the Imperial period there is no evidence that the administration took an active role in organizing, administering or investing in civilian healthcare. We are, however, able to point to several examples of more passive interventions in the form of laws and rescripta that influenced the profession and its practices. 314 In the Imperial era, these laws and decrees were largely (but not exclusively) aimed at regulating the economic privileges of physicians, with the result that the role of public physician in a city or town became both a more clearly defined and a more highly coveted position. 315 A straightforward and broad definition for the term “public physician,” as it applies to the civic medicine in the Imperial Roman period, is offered by Ido Israelowich when he states that the title refers to those “in each city who were entitled to privileges.” 316 From the mid-second century C.E., a “public” physician was one who was exempted from munera, the financial and service obligations that were required of wealthy male citizens by the Roman state, and who 312 Suet. Iul 42. Since the wealthy often had a doctor among their household staff, Caesar’s measure is presumed to have been made with the well-being (and the political support) of the plebs in mind. See Israelowich 2015, 22. 313 Cass. Dio 53.30.3 (= Cary 1917, 272). 314 Rescripta were written replies to legal queries submitted by individuals or public bodies concerning aspects of Roman law. The emperor’s reply had the power of law and could be cited as precedent. See Honoré 1994. 315 Cohn-Haft 1956; Nutton 1977 and 1995; Samama 2003, 38-45; Alonso 2018, 172-182. 316 Israelowich 2015, 131. 118 could also be eligible for a publicly funded salary. 317 While the office of public physician became more clearly delineated and defined in the mid-second century, its appearance at that time was not improvisatory. The earliest epigraphic evidence for the institution of public doctors in ancient Greece comes to us in the form of several late fourth/early third-century B.C.E. inscriptions. 318 In these, public physicians are referred to as demosioi iatroi, though Vivian Nutton, Israelowich and others note that the term archiatros, which was originally used to connote a physician who treated rulers, was often used to refer to a public physician from the mid-second century C.E. onwards, particularly in the eastern Empire, where the influence of the Greek culture was more pronounced. 319 While the institution of a public physician may have had its origins in Classical Greece, its adaptation as a comparable Roman public office took several centuries. Without any sort of regulatory body or universal professional standards that are sine qua non for the medical profession today, the skill levels of physicians in the Roman world varied wildly. The suspicious regard with which some Romans viewed medical practitioners attest to the proliferation of incompetent or intentionally deceitful quacks among the cohort of professional physicians by the end of the second century B.C.E., though certainly some of this may be attributed to Roman xenophobia since most physicians at this time were Greek. 320 Despite this, by end of the 317 OCD, 973-4 s.v. “munus.” The term corresponds to the Greek concept of “liturgy,” an institution “by which rich men were required to undertake work for the state at their own expense.” OCD, 850 s.v. “liturgy.” 318 IG II-III 2 , 374 (= Cohn-Haft 1956, 76 no. 4 and Samama 2003, 113 no. 6); IG II-III 2 , 483 (= Cohn Haft 1956, 76 no. 5 and Samama 2003, 115 no. 7), also see Alonso 2018, 172 n. 141; IG II-III 2 , 772 (= Cohn-Haft 1956, 76 no. 8 and Samama 2003, 118-9 no. 11); Nutton 1977, 199. 319 BNP, 986-7 s.v. “archiatros”; Nutton 1977, 198-9; Israelowich 2015, 131; Below 1953, 22-40; Samama 2003, 38-45; The Latinized version of the term, archiater, also refers to a public doctor but it appears very rarely in the Latin west, where public physicians were generally connoted with more descriptive terms such as medicus salariarius. Alonso 2018, 172-82. Ákos Zimonyi suggests that in addition to connoting a public physician, the term “archiatros” was also used as an honorary title given to physicians of particular skill or fame. See Zimonyi 2015. 320 According to Plutarch, Cato warns his son to be wary of the corrupting influence of the Greeks and especially their doctors, who, he claims, had sworn an oath to kill foreigners with their practice (Plut. Vit. Cat. Mai. 23.3-4); Also see Chapter 7 “The Public Estimate of Roman Medicine” in Scarborough 1969. 119 Republican period, it was generally acknowledged that the services offered by doctors were of enough benefit to society that Julius Caesar granted citizenship to foreign doctors working in Rome. 321 Around the same time, evidence demonstrates that physicians in Ephesus were granted immunity from munera, freeing them from the expense and time involved with such responsibilities in order to incentivize them to stay and work in the city. 322 While it is unclear exactly what was required of them in their capacity as employees of the city and to what degree they treated individual inhabitants at the city’s expense, it is apparent that, by the height of the Imperial period, municipal governments considered that the benefits of providing a degree of medical care to their citizenry were sufficient enough to warrant having at least some doctors on their public payrolls, a circumstance that will be further addressed shortly. 323 Given the significant benefits afforded to physicians, it is hardly surprising that the profession became popular with those wishing to benefit from the exemption laws. 324 Nutton notes that “increasingly, in an age of inflation and onerous civic liturgies, tax-exemption became valuable in itself…” 325 In his treatise On the Doctrines of Hippocrates and Plato, Galen disapprovingly observes that some of his colleagues’ entered the profession solely for the exemption benefits. 326 By the mid-second century C.E., it is clear that the number of physicians claiming immunity had reached such numbers that their exemption from taxes and other public responsibilities were perceived as too burdensome for the state. In order to reign in the loss of tax 321 “He conferred citizenship on all who practised [sic] medicine at Rome, and on all teachers of the liberal arts, to make them more desirous of living in the city and to induce others to resort to it.” Suet. Iul. Caes. 42.1 (= Rolfe 1913, 59). 322 IEph 4101 (= PHI 223, Samama 2003, 329 no. 206); Jackson 1988, 56; Knibbe and Īplikçioğlu 1981/2; Israelowich 2012, 27-9. 323 Cod. Theod. 13.3.1.2, Dig. 50.9.4.2. 324 Presumably the occupations of “grammarians and other professors of literature” were also attractive occupations. Unlike these professions, however, doctors were not obliged to be literate, which presumably made the medical arts an even more appealing option for those with little to no formal education. 325 Nutton 1981, 16. 326 Gal. PHP 9.5.4 (= DeLacy 1981, 564). 120 revenue and enable the cities’ governing bodies to staff their civic positions, Antoninus Pius issued a decree limiting the number of exempt physicians in each city or town according to their size. In a rescriptum written to the province of Asia concerning the number of doctors who could be exempted from public duties, the emperor instructed that “lesser cities can have five doctors immune from public duties,” while larger cities may have “seven medical men” and the largest cities may have “ten doctors…[however] beyond this number even the greatest city is not granted immunity.” 327 The fact that the immunity benefit offered to physicians was taken advantage of in such large numbers that the emperor was forced to impose limits was almost certainly a result of the fact that very little was required in order to declare oneself to be a physician. While it seems that there was no ancient equivalent of a formal training and accreditation system for medical practitioners, the emperor’s restrictions on exemptions from munera made it necessary to establish some sort of process whereby physicians were chosen for the few public positions now remaining in each city or town. To address this, Antoninus Pius issued another rescriptum that settled this responsibility upon the individual municipal governments of each city or town rather than the provincial governor: “The decision on the doctors to be included within a prescribed number is not entrusted to the governor of a province but to the ordo and the landholders of each community, so that they themselves, being certain about their uprightness and skill, may choose men to whom they may entrust themselves and their children when ill.” 328 Though far from a formal rubric for distinguishing competent physicians from charlatans, it appears Antoninus Pius’ edict gives the appearance of having been made with an eye toward 327 Antoninus Pius’ decree concerning the limitations placed on the number of munera-exempt physicians each city could have was recorded by Modestinus in Justinian’s Digesta (Dig. 27.1.6.1-2). 328 Dig. 50.9.1. 121 implementing a vague measure of “quality control” vis-à-vis the competence of the physician chosen for “public” status. Presumably the city authorities would have had some firsthand knowledge of the doctor in question, and could choose practitioners from whom they themselves would feel comfortable seeking treatment. 329 Thus these edicts represent some of the first examples of a degree of quasi-regulation by the Imperial authorities with regard to the medical profession as it operated in the civilian sector, though they were made with financial and/or political aims in mind and not as a means to ensure professional competence – at least not directly. Antoninus Pius’s rescripta laid out several basic parameters for the office of a public physician; the choosing of such positions was generally left to the municipal governments, who also bore the economic responsibility for the privileges afforded to their city or town’s public doctors. 330 Those privileges included exemptions from munera and liturgical obligations. Eventually, they also included publicly funded salaries, which were often augmented by the fees that such physicians were permitted to charge individual patients. 331 It is unclear when, exactly, the privileges enjoyed by physicians began to include a salary, but by the mid-second century C.E., it is evident that such salaries were often among the benefits enjoyed by public physicians. Ulpian notes that by this time, publicly funded salaries were offered to physicians who taught medicine in addition to special accommodations that were made for physicians at judicial hearings for which their presence was required. 332 By the early fourth century, an edict issued by Emperor Constantine makes it clear that the benefits extended to physicians also included an 329 It was not until the creation of the extremely elite College of Physicians in the mid-fourth century C.E. that public physicians were evaluated and chosen by their peers. See Cod. Theod. 13.3.8-9 (from Nutton 2013a, 256 n. 13). 330 Cod. Theod. 13.3.1.2; Dig. 50.9.4.2 331 Cod. Theod. 13.3.8.I. 332 Dig. 50.13.1.1. 122 exemption from having to accommodate billeted soldiers. Moreover, all of the privileges and benefits afforded to physicians also applied to their wives and children: “Emperor Constantine Augustus to the people: We instruct that doctors and chief physicians and former chief physicians, grammarians and other professors of literature, along with their wives and children as well as their property that they have in their cities, be immune from every payment (functio) and from all civic or public services, and that in the provinces they not receive guests (i.e., billeted soldiers) or perform any service, or be summoned to or produced in court or suffer an injury, so that, if anyone bothers them, he will be punished with a penalty at the discretion of the governor. We order that their compensation and salaries be given to them, so that they might more easily instruct many… Posted September 27, at Constantinople, in the consulship of Dalmatius and Zenophilus (333)” 333 When considering what type of role a “public” doctor played in his community, a modern person might reasonably assume that a physician who received tax immunity and whose income derived – at least in part – from public coffers would be required to render certain services to the poor in his community free of charge. Interestingly, while it seems that there was indeed such an expectation, there is no evidence of an explicit law obligating them to do so. The closest we come is the issuance of a few public decrees on the expected professional behavior of practitioners vis-à-vis serving the more disadvantaged members of the community. 334 One such a decree is a letter from the fourth century emperors Valentinian and Valens to Praetexatus, Prefect of Rome, in which they state that public physicians, “knowing that their subsistence allowances are paid from the taxes of the people, shall prefer to minister to the poor honorably rather than to serve the rich shamefully.” 335 However, when it came to the fees doctors were allowed to collect from their patients above and beyond their public salaries, Praetexatus was instructed that “We allow these physicians also to accept those offerings which healthy persons offer them for their 333 Cod. Iust. 10.53.6. 334 Cod. Iust. 53.1, 5-6, 9-10. 335 Cod. Theod. 13.3.8. (368-370 C.E.) 123 services, but not those offerings which persons in danger of death promise them for saving their lives.” 336 It would appear that the emperors’ willingness to rely on a physician’s conscience to dictate his professional behavior only went so far. And yet, as far as the legal obligations placed upon a public physician by the state in exchange for the considerable benefits of his office, it would seem that there were very few. Unsurprisingly, the considerable economic benefits that could be gained by establishing oneself as a public doctor meant that the competition for such roles could be fierce. Presumably, the sustained effective performance of a physician was the only guarantee of the physician’s “public” status and continued tax immunity, though no record exists of any doctor being deprived of such privileges. A second-century papyrus document from Egypt records a bitter dispute over the privileges granted to – and the competence of – one Psasnis, who complained in a court case before the Roman prefect of Egypt, Valerius Eudaemon, that liturgy responsibilities had been imposed upon him by members of the council whom he had treated as patients. Valerius replied by derisively suggesting that perhaps the doctor’s incompetence had caused the city council members to reassess his status. Nevertheless, all that was required of Psasnis so as to retain his immune status was to declare before the strategos (military governor) that he was a practicing doctor. 337 It is unclear whether or not this particular case took place before or after the rescriptum of Antoninus Pius limited the number of public physicians allowed per city or town, and so it is impossible to know whether or not Psasnis was a “public” physician in the sense that he had been chosen by his city’s municipal authorities for the role, or if he was simply taking advantage 336 Cod. Theod. 13.3.8.I. 337 POxy. 40, from Nutton 1977, 213. Also see Nutton 2013a, 256 and Israelowich 2015, 35-43. 124 of the privileges afforded to all physicians prior to the emperor’s restrictions. 338 Regardless, what is of interest here is that while Valerius may not have held the complainant’s professional competence in high regard, his instructions to Psasnis concerning the reinstatement of the physician’s tax privileges indicate that there were few legal impediments imposed upon those who wanted to assume the professional identity of a physician in Roman society. What we understand of the public physician and his role during the Imperial period thus far comes to us in the form of epigraphic evidence and extant primary source texts, such as the rescripta recorded in the Codex Theodosianus and the Digesta. While the sites of Rimini, Allianoi, Marcianopolis and Rhodiapolis offer us much in terms of evidence for Roman medicine and its practitioners in a civic context, this evidence unfortunately gets us no closer to a deeper understanding of the role of the public physician specifically. Likewise, we are unable to definitively attribute the role of public physician to any of the medical practitioners from the four sites. However, examining the evidence from these four sites (Rimini and Rhodiapolis in particular) through the lens of what we know of public physicians in this period may offer some new lines of future inquiry. The limitations of the evidence from Rimini do not allow us to know for certain whether or not the Rimini medical practitioner Eutyches was a “public” physician of ancient Ariminum. His property is certainly indicative of the wealth and status associated with the wealthy public physicians attested to in the epigraphic evidence from cities like Aphrodisias and Ephesus; it is possible that he may have owned an estate that produced revenue or had some other source of 338 Valerius Eudaemon was a contemporary of the emperors Hadrian and Antoninus Pius (SHA Hadr. 15.3). Since we do not know precisely what year Valerius presided over the case involving Psasnis, nor the precise year that Antoninus Pius issued the rescripta concerning public physicians, it is impossible to know which came first. 125 income unrelated to his profession. 339 For if it was not exactly common, it was at least not unheard of for physicians to occupy a high stratum of socio-economic class in Roman society. For example, in Aphrodisias, a third-century C.E. funerary inscription dedicated to the physician M. Aurelius Apollonios by his wife indicates that he was of equestrian rank, while a second- century C.E. inscription from Ephesus indicates that the archiatros Attalus Priscus was a friend of the emperor. 340 However, I nevertheless find it tempting to consider the possibility that Eutyches’ wealth, at least in part, may have been a result of tax exemptions and perhaps a publicly funded salary, which could have augmented the fees received from his wealthier patients. In addition to his evident wealth, the humble graffito describing him as a “good man” inscribed by one of his grateful patients – one of the “miserable ones” – into the wall of the cubiculum could be read as a grateful acknowledgement of charity received. 341 In this context, such charity would most likely have taken the form of pro bono medical care given to a poor patient by a public physician in fulfillment of the expectation, if not the legal obligation, placed upon him as a condition of his office. However, my suggestion is purely speculative, and must remain so pending additional evidence. The evidence concerning the nameless physicians of Allianoi and Marcianopolis allow even fewer substantive grounds for speculation when it comes to identifying the presence of public physicians in these cities. That both towns likely had them, a least from the mid-second century C.E. onwards, is a conclusion we can only broadly surmise based on the Antonine decree 339 A number of studies exist on the class and socio-economic status of physicians in the Imperial era that have determined that at least some physicians could and did belong to wealthy, landowning families, particularly in the Greek east. While this particular aspect of the field is outside the scope of the current work, some of the more recent studies on the topic include Nutton 1992, 1995 and 2004, 248-72 and Pleket 1995. Also see Zimonyi 2014, 189 and Israelowich 2015, 130-1. 340 Nutton 1977, no. 38 (= Samama 2003 no. 256) and Nutton 1977, 193 no. 47 (= IEph 1119 and Samama 2003 no. 216). For additional examples of inscriptions that attest to physicians belonging to families of high status, see Nutton 1977, nos. 23, 25, 28, 32, 34, 48, 59 and 82. 341 See Chapter 1 of this study, s.v. “Rimini.” 126 limiting the number of such offices the municipal authorities were permitted to grant. If the emperor felt obliged to intervene in order to protect state revenues, it was clearly a common practice. Furthermore, the fact that he delimited quotas for cities of varying sizes indicates that not only was the office of the public physician a common one, but that it was not limited to the Empire’s major urban centers. So while it is possible, perhaps even likely, that public physicians were part of the landscape of civic medicine in Allianoi and Marcianopolis, we are nevertheless limited to mere supposition. When it comes to the presence of a public physician in Rhodiapolis, we might perhaps find ourselves on firmer ground in suggesting that Heraclitus held such an office, and yet even here we cannot be certain. The wealth and socio-economic status of Heraclitus is not in dispute; after Opramoas, he was the second-century city’s most generous benefactor. 342 Two of the five known inscriptions pertaining to him specifically mention that he had been “honored with exemption from liturgies” and that he “treated the needy for free,” both circumstances that could point to his role as a public physician. 343 However, Bülent Īplikçioğlu notes that such exemptions could also be conferred upon an individual in recognition of his having rendered a great service or otherwise brought honor and status to his city. 344 So in the case of Heraclitus, we are left with a somewhat frustrating “chicken or the egg” conundrum: Was Heraclitus exempted from liturgies because he held the office of a public doctor and thus, in the fulfillment of the moral obligations of his office, he treated the poor without charge? Or was it that his generous donations to the city in the form of buildings and books, together with his pro bono treatment of 342 See Chapter 1 of this study, s.v. “Rhodiapolis”; Īplikçioğlu 2014; OCD 4 :1041, s.v. “Opramoas.” 343 TAM II 910 and Inv. 846. 344 Īplikçioğlu 2014, 240-1. For physicians who received honors from a city without necessarily holding the office of a public physician, see Zimony 2015. 127 the city’s poor, prompted the city council to honor him by exempting him from additional obligations? Had the inscriptions that lauded Heraclitus’ civic works been made even a few decades later, we might have had a clearer picture as to the status of this question. Nutton and others have noted that following the Antonine decree restricting the number of public physicians a city was permitted to employ, the Greek term archiatros, which had until then been used primarily to refer to physicians who treated a ruler and his family, increasingly began to be used to refer to public physicians, particularly in the eastern regions of the Empire. 345 However, of the five inscriptions from Rhodiapolis that relate to Heraclitus, at least four are believed to date to the reign of Trajan (r. 98-117 C.E.), when the more generic term iatros (“doctor”) was employed to describe the physician. 346 The fifth inscription (Inv. 776) is believed to have been made almost 200 years later, when the term archiatros could be expected to be used to connote a public physician. The fact that Heraclitus is still referred to as an iatros in this example may suggest that Īplikçioğlu is correct when he states that “Heraclitus does not seem to have taken on an office in Rhodiapolis [since] there is no direct mention [in the epigraphic evidence] that he held the office of public doctor.” 347 On the other hand, Īplikçioğlu also notes that the late-third/early fourth century inscription that refers to Heraclitus as an iatros may in fact be a duplicate of an earlier copy that had been damaged, made by a city still eager to emphasize the accomplishments 345 Nutton 1977; Cohn-Haft 1956, 5-11; Below 1953, 22-40; Israelowich 2015, 130-1; Zimonyi 2015. It should be noted that while the use of the term archiatros to refer to a public physician following the mid-second century decree is widely attested to in epigraphic evidence from the Greek east, only four confirmed examples of the term appear in inscriptions from the Latin west. Of these, three are from regions in the southern Italian peninsula, where Greek influence was more pronounced (Alonso 2018, 179-82). This is, however, likely a reflection of linguistic preference rather than a relative scarcity of such offices in the west. In her study of the epigraphic evidence for Imperial-era physicians in the Italian peninsula, Maria Alonso notes that the titles of public physicians in the Latin west were frequently less precise and often simply referred to a medicus who received a municipal salary. See Alonso 2018, 172-82. 346 Īplikçioğlu 2014. 347 Īplikçioğlu 2014, 240. 128 of one of its most prominent citizens two centuries later. 348 Furthermore, it is far from clear to what degree the role of a public physicians differed from that of a private one prior to the restrictions set forth by the Antonine decree. Antoninus Pius acted in order to counteract the established tradition in which any doctor could claim tax exemptions. This means that prior to the decree, a public physician was one who, in addition to the exemptions to which all doctors were apparently entitled, also claimed the benefit of a public salary. The presence of demosioi iatroi (“public doctors”) on the municipal payrolls are well-attested to in Hellenistic Greece. 349 While it is generally acknowledged that such offices were particularly common to cities of the eastern Empire due to the prevalence of Greek institutions, the question of whether or not Heraclitus held the office of a public doctor must remain an open one. The epigraphic evidence from the site provides us many details concerning the role of the “Homer of medical poetry” in his community, but on this issue, they are silent. That Heraclitus made a significant mark on his home city of Rhodiapolis is clear; whether he did so in the role of a public physician is a question that, for now, must remain unanswered. Laws Regulating Professional Practices The practical application of medical treatments, surgical or otherwise, was largely left to the sole discretion of the practitioner. With a few exceptions, a physician’s professional behavior was left largely unregulated by the Imperial government, at least in terms of law. However, while the Imperial administration took a mostly “hands-off” approach when it came to the medical practices and competency standards of civilian physicians, there are a few interesting and notable 348 Īplikçioğlu 2014, 244 n. 120. 349 Samama lists at least 22 confirmed epigraphic examples of public physicians with two additional inscriptions that are also likely possibilities. See Samama 2003, 41 n. 50. 129 examples of specific legal restrictions when it came to the types of procedures and treatments physicians were allowed to perform or administer. One such law concerned the state’s almost-obsessive preoccupation with population expansion, especially among the elite class. In order to ensure that as many healthy, future citizens were born as possible, birth control and abortion were strictly proscribed. 350 For example, it was forbidden to administer any abortifacient or aphrodisiac potions. 351 Likewise, it was illegal to sell or administer poisons for the purpose of homicide. This particular law is admirably precise regarding intent, acknowledging that certain “baneful” substances had beneficial therapeutic effects if prepared and administered properly. It therefore makes clear that only those who prepare or administer substances “for the purpose of homicide” are punishable. 352 A third law specifically addresses the illegality of performing surgical castration with what may appear to the modern reader to be baffling degree of specificity. Evidently enacted by Hadrian to “end the practice of the making of eunuchs,” this edict not only forbade surgeons (or anyone else) from performing such surgeries, but also explicitly prohibited any man from voluntarily undergoing such a procedure. Hadrian further goes on to declare that anyone who performs such an operation “shall suffer a capital penalty, as shall anyone who voluntarily offers himself for the surgery.” 353 Notably, in a society as rigidly stratified by class as ancient Rome, even slaves were included in the protections – and prohibitions – of this particular edict, and 350 Though her study of Greek funerary monuments depicting scenes of childbirth, Nancy Demand notes that evidence of the male concern with controlling women’s productivity can be seen in the Greek world as early as the late-fifth century, when male doctors became increasingly involved in gynecological cases (Demand 1995, 285). 351 Dig. 48.19.38.5. 352 Dig. 48.8.3.2. 353 Dig. 48.8.4.2. 130 provincial governors were instructed to give a hearing to anyone, “freeman or slave” who had “suffered this outrage” against their will. 354 Though few in number, these laws are the only examples we know of in which the Imperial authorities seemed to take a direct interest in imposing some sort of framework for the professional behavior of Roman physicians. However, we should be cautious in interpreting these laws as being representative of a government interest in establishing professional standards for the medical profession. I suspect it is far more likely that these laws were devised with an eye toward legislating Roman morality; the fact that they created a (very limited) set of universal standards for professional medical conduct was merely a resulting consequence. Since there is little evidence for the Imperial administration’s direct involvement with regulating medical practices, the most sophisticated apparatus for distinguishing and “regulating” medical professionals in the Imperial period would ultimately come from the physicians themselves. The emperor’s decree limiting the number of public physicians a city or town could have was economically motivated; there is no evidence to suggest that the Imperial administration had an interest in contributing to, or otherwise imposing, a system of professional stratification within the civilian medical profession. Nevertheless, once the tax exemptions and other benefits previously afforded to all physicians (keeping in mind that all one had to do to be considered a doctor was to declare oneself such), were drastically limited, the resulting competition for the coveted public physicians’ positions served to concretize a professional medical hierarchy. Though the city and town councils who choose their municipalities’ public physicians were comprised of laymen and not doctors, those physicians so recognized may have eventually become the de facto arbiters of worthiness when it came to conferring legitimacy on other 354 Dig. 48.8.4.2. 131 doctors within their jurisdiction. This power over their colleagues was formalized in 368 C.E. (at least in the city of Rome) when regulations introduced by Valentinian mandated that Rome’s public physicians be chosen by their fellow professionals. 355 Until then, it does not appear that there was any official apparatus whereby physicians could be evaluated as to their professional competence or their worthiness for upward professional mobility (the former not necessarily being a requirement for the latter, see further discussion below). However, this does not mean that the physicians themselves did not devise various means to impose a degree of self-regulation on their profession as well as create – and obstruct – opportunities for financial and professional advancement. One of the ways in which this may have been done was through the granting – or withholding – of membership to a physicians’ collegium. The Physicians’ Collegia Physicians’ collegia are attested to from at least the first century C.E. 356 In some cities, the membership of the collegium, to which physicians belonged, also included teachers, such as the collegium of medici and professores at Aventicum (modern-day Switzerland). 357 The professional link between doctors and educators was not unusual; the two professions were regularly grouped together in legal decrees concerning tax immunities. 358 That this was the case is likely reflective of the way in which physicians were perceived by both the state and their fellow Romans as having the same intellectual proficiencies and societal roles as teachers. 355 Cod. Theod. 13.3.8.9. 356 The earliest reference to a plethos (in this case considered to be the Greek equivalent of a collegium) is from Alexandria and dates to 7 C.E. ZPE (1990) 84 (= Samama 2003 no. 395); Also see Israelowich 2015, 24-5 and Samama 2003, 474-5, n. 9. 357 CIL XIII 5079 (from Nutton 1995c, 9). 358 Cod. Theod. 13.3.3; Cod Theod. 13.3.10; Dig. 50.9.4.2; Dig. 50.13.1.1. Also see Nutton 1995c, 8-9 and Scarborough 1969, 131. 132 Indeed, such intellectual abilities, whether real or perceived, seemed to have been an indicator of medical competence and professional worthiness. Galen’s treatise On Recognizing the Best Physician describes a rigorous set of standards for both philosophical and medical knowledge against which, in his opinion, the best of his profession should be evaluated. 359 Never one for subtlety, Galen wrote a second text that leaves no room for doubt concerning the importance he placed on the philosophical competency of physicians, titling it The Best Doctor is also a Philosopher. 360 Galen was not the only one to claim intellectual as well as medical aptitude. In the funerary inscription of Galen’s fellow Pergamene practitioner, Philadelphos, the deceased physician is lauded as a having been not only the “best of all the doctors,” but also of having been “exceptional for his wisdom.” 361 The late-second/early-third century physician Barbas, despite having lived in at the edge of the Empire in far-flung Pontus (the modern Black Sea region of Turkey) would have been “inferior to none” and known “all the way to Rome” for his “cultured learning” and medical arts had he not died in the prime of his life. 362 The first-/second- century Corinthian physician Thrasippos was “inferior to no Greek” when it came to his medical knowledge as well as his poetry. 363 To the portrait of intellectualism among the most educated of medical practitioners painted by Galen’s braggadocio and a handful of epigraphic examples we may perhaps also add the mythological Chiron, the august centaur who represented both superlative wisdom and medical skill. 364 359 Gal. Opt. Med. Cogn. 360 Gal. Opt. Med. 361 GVI 2040 (= Samama 2003 no. 187); Translation mine from Samama. 362 SEG 32 (1982) 1261 (= Samama 2003 no. 321); Translation mine from Samama. (From Nutton 1995c, 9). 363 GVI 2020 (= Samama 2003 no. 28); Translation mine from Samama. (From Nutton 1995c, 9). 364 Nutton 1995c, 9. 133 It seems apparent that, for some physicians at least, intellectual accomplishments were both a valued part of their identity as medical practitioners and a standard by which they judged their colleagues. This is hardly surprising in this period, for as Israelowich notes, “the prevalence of Greek culture under Roman rule promulgated medicine as part of the Second Sophistic phenomenon,” a cultural movement in which the ideals of paideia were central. 365 This is consistent with the evidence from Rimini and Rhodiapolis, where it seems that the physicians associated with each of these sites cultivated images that portrayed them as educated intellectuals. Three of the five inscriptions from Rhodiapolis that concerned Heraclitus are explicit with regard to the physician’s accomplishments as a man of “learning and cultivation” whose intellectual prowess earned him honors from his fellow Rhodiapolitians as well as from “Epicurean philosophers” and “Dionysian artists” in Athens. 366 While perhaps not as explicit as Heraclitus in declaring his intellectualism, some of the evidence from the Domus del Chirurgo in Rimini suggest that Eutyches likewise sought to project an image of a learned man, knowledgeable in philosophy in addition to the medical arts. Excavations of the domus’ inner courtyard revealed a statuary fragment consisting of a sandal- clad foot attached to a fragment of the base. By conducting a comparative study that brings to mind the detective work conducted by Cinderella’s prince, Jacopo Ortalli identified the foot as belonging to a statue of Hermarchus, the third-century B.C.E. disciple and successor of Epicurus (Figs. 3.1 and 3.2). 367 While perhaps not as overt as Heraclitus in the signaling of his learned status, Eutychus nevertheless unmistakably announced his intellectual affiliation via this visual 365 Israelowich 2015, 130; For a brief commentary on physicians within the context of the Second Sophistic, see Israelowich 2015, 31. 366 Inv. 776; TAM II 910; Inv. 846. 367 Ortalli 2007, 109-12; OCD: 668, s.v. “Hermarchus.” For examples of discussions concerning the relationship between Graeco-Roman medicine and Epicurean philosophy, see Kilpatrick 1996 and Santacrocce et al. 2017; For an analysis of the iconography associated with images of Epicurus and Hermarchus, see Zanker 1995, 113-29. 134 representation of a well-known philosopher in his garden; no doubt the almost-life-sized statue would have been visible to any colleagues or potential patients who came to consult with the successful surgeon. Whether or not he had actual Epicurean leanings is impossible to know, but in terms of his professional image it was likely the perception of those leanings that mattered more. Given the importance that at least some physicians (and probably their patients) placed upon the relationship between intellectualism – actual or perceived – and medical skill, the existence of collegia whose memberships were comprised of both teachers and doctors is unsurprising. 368 They were likely a natural extension of the way in which these two professions were viewed by society as well as the Roman state. In the early Imperial period, a least, it seems that there was little to distinguish the two groups, both legally and in the eyes of society. It is unclear how this may have changed with the implementation of the Antonine law limiting the tax privileges of physicians; there is no known parallel set of limitations for teachers. It is likewise impossible to know how the role of the physicians’ collegia might have changed following the Antonine decree. However, it is easy to imagine that the substantial increase in competition for tax-exempt status that must have occurred following the law’s implementation would have made membership to a collegium professionally advantageous, thereby increasing the number and importance of the collegia themselves by the mid-second century. Whether the apparent rise in prominence and the number of medical collegia was a direct result of the Antoine law is unclear, since there seems to be a general increase in the popularity of Imperially sanctioned professional organizations after the first century. 369 But the epigraphic 368 Nutton 1995c, 9. 369 For examples of studies concerning the development and importance of collegia in the Imperial period, see Tran 2006 and Diosono 2007. 135 evidence may suggest that collegia took on a role of greater importance for the ambitious medicus from the mid-second century onwards; or at least that is a possible explanation for the increase in extant inscriptions that mention collegium membership. This is admittedly speculative, since we see a marked increase in epigraphic material in general during the second century. Yet following the edict limiting the number of those who could claim the privileges of tax and liturgy exemptions, acceptance into a physicians’ collegium may have become more important as an avenue toward achieving legitimacy and esteem in the eyes of one’s peers and community and as a means to achieve social advancement. Several studies conducted in the field of social relations in antiquity in the last several decades suggest that this was an important – if not the most important – role of the professional collegia. 370 Membership may also have had the practical benefit of increased profits in the form of access to wealthy clients as well as potential patrons. 371 Likewise, exclusion from a medical collegia could negatively affect a physician’s opportunities for social advancement and professional prospects. It remains unclear whether or not membership to a professional medical collegium was dependent upon the pre-existing wealth and status of a potential member; it is possible that this varied from city to city. For example, in his discussion of an inscription from Ephesus that records the names of doctors who sacrificed to Asklepios and honored the Imperial physician T. Statilius Crito in the early second century, Nutton notes that “the list certainly included men of wealth and substance, and one might suspect that only the successful made it into their number. But it is equally likely that the leadership of the college was formed by the rich and powerful, 370 Examples of such studies include MacMullen 1974, Alföldy 1985; Patterson 1995, 2006; Van Nijf 1997, Tran 2006, Verboven 2007 and Perry 2011. 371 Providing opportunities to its members to secure patronage is believed to have been an important function of the collegia. Jonathan Perry observes that “by selecting and nurturing patronage relationships…members of the collegia engaged in a none-to-subtle campaign for increased social status.” Perry 2001, 510. For a broader discussion of the role of patronage in collegia, see Verboven 2007. 136 and that the inherent bias of the epigraphic evidence has robbed us of information on the lesser members.” 372 Of these two possibilities, the latter seems to me to be the more likely as this would be consistent with what we know of other professional collegia from this period. Koenraad Verboven observes that the hierarchal structure of a collegium was often modelled on the hierarchies of a city’s political institutions and that “the higher one rose in the [collegium’s] hierarchy, the more prestigious one’s position.” 373 Like the city’s higher public offices, it seems that achieving a high rank in a collegium involved significant expense. Such was the case with Ostia’s M. Licinius Privatus who, after donating 50,000 sesterces to the city, was given a number of honors and civic positions, a social ascent that was paralleled by his rise in rank within Ostia’s collegium of bakers. 374 In cases such as this, it would seem that achieving a high office within a collegium was contingent upon the ability to meet the financial obligations that such offices entailed, though a lack of significant financial resources did not preclude membership. Indeed, the general membership of most collegia seems to have consisted of working-class professionals who made “enough money to cover living expenses and in addition to engage in social activities such as college membership, but hardly enough to live in luxury.” 375 We have no reason to believe that physicians’ collegia differed from those of other professions in this respect. Wealthier medici may have occupied the higher offices within a collegia, but those who comprised the rank-and-file membership would have benefited from the prestige conferred by their association, for even in the smaller collegia, observes Verboven, “membership always distinguished the ‘ins’ from the ‘outs.” 376 372 IEph 719, from Nutton 1995c, 6. Also see Engelmann 1990. 373 Verboven 2007, 22. 374 CIL XIV 128, 374, 4569 (from Verboven 2007, 22). 375 Verboven 2007, 20; Such a conclusion is supported by a variety of epigraphic examples that record distributions made to collegia members during formal ceremonies or banquets. Such examples include CIL X 5796, CIL XI 6378 and 6053 (from Patterson 1994, 234). 376 Verboven 2007, 20. 137 With the exception of the collegium of Ephesus, there is little evidence of any specifically medical activities carried out by the various physicians’ collegia. Much of the existing epigraphic evidence suggests that their most publicly visible activities were related to worship, such as the two dedicatory inscriptions to Asklepios from Rhodiapolis, as well as more mundane civic roles such as looking after the tombs of their fellow members. In this the medical collegia were no different than the collegia of other professions. 377 Similarly, medical collegia were well- regarded enough that they sometimes received generous donations from wealthy citizens, such as those attested to in Dionysopolis and Histria. 378 The fact that there is little evidence of formal medical activity associated with the collegia is perhaps not as surprising as it might seem. There is likewise no evidence to suggest that the collegia facilitated any type of training (with the possible exception of Ephesus, addressed below). Rather, simply being seen as an accepted member of the collegium was perhaps the primary benefit of membership. Nutton notes that a collegium’s public processions and ceremonies visibly indicated to “their potential patients just who the medici or iatroi were. In this sense, simply being among the plêthos or collegium was a public qualification, for it involved an open acknowledgement by fellow iatroi that you were one of them…Just taking part in this public worship embodied what might be considered a judgment by fellow professionals.” 379 In terms of securing legitimacy in the eyes of the public, acceptance by one’s fellow medici may have been as important as the demonstration of medical skill. The institution of the physicians’ collegia in the Imperial period would have therefore played an important role in legitimizing physicians in the eyes of their peers, if not their communities. Regarding the 377 For studies of the social and civic aspects of collegia, see Kloppenborg 1996; Wilson 1996; Cotter 1996, Van Nijf 1997, Diosono 2007 and Perry 2011. 378 Aparaschivei 2012a, 114 (= Samama 2003 no. 96 and 99). 379 Nutton 1995c, 4. 138 latter’s point of view, we unfortunately have little information on how membership in a collegium influenced the perception of patients, though I am inclined to agree with Nutton that a physician’s association with a collegium was likely seen as a legitimizing qualification – or at least one of them. With respect to civic medicine and its practitioners, the collegia functioned as an important organizing force that both defined and reinforced a social and professional hierarchy in addition to serving as a means to achieving social and professional legitimacy. Association with a collegium may have distinguished those medici who were considered professionally “in” from those who were “out,” but such distinctions were, as noted in the above discussion, inherently social in their foundations. Membership in a collegium conferred status and may have given a physician the appearance of being skilled and competent in the eyes of his fellow citizens, however there is thus far no evidence to suggest that medical collegia required actual proof of such professional attributes from those whom they admitted to their ranks. In terms of practical (i.e., effective) medical skills, I agree with Nutton’s observation that “there are limitations to viewing membership of a medical collegium as a form of qualification.” 380 As such, we cannot look to the collegia as arbiters of actual medical competence. But appearance, as the adage goes, can be everything. In terms of professional legitimacy, it seems that genuine competence in the medical arts was only a component. And if we are to take Galen at his word, it was not even a particularly important one – least as far as the medical collegia were concerned. 381 Thus far, the evidence from Rimini, Rhodiapolis, Allianoi and Marcianopolis are silent on the medical collegia of these cities. However, we do have some information concerning the 380 IEph 719, from Nutton 1995c, 6. Also see Engelmann 1990. 381 Galen complained that medical charlatanry was rampant and that physicians with little skill achieved professional success through sycophancy. Gal. Opt. Med. Cogn. 1.9, 9.16, 9.22 (= Iskander 1988, 45, 111 and 115, from Nutton 1990, 245). 139 collegium medicorum of Odessos (modern Varna), located 30km east of Marcianopolis. The same second-century tomb that suggests that the physician Asklepiades who was likely a former military surgeon also informs us that he was an archiatros as well as the head of the city’s medical collegium. The accompanying list of his accomplishments and offices paints a vivid picture of his importance in civic life. 382 Since forming such a collegium could only be done with the permission of the ruling emperor in the form of a special decree, we may safely assume that the number and relative skill of the city’s physicians not only warranted their own, imperially sanctified professional organization, but also that the presence of such a collegium in Odessos was something which the city’s ruling authorities both encouraged and supported – so much so that they invited the head of the collegium medicorum to fully participate in the elite activities and responsibilities of the ruling class. 383 In addition to serving as the head of the city’s gymnasion (school) and as the high priest of the cult dedicated to the “Great God” of Odessos, our distinguished physician was designated an aristeus by his fellow citizens, who proclaimed him to be one of the “best” among them in recognition of his service to the city. 384 Medical Competitions As we have seen, much of the extant evidence concerning the activities of physicians’ collegia suggests that many of their functions were social or religious, such as attending an annual banquet or sacrificing to Asklepios. 385 But at least one collegium held competitions for physicians who wanted to publicly demonstrate their skills. Inscriptions from Ephesus that were once displayed on the wall of the “Hall of the Muses” record the victors of the annual medical 382 See page 80 in this study. 383 Scarborough 1969, 131. 384 IGBulg. I 2 150; Aparaschivei 2012c, 75-77. 385 CIL 5, 6970 (Turin); IEph 719 (= PHI 1522); See Nutton 2013a, 256, n. 17. 140 competitions that took place during the festival of Asklepios. 386 One such inscription records that Cornelius Varinus Demetrius, an archon (magistrate) of the Ephesian physician’s collegium, won the competition in the year 153 or 154 C.E. 387 Another physician and archon of the collegium, T. Claudius Demostratus Caelianus, is recorded as having won the physician’s prize during the Asklepian games during the reign of Antoninus Pius (138-161 C.E.). 388 Concerning the nature of the competitions themselves, epigraphic evidence once again provides us with a limited window into the various categories of skill in which physicians would compete. The medical agones were divided into four categories: composition (suntagma), medical instruments (organa), surgery (cheirourgia) and problems (problemata). Israelowich notes that in the context of the Second Sophistic, this latter category likely refers to topics that would be proposed by the audience, which the participants would then improvisatorially argue. 389 At present, it is uncertain whether or not competitions of this specific type were held elsewhere or if they were unique to Ephesus. Nutton notes that a fragment of an inscription discovered during excavations in Smyrna (modern Izmir), located approximately 80 kilometers north of Ephesus, suggest that similar medical competitions may have also taken place in that city. 390 It is likewise unclear if the competitions in Ephesus were open only to physicians of that city or if medical competitors came from other regions in order to compete in the games; it is tempting to imagine that Heraclitus of Rhodiapolis, or some of his students or colleagues, may have traveled to Ephesus to test their skills against other physicians. 386 IEph 4101b (= PHI 531); IEph 1161-69 (= PHI 532-41). All these inscriptions date to the reign of Antoninus Pius (138-161 C.E.). Also see Nutton 2013a, 256. 387 IEph 4101b (= PHI 531, Samama 2003, 334 no. 210); Israelowich 2015, 131. 388 IEph 1162 (= PHI 533, Samama 2003, 335-6 no. 211); Israelowich 2015, 131. 389 Israelowich 2015, 132. Also see Mattern 2008, 7-10. 390 LBW 1523, from Nutton 1995c, 7 n. 23. Nutton notes that the inscription fragment, which had been used as spolia and was recovered from a wall of a barrack, was in poor condition and only the words archiatros and agônothetês (a superintendent who presided over public games) could be distinguished with any certainty. 141 From Galen’s writings, we know that a medical competition of a slightly different sort took place on at least one occasion in his home city of Pergamon. In his treatise On Examinations by which the Best Physicians are Recognized, Galen describes his participation in a competition during which he “performed many anatomical demonstrations before the spectators.” 391 In rather gruesome detail he goes on to inform us that it was his skillful evisceration of an ape – and his subsequent ability to replace all the viscera back in the abdominal cavity correctly – that won him the position of physician to Pergamon’s gladiators. 392 According to Galen, this particular demonstration took place before “a large public gathering where men had met to test the knowledge of physicians.” 393 From Galen’s description, it certainly seems as if Pergamon held a public medical competition in which he and others participated. What remains unclear is whether this competition was held specifically to determine who would be awarded the public office of Pergamon’s gladiator physician, or if his prestigious appointment was the result of his performance in regularly held agones that were similar to those held in Ephesus. That such competitions were a means of attracting physicians and patients into the cities, as Israelowich suggests, may have indeed been the case. 394 However, since only Ephesus has yielded concrete evidence of regularly held competitions for medical professionals, caution should be exercised when suggesting that medical competitions were an inherent part of the agones that were so popular among the cities of the eastern Empire. Susan Mattern observes that the language used by Galen in many of his case histories contain elements of “agonistic” language. She notes that “the cure, or diagnosis, or prognosis is part of a broader story of victory 391 Gal. Opt. Med. Cogn. 9.6 (= Iskandar 1988, 105). 392 Gal. Opt. Med. Cogn. 9.6-7 (= Iskandar 1988, 105). 393 Gal. Opt. med. cogn. 9.6-7 (= Iskandar 1988, 104). 394 Israelowich 2015, 131. 142 and defeat, glory and humiliation.” 395 In light of this observation, we may want to be cautious in associating Galen’s linguistic flourishes with the idea that regularly held medical competitions were the norm in his world, though there were certainly other publicly performed aspects to his practice, such as the anatomical demonstrations he performed on animals. 396 That said, it does seem unlikely that that Ephesus and Pergamon were unique in their medical competitions. Given the popularity of competitions in disciplines that ranged from athletics to poetry and art, it seems reasonable to suggest that the medical competitions held in Ephesus by the city’s collegium medicorum and those in which Galen participated in Pergamon were also to be found in other cities as part of the agones that were so popular in the Greek east. Medical Education and Libraries The existence of an organized, state-financed medical training system from the early second century C.E. is a point of debate, and rests largely on a passage from the Life of Alexander Severus in the Historia Augusta. In its recounting of the accomplishments of the emperor, the author states that Severus paid physicians salaries and assigned them lecture rooms. He is further credited with giving rations to their pupils, “provided these were the sons of poor men and free- born,” presumably so that promising students could pursue the medical profession unimpeded by their lack of financial resources. 397 Taken at face value, it is tempting to infer from this passage that “the basis of a medical system financed by the State was put into place” from the time of Alexander Severus (r. 208-235 C.E.) onwards, as Dan Aparaschivei suggests. 398 However, 395 Mattern 2008, 69. For additional commentary on the agonistic terminology used by Galen in his works, see Barton 1994, 147-9. 396 Gal. Anat. admin. 8.4 (= Singer 1956, 208-9). 397 SHA Alex. Sev. 44.5. 398 Aparaschivei 2010, 2. 143 Nutton argues against this conclusion, noting that the passage’s “text and meaning are uncertain,” and that furthermore “the renowned untrustworthiness of this particular Life casts further doubt on the truth and validity of this statement.” 399 While the passage upon which Aparaschivei rests his assertion concerning the state-sponsorship of medical education may be unreliable, his suggestion is not altogether impossible, but how likely is it? There is some evidence that the Roman state took a slightly more proactive role in encouraging the study of medicine in the fourth century C.E. In 337, the emperor Constantine issued an edict that granted immunity from the obligations of public service to those who were engaged in training for certain professions, including medicine. 400 While immunity from the expense of public services would certainly have been helpful to aspiring physicians, it is not the same thing as the direct financial support implied by passage from the Historia Augusta. However, we do have evidence for a handful of precedents for other types of free education in some Graeco-Roman cities. In such cases, epigraphic and literary sources attest to the existence of teaching positions that were established either by public funds or private bequests for the benefit of educating children whose families could not afford to pay for a private education. 401 Is it possible that such situations may have also extended to the training of physicians? Publicly and privately funded teaching positions seem to have been well-established, in the Greek east at least, several centuries before the Imperial period. 402 For example, Diodorus credits the early Greek ruler Charondas with the establishment of a law that provided public funds for teachers’ salaries, so that the children of citizens who lacked the resources to provide a private education would not be denied the opportunity to learn to read and write, and would thus 399 Nutton 1977, 216. 400 Cod. Theod. 13.4.2. (from Nutton 1977, 210). 401 Casson 2001, 53-4. 402 See Harris 1991, Chapter 5 and Casson 2001, Chapter 4. 144 not “be cut off from the noblest of pursuits.” 403 In other cases, such provisions were made for the children of some cities and towns via private bequests, such as those from the town of Teos (modern Sigacek, Turkey) located approximately 60km southwest of Izmir. A second century B.C.E. inscription records that a private citizen left the city a sum to pay teachers’ salaries so that “all freeborn children receive an education.” 404 A similar bequest was left to the city of Miletus, also located on the Turkish coast south of Teos, for the salaries of four teachers and four athletic instructors to instruct the children of the city. 405 While examples such as these serve to illuminate an interest in providing accessible education on a local level, the evidence falls well short of proof that the Roman state-sponsored a universal educational system throughout the Empire, rendering the existence of such a system for medical education more unlikely still. Establishing and maintaining a free educational system throughout the Empire at the Imperial administration’s expense would have been such a significant undertaking that one would expect at least some documentation to have survived. That the extensive legal records from the Imperial period compiled under Justinian are silent on the matter provides a rather compelling argumentum ex silentio against the existence of a universal educational system in general, let alone one that included a subject as specific as medicine. Furthermore, other than the passage from the Life of Alexander Severus, we have no other comparable literary evidence suggesting that teachers of medicine were included in the types of publicly or privately funded teaching positions that some cities such as Teos and Mitelus enjoyed. Given his extensive commentaries on and opinions of medical training available in his time, one would expect that the garrulous Galen would have mentioned such a system, 403 Diod. Sic. 12.12.4. 404 Syll. 3 578.2-13 (translation from Casson 2001, 53). 405 Syll. 3 577.4-5, 50-53. (from Casson 2001, 54). 145 particularly if it had been institutionalized at the state level. Such a system would have almost certainly invited an extensive critical commentary from one of the Imperial period’s most opinionated medical writers. However, the absence of a state-sponsored system of medical education does not mean that such an education could not be obtained by aspiring physicians of more limited means. Particularly in the civilian sphere, the medical education one obtained depended on a variety of factors. Some physicians trained as apprentices to established physicians, others enlisted in the army medical corps – some almost certainly did both. 406 Primary source literature tells us of a third avenue: a medical library in Alexandria where practicing doctors and their students would gather to exchange ideas and study the texts of famous physicians. As a result, this library functioned as a medical center of learning, with medical demonstrations performed by physicians for the benefit of colleagues and students in additional to the more traditional pursuits of manuscript study. 407 The medical library in Alexandria was part of a much larger institution; Alexandria boasted the most famous library in the ancient world. Galen reports that the Ptolemies went to great lengths to fill their libraries with every available text by confiscating them from ships that arrived into Egyptian ports. 408 Galen himself underwent part of his medical education at Alexandria’s medical library for approximately five years (ca. 152 – 157 C.E.). 409 406 Galen himself actively sought out the students of the renowned anatomist Quintus, who lived during the time of Hadrian but who had died before Galen began his medical education, in order to learn anatomy from them. Gal. Anat. admin. 14.1.231-32 (= Duckworth 1962, 183-4). 407 In his writings, Galen encouraged aspiring students to visit Alexandria to take advantage of the anatomical exhibits and live demonstrations of dissections for which the medical center was renowned. Gal. Anat. admin. 1.2.220 (= Singer 1956, 3). 408 Gal. Hipp. Epid. III 17a.606-7. For a study of Alexandria’s Mouseion and its famous library’s role as the largest center of learning in the ancient world, see Heller-Roazen 2002. For its role in medical education in particular, see Nutton 2013a, chapter 9. For Galen’s medical education at Alexandria, see Mattern, 2013, 70-80. 409 Galen refers to his student years in Alexandria in several of his patient case studies: Gal. Loc. affect. 3.11; Gal. Trem. palp. 8; Gal. Comp. med. loc. 1.2 (from Mattern 2008, 61 n. 45). For the chronology of Galen’s career, see Mattern 2008 and 2013; Nutton 2013a, 222-35 and Nutton 1973. 146 Galen’s home city of Pergamon was itself the site of one of antiquity’s famous libraries; it rivaled the institution at Alexandria to such a degree that Marc Antony reportedly appropriated over 200,000 of its texts and presented them as a gift to Cleopatra. 410 Such was the fame of these cities’ libraries – and the prestige that such institutions conferred – that it is hardly surprising that other cities sought to acquire their own. While the existing evidence is hardly comprehensive, there is enough extant epigraphic and literary material to indicate that by the Imperial period many of the Empire’s cities featured libraries. Outside of the capital city, which was home to several libraries established by the emperors the majority of libraries seem to have been established, augmented, and maintained by private donations made by guilds or individuals. 411 For example, excavations of the Ptolemaion, a library in Athens located near the agora, uncovered a series of inscriptions that recorded regular donations to the library, such as a gift of 100 books made by the epheboî of Athens. 412 In a strange twist of evidentiary fate, we have no direct references to the activities of other medical libraries besides that of Alexandria. Indeed, the historical record is strangely silent on the medical collections that must have been a part of the great library complexes of Pergamon and Rome. We can safely assume that such collections existed at these places because Galen casually mentions them in his writings, though he gives us no insights as to whether or not more demonstrative instructions, such as the anatomy expositions at Alexandria, took place at medical libraries elsewhere. 413 Should the medical library at Alexandria be considered unique in this 410 Plut. Vit. Ant. 58.5.; For the library of Pergamon and its importance as a rival to that of Alexandria’s, see Casson 2001, 48-53. For the rivalry between the libraries of Alexandria and Pergamon and a comparative study of the two, see Nagy 1998. 411 Casson 2001, 57-8. 412 IG 2 1029 and 1030 (= Plathy 1968, 110-11 no. 30 and 31); epheboî were “a formally constituted body of young men from good families often associated with a gymnasium.” Casson 2001, 58. 413 In his treatise Avoiding Distress, Galen laments the loss of many of his medical texts when the fire that swept through Rome’s Forum of Peace in 192 C.E. also destroyed the nearby storerooms where he kept a portion of his personal library. The lost storerooms had contained a number of his own works in addition to texts by famous 147 respect? After all, Galen’s own city also boasted a famous library and yet he still traveled to Alexandria and spent five years pursuing medical education there. While other cities’ medical libraries may have offered a degree of training beyond what students could glean from their collections of texts, the medical training at Alexandria was clearly considered the gold standard. If Ammianus Marcellinus is to be believed, simply having trained there was enough for a physician to be recognized as being among the best in his profession. 414 For a man such as Galen, this would have been sufficient reason to undertake training there, though in the end he had few positive things to say about the experience. 415 But while Alexandria’s medical library and the learning opportunities available there may have been the Empire’s most famous, we know that other medical centers of learning existed in cities such as Smyrna, Ephesus and Tarsus. 416 Tarsus, in particular, seems to have produced pharmacologists of some renown with relative consistency. John Scarborough and Nutton note that some of the Imperial period’s most famous authorities on medicinal substances all hailed from Tarsus, a roster that likely included the famous Dioscorides. 417 physicians, copies of which he had commissioned from those in Rome’s libraries. Those libraries, Galen reports, were also destroyed in the same fire. Gal. Ind. 6 (= Nutton 2013c, 81-4). Galen also refers to a set of his own medial writings that were intended to be sent to the public libraries of Pergamon. Though he makes mention of medical texts intended for Pergamon’s libraries as a casual comment in the larger and (to him) the much more important context of his destroyed books, it does indicate that the libraries of Pergamon must have also had medical collections. Gal. Ind. 9 (= Nutton 2013c, 84). For an in-depth study of Galen’s storeroom and the fire that destroyed it, see Tucci 2008. 414 “Medicinae autem, cuius in hac vita nostra nec parca nec sobria desiderantur adminicula crebra, ita studia augentur in dies ut, licet opus ipsum redoleat, pro omni tamen experimento sufficiat medico ad commendandam artis auctoritatem, si Alexandriae se dixerit eruditum.” (“Moreover, studies in the art of healing, whose help is often required in this life of ours, which is neither frugal nor sober, are so enriched from day to day, that although a physician's work itself indicates it, yet in place of every testimony it is enough to commend his knowledge of the art, if he has said that he was trained at Alexandria.”) Amm. Marc. 12.16.18. (= Rolfe 1940, 307). 415 For a discussion of Galen’s various complaints about his teachers at Alexandria, see Mattern 2008, 73-5. 416 Smyrna: Cadoux 1939, 232; Ephesus: I. Eph. 4101; Tarsus: Scarborough and Nutton 1982, 192-3. Also see Nutton 1995c, 17-8. 417 Scarborough and Nutton 1982, 193. 148 What exactly happened at these centers, and to what extent they resembled the formal educational structure a modern student would recognize, is as yet unknown. At Ephesus, for example, we know of the medical agones (competitions) held by the city, but we know little about what other types of medical training that may have taken place in the context of its library or its medical collegium. Indeed, Nutton rightly cautions against thinking of such centers as medical schools in the modern sense, since the term calls to mind a formal institution with “all the modern paraphernalia of learning” that is so familiar today but which we cannot attribute to the Imperial age with any degree of confidence. 418 “At best,” Nutton suggests, such centers likely represented “loose groups of practitioners associated with particular theories, teachers and places, not well-organized teaching establishments.” 419 More formal, structured educational models for medicine, Nutton argues, did not begin until Late Antiquity, having resulted from “increasing social and intellectual rigidity,” when “Galenism had triumphed in Greek medicine, and when ‘proper’ medicine could be defined as a series of specific medical texts.” 420 And yet traditions of medical learning certainly existed in other Imperial-era cities, if only in the form of libraries that contained collections of medical texts. Whether or not more interactive training may have been a part of the learning environment at medical libraries in cities such as Pergamon is unknown, though certainly Galen’s references to his anatomical demonstrations imply a form of didactic instruction, even if the primary reason for the demonstrations was their competitive aspect. Medical education in the form of competitions such as the ones held at Ephesus and (on at least the one occasion noted by Galen) in Pergamon could have been unique to those cities. Likewise, the anatomy demonstrations conducted for 418 Nutton 1995c, 18. 419 Nutton 1995c, 19. 420 Nutton 1995c, 18. For a study of the sixth century C.E. epigraphic evidence concerning the medical school in Ravenna, see Mazzini and Palmieri 1991. 149 instructional purposes that were witnessed by Galen in Alexandria may have been unique to that city’s famous medical center. However, it is possible that such educational paradigms may have been copied, albeit on a smaller scale, in other cities. The evidence from Rhodiapolis, while hardly conclusive, certainly raises the possibility. While many Graeco-Roman cities boasted libraries, it is unknown whether or not medical collections were standard features of such institutions. Clearly such collections were present in the libraries of Alexandria, Pergamon and Rome. However, the inscriptions discovered at Rhodiapolis indicate that there were also medical collections in the libraries of that city as well as Rhodes and Athens, since the epigraphic evidence tells us that Heraclitus donated copies of his works to the libraries of those cities in addition to that of Alexandria. 421 That Rhodiapolis boasted a medical library in the second century C.E. is certain, even if the collection contained only the volumes donated by Heraclitus. 422 This alone is significant; while we know of a handful of medical libraries and schools in the ancient world, we have little information about how these institutions were originally formed and what works and authors they may have contained. While the works of Heraclitus may now be lost, we now know that they existed, and that the medical knowledge and philosophy of this particular physician was transmitted to at least three other cities via his own donations. At Rhodiapolis, the presence of medical implements recovered from one of the rooms on the west side of the complex’s courtyard – the same side in which the room that the excavators speculate was the library is also located – has led the excavators to suggest that these might have been treatment rooms. 423 If so, when viewed in the context of the teaching environment known to 421 See discussion in Chapter 1 of this study. 422 While this seems unlikely we do not, at least at this time, have any evidence for other works that may have been part of the library’s collection. 423 Kızgut 2011, 94-5. Also see discussion in Chapter 1 of this study. 150 have been fostered at the medical library in Alexandria, it is tempting to imagine that a similar dynamic was at work in Rhodiapolis. 424 Could the series of small rooms have served as the loci of a sort of teaching clinic, where students could observe and participate in medical procedures performed on patients who had come to the city seeking treatment for various medical conditions? The presence of a disproportionate number of tombs belonging to individuals who were from cities far from Rhodiapolis reported by the excavation team from Akdeniz University would suggest that something was drawing foreign visitors to the city in unusual numbers. 425 Could some of these tombs belong to patients, or even to aspiring physicians who came to seek training and access to the medical knowledge in the city’s library? If the “Homer of medical poetry” was as wealthy and as conscious of his reputation as the various epigraphic evidence suggests, it is not difficult to imagine him as the ambitious and enthusiastic founder of a medical center of learning modeled on the famous example at Alexandria. 426 Additional excavations of the Rhodiapolis medical complex and a systematic survey of the known tombs in the city might well provide some answers to these questions. Such work has the potential to shed additional light on the extent to which libraries served as centers of medical education in the Roman world. And while additional investigations of this site could prove critical in furthering our understanding of the educational and training opportunities available to aspiring physicians, the findings at Rhodiapolis do seem to support the conclusion that whatever educational infrastructure was made available to those who lacked the resources to pay for a private 424 Providing education as a philanthropic endeavor would have been in keeping with the general tone set by Heraclitus’ contemporary and fellow-Rhodiapolitian Opramoas, who directed portions of his vast wealth toward the establishment of free education for the children of citizens throughout the region of Lycia. Inscriptions attesting to his educational benefactions have been found in Rhodiapolis, Xanthus, Lymra and Myra. SEG 30.1535. Also see OCD:1041, s.v. “Opramoas,” Harris 1989, 244 and https://www.livius.org/articles/person/opramoas-of-rhodiapolis/ (accessed Oct. 27, 2020). 425 Conversation with İsa Kızgut on June 1, 2019. 426 See Chapter 1 of this study. 151 education, such resources were generally available as a result of private benefactors and not the Roman state. There is nothing in the evidence at Rhodiapolis, or, for that matter, at Rimini, Allianoi or Marcianopolis, to suggest that there was any apparatus established by the Imperial authorities to provide medical education and training to students. As tempting as it may be to take the passage from the Life of Alexander Severus at face value, the unreliability of the text and, more importantly, the complete lack of corroborating evidence from both archaeological and textual sources support Nutton’s notion that no such system existed. It may be possible, however, that the medical library at Alexandria, while the most famous, was not the only one of its kind. Further investigation of the medical complex at Rhodiapolis may well reveal evidence of a smaller scale medical center based on the Alexandrian model, where students who came to access the library’s medical collection could also receive more interactive medical training. Medical Meritocracy? The “Free Market” of Medical Competence Just as there is no evidence that a deliberately constructed, Empire-wide medical infrastructure existed for the care of civilians, there was likewise a complete lack of regulatory oversight when it came to a physician’s expertise. The mid-20 th century scholar Louis Cohn-Haft put it quite clearly when he states that “no system for licensing medical practice existed in classical antiquity...so far as is known no legal or generally employed method existed to prevent an amateur, an inadequately trained apprentice, or a quack from practicing.” 427 In the over six decades since Cohn-Haft’s publication on the subject, no evidence has thus far surfaced that would warrant a re-evaluation of this statement. Almost anyone could declare themselves a doctor; it was up to other factors to determine whether or not one could be effective at it. 427 Cohn-Haft 1956, 17. 152 The Roman state’s laissez-faire attitude concerning the actual medical competence of those recognized as medici meant that charlatanry was rampant, but the identification of charlatans was often a matter of personal opinion. Never one to be short of such opinions, Galen wrote an entire treatise concerned with the characteristics and practices of those whom he considered to be the “best physicians,” himself presumably included among them. 428 Galen also observed that a physician’s skill – or lack thereof – was easily ascertained by citizens in smaller towns. This type of social regulation was lacking in larger cities like Rome, however, which Galen glumly notes were too populous for this type of de facto quality control mechanism. 429 However, even in the smaller towns these informal systems were hardly foolproof. Galen alleges that physicians who treated a town’s most distinguished citizens sometimes achieved their success through charlatanry and sycophantic behavior, the latter being a technique to which Galen suggests the wealthy were particularly susceptible. 430 If Galen is to be believed, then financial success alone cannot be considered an indicator of competence or expertise, though it may perhaps be safely assumed that an egregiously incompetent physician would not have had the means to purchase a refined property such as the one owned by the Rimini physician – at least not without other avenues of income. Furthermore, the instrumentaria recovered from the Rimini and Marcianopolis sites represent significant investments, and in both instances highly specialized surgical tools were identified amongst the more “standard” implements of a medicus in the Imperial period. 431 The presence of such specialized instruments suggest that their owners had the expertise to use them. It seems unlikely 428 Gal. Opt. Med. Cogn. 429 Gal. De Praecog. 4.5-11 (= Nutton 1979, 91-3, from Israelowich 2015, 42); Gal. Opt. Med. Cogn. 1.12 (= Iskander 1988, 47, from Nutton 1990, 244). 430 Gal. Opt. Med. Cogn. 1.9, 9.16, 9.22 (= Iskander 1988, 45, 111 and 115, from Nutton 1990, 245). 431 For a discussion of the specific instruments in the Rimini and Marcianopolis instrumentaria and the types of medical expertise they represent, see Chapter 4 of this study. 153 that the Rimini and Marcianopolis physicians would have owned tools that they did not know how – or have occasion – to use. Even allowing for the possibility that their tools – or their incomes – were acquired by other means (e.g., inheritance, income from an estate), a possible scenario is that these two physicians were skilled enough to have achieved sound reputations in their cities based on a degree of medical competence, which in turn led (or at least contributed) to their to financial success. If this is true, then we may be able to consider the Rimini and Marcianopolis physicians as examples of basic economic forces working to influence a hierarchal stratification within the profession. In other words, consumer confidence in the skill of these physicians would have led to these medici having enough affluent clients that they were able to afford such large and specialized instrumentaria, and also – at least in the case of the Rimini physician – an expensive house. 432 Israelowich acknowledges this power held by patients in his discussion of their role in the “medical market place” of the Imperial period, noting their agency in determining which practitioners to choose and which treatments to pursue. 433 The “authority,” he states “was in the hands of the health care providers but the power remained in the hands of the sick, insofar as they chose which of the available treatment options to follow.” 434 In this case, the power exercised by the medical “consumer” (i.e., patient) to choose one physician over others, assuming he or she had access to more than one, is an example of one of the dynamics at work in the “free market economy” of civilian medicine. In practical terms, it meant that patients could presumably affect the degree of professional success a physician could achieve by granting or withholding their custom. While this type of scenario cannot be said to represent a deliberate 432 The circumstances surrounding the excavation of the Marcianopolis instrumentarium precluded an investigation of the domus in which it was found. See Chapter 1 of this study. 433 Israelowich 2015, 30-2. 434 Israelowich 2015, 31. 154 effort on the part of government authorities or even the physicians themselves to impose an organizational hierarchy on the medical profession, the result nevertheless may have led to at least a certain degree of meritocracy within the civilian medical landscape. While hardly perfect, as Galen pointed out, such forces could allow the more competent physicians to rise to the top of their professions, and in so doing achieve a degree of financial success. While we cannot exclude other sources of income, the suggestion that the Marcianopolis medicus and especially Rimini’s Eutyches may be examples of this particular market dynamic at work; it is well within the realm of possibility. In terms of market forces and their effect on the medical profession in the Imperial period, the evidence from Allianoi offers a different type of view. The large quantities of medically related material recovered from Allianoi do not, as in the cases of Rimini, Marcianopolis and Rhodiapolis, illuminate the activities of a single physician, but rather offer us a window into the possible dynamics at work in a town whose economy was at least in part founded upon medicine. When considering a “medical marketplace,” it is not only the physicians themselves who would have been affected by consumer demand. In some instances, the physicians were the consumers, and as such would have been participants in a broader medical economy that included the manufacture and supply of medical instruments and medicines. What did the Imperial period’s version of a medical supply industry look like? How, and from what sources, did physicians procure the tools and substances they needed to successfully practice their craft? I suggest that the evidence from Allianoi sheds some light on these questions. While we know of very few archaeological sites where we can say with certainty that medical instruments were forged and sold, primary source literature indicates that such places 155 existed. 435 Particularly in the case of the more complicated and specialized instruments, a metal worker with the skill to manufacture them would have to have been a master of his craft. Such craftsman and their role in producing the implements of a physician’s instrumentarium are referred to by Galen. 436 Moreover, there are some extant sculptural reliefs depicting metalworkers’ shops that display medical tools such as scalpels for sale among other wares. 437 Metals used to manufacture medical implements included bronze, iron, silver, gold and brass, and multiple types of metals were often incorporated into the design of a single instrument. 438 A typical scalpel, for example, was composed of an iron blade inserted into a bronze handle. 439 Fabricating such instruments required an expertise in the unique, individual properties of a variety of metals as well as a scrupulous manufacturing process in order to ensure they would not break during use. 440 In his discussion of a set of instruments used for cataract removal recovered from the river Saône in Montebellet, France, Ralph Jackson notes that an extraordinary syringe with a fine, retractable needle could only have been realized by a highly skilled craftsman (Figs. 3.3 and 3.4). 441 The same is true for an ingeniously designed set of plunger forceps in the collection of the Asmolean Museum in Oxford, an instrument so finely calibrated and manufactured that it is still functional (Fig. 3.5). 442 Such objects could not have been produced by an ordinary metalworker. In fact, when it comes to surgical implements, Jackson notes that they are unique “within the whole field of Roman artefact technology: not only are the tools usually precision-made to the highest level of craftsmanship, but they appear 435 Gal. Ind. 3.5 (= Nutton 2013c, 79). 436 Gal. Hipp. Epid. 6, 17b.229K (= Wenkebach and Pfaff 1956, 256-57). 437 Krug 2008, 26-31; See further discussion in Chapter 4 of this study. 438 Jakielski and Notis 2000, 382. 439 Jackson 2014, 134. Iron’s greater vulnerability to corrosion explains why the bronze handles of scalpels are frequently all that remain when such objects are recovered from archaeological contexts. 440 Jakielski and Notis 2000, 382. 441 Jackson 1990a, 8. 442 Jackson 2014, 133. 156 sometimes to have been used as vehicles for the ostentatious display of innovative design and features.” 443 While the degree of specialization required to produce such objects seems clear, what is less certain is whether or not a craftsman would specialize in only medical instruments. Though possible, this seems improbable. The volume of demand for high-quality surgical instruments was unlikely to be enough to sustain an entire metal workshop. It seems more likely that such instruments were among a broader selection of high-quality wares produced and sold by metalsmiths or even jewelers. 444 The scant archaeological evidence we have of metal shops that manufactured surgical implements seems to suggest this is the most likely possibility. One example of such a place is in Pompeii. A residence with an attached metal workshop near the Porta Stabiana had a variety of medical implements amongst its other manufactured objects, including a scalpel handle made of copper alloy that was fashioned in the form of a bust of Hercules. 445 Three other such handles were recovered elsewhere in Pompeii, leading Lawrence Bliquez to conclude that they likely originated from this workshop, because “this sort of peculiar handle is unknown outside of Pompeii.” 446 Another likely example of such a workshop was identified in Dion, Greece. A trivalve vaginal speculum dating to the first century C.E. was recovered from the metal worker’s shop, where it is believed it was either manufactured or brought in for repair. 447 443 Jackson 1997, 235. 444 While a number of studies have been produced concerning the innovative designs and manufacture of specialized instruments, there has thus far been little attention paid to the manufacturers themselves. While at this juncture it remains purely speculative, I suspect that the smaller instruments, such as the retractable needle syringe mentioned by Jackson (see above), were likely produced by jewelers. A future study of the craftsmen behind the production of complex surgical instruments would be well-worth undertaking. 445 VIII 7, 5.6; Bliquez 1994, 83-4. 446 Bliquez 1994, 84. 447 Jackson 1997, 234 and 248 (Fig. 10); For a detailed study of this particular type of trivalve speculum design, see Bouzakis, K. and D. Pantermalis 2008. 157 Allianoi: A Medical Market? The incomplete state of excavations at Allianoi prior to its inundation leave us with no information about whether or not a metal workshop that specialized in the production of surgical instruments existed there. Of the almost 350 medically related objects identified by Daniş Baykan and his colleagues, none were recovered within the context of a clearly identifiable metal workshop. The remains of two glass furnaces and an iron workshop recovered by the excavators indicate that Allianoi had at least some production facilities. 448 Allianoi’s thermal waters and popularity with patients seeking treatment likely meant that the number of physicians practicing in Allianoi would have been higher than that of an average Graeco-Roman town of similar size. Therefore, it seems possible that at least some of the medical implements sought by the town’s physicians would have been manufactured locally. But regardless of where the objects were originally produced, a steady stream of doctors seeking high-quality surgical instruments would have been an attractive prospect for Allianoi’s enterprising shopkeepers. Approximately 65 instruments were found in the multi-room complex located in the north locus. As noted in the discussion of the Allianoi findings in Chapter 1, the identifiable instruments recovered from at least four of the rooms – B4, B5, B7 and C1 – were grouped together by category (uvulectomies/hemorrhoidectomies, eye procedures, urological procedures such as lithotomies and wound care procedures, respectively). In considering these enigmatic groupings of medical instruments recovered from the four rooms in this complex, the site’s excavators have proposed the possible interpretation that this building represents a medical workshop in which multiple practitioners worked in a collaborative 448 Yaraş 2005a, 18. 158 fashion, similar to the group medical practices of our modern era. 449 The groupings of instruments according to the procedure for which they were used led Baykan and his colleagues to surmise that each room was designated a specific type of surgical intervention (e.g., lithotomy procedures would have taken place in room B7). 450 Nutton concurs with this conclusion, noting that while there is as yet little archaeological evidence of group surgical practices in the form of architectural structures, there is at least some evidence that suggests that group medical practices were, if not common, at least not unheard of in the Graeco-Roman world. 451 He refers specifically to a polemical third century B.C.E inscription from Metapontum, in which an irate patient cursed an entire “workshop” (ἐργαστήριον) of physicians. The disgruntled patient must have been furious indeed, since he went to the expense of having the names of 17 physicians with whom he was displeased listed by name. 452 Nutton further notes that “in Gaul and elsewhere in North West Europe, doctors seem to have gone out on circuit [into the countryside] from a particular center,” while the Greek verb meaning “to do the rounds” (περιοδεύειν) “came to characterize medical activity.” 453 While the evidence is admittedly scarce, it would seem that group medical practices did exist, though it is impossible to know how common such collaborative arrangements may have been. Nor do we have a clear picture of how closely practices involving multiple doctors may have resembled the military valetudinaria that served soldiers of the Roman army, though certainly the military hospitals could have been used as models for similar establishments in the civilian context. After all, the army’s valetudinaria were a sort of group medical practice, staffed 449 Baykan 2012a, 163-66. 450 Baykan 2012a, 164. 451 Nutton 2014, 386-7. 452 SEG 30 1175 (= Samama 2003, 542 no. 506); Nutton 2014, 386-7. 453 Dig. 27.1.6.2 (from Nutton 2014, 387). 159 by multiple physicians – a personnel structure that was no doubt necessary in order to deal with the influx of patients following a conflict. But the primary source literature on comparable medical institutions for civilians is almost completely absent. Of the existing extant literature, Celsus alone mentions valetudinaria in what could be a civilian context, but his comment on the subject is frustratingly vague. His reference is made obliquely, briefly mentioned as part of a larger polemic against practitioners who only took into consideration the common characteristics of diseases when making their diagnoses, rather than paying attention to the particulars of individual cases. Such physicians, complains Celsus, were like “those who take charge of large hospitals, because they cannot pay full attention to individuals.” 454 Unfortunately, he fails to elaborate on whether or not the “large hospitals” to which he refers are found in civilian contexts. While it is clear how Celsus feels about a generalized approach to disease diagnosis, on the subject of hospitals he has nothing more to say. Baykan and Nutton both point out that the architectural organization of the partially excavated northern complex at Allianoi parallels the plans of some known military valetudinaria. 455 However, Patricia Baker has convincingly argued against a standardized plan for military hospitals. She observes that the structures that have been interpreted as hospitals in legionary fortresses such as Vetera I and Neuss, which are rectangular arrangements consisting of double halls of rooms arranged around a central courtyard, share the same general layout with other types of buildings such as workshops, barracks and storage facilities (Figs. 3.6 and 3.7). 456 Indeed, she notes that such structures could and likely did serve a multiplicity of purposes, depending on the needs of the camp, and that while some rooms in such a structure may indeed 454 “Et qui ampla valetudinaria nutriunt, quia singulis summa cura consulere non sustinent.” Cel. Med. Proe. 65 (= Spencer 1935, 35). 455 Baykan 2012a, 166; Nutton 2014, 388. 456 Baker 1998, 71. 160 have served as loci of medical interventions and patient convalescence, other rooms in the same building may have been used for other purposes entirely. 457 The fact that the Allianoi structure was only partially excavated means that we do not have a complete schematic of the complex, and yet the double rows of rooms in the complex’s southeast corner are indeed reminiscent of the structure identified as a hospital in Vetera I. While it is tempting to imagine that the Allianoi complex was deliberately modeled on a military valetudinarium, Baker’s observations on the ubiquitous nature and multifunctional uses of such buildings means that an interpretation based on architectural layout alone must be made cautiously and can only be speculative. It is, of course, the sheer number of instruments recovered from the Allianoi complex and their arrangement by room according to their specific function that lends the strength to Nutton and Baykan’s interpretation of the structure as a civilian hospital. While this is quite plausible, I would like to suggest a second possible interpretation, which is that this particular complex may have functioned as a site where specialty medical instruments were sold and possibly even manufactured. This does not, of course, preclude the possibility that specialized surgical procedures may have also been conducted in this complex; after all, less than half of the structure was able to be excavated. Given the presence of the thermal baths, the ubiquitous spread of medical instruments recovered from both the north and south regions of the town of Allianoi and its proximity to the nearby Asklepeion, it seems clear that Allianoi served as a locus for the ancient world’s version of a “medical tourism” destination, i.e., a place to which people traveled in search of therapeutic treatments for various ailments. Given this, it is reasonable to suggest that it may have also served as a place where medical instruments and medicines were either produced or imported 457 Baker 1998, 75. 161 and then sold to the numerous medical professionals and their patients (in the case of medicines) who would have either worked in or visited the town. The individual rooms with collections of instruments grouped together by function may represent the inventory of a dealer – or dealers – who specialized in the production, importation and/or sale of medical instruments rather than operating rooms. Complexes full of shops dedicated to the selling or ordering of specific wares were common to cities in the Roman Empire, with multiple shops that sold similar products frequently grouped together in the same building or along the same streets. 458 If indeed the rooms in the north locus were arranged around a central courtyard, as the excavated southeast and north sections of the building seem to suggest, it is possible that the central courtyard could have functioned as a location for smelting or other related, metal-working tasks involving fire and extreme heat that were best conducted outdoors. However, since the entire courtyard was unable to be excavated, we cannot know if such features related to metal forging existed there. Allianoi’s excavators indicate on their site plan that a number of surgical instruments were recovered from the small, southeast corner of the courtyard that was able to be excavated (Fig. 1.8). Nutton reasonably suggests that they may have been washed out of the rooms where they had originally been located by the river’s floodwaters. 459 However, this seems to be speculation, since Baykan’s report does not indicate the geological composition of the stratum in which the instruments recovered from the courtyard were found. If they were indeed found in a layer of river silt, this would be a concrete confirmation of Nutton’s hypothesis. 460 Lacking this, however, we are left with a second possibility: might this have been a location where these 458 Examples of this include Rome, Ostia Antica and Pompeii. See Holleran 2012, 53-60 and especially Goodman 2016. 459 Nutton 2013b, 123. 460 It is also possible that the composition of the stratum in the courtyard was communicated by the site’s excavators directly to Nutton, who reviewed Baykan’s site report, though Nutton makes no mention of this. 162 specialized instruments were manufactured, such as the workshop identified in Pompeii? Given the site’s fate, we unfortunately will probably never know, but the possibility is an intriguing one as it would represent the largest example of a market space in which such instruments were produced and sold. Given the number of medical instruments recovered from this particular locus, it seems likely that whatever the function of this section of the building complex, it was certainly medically related. Whether or not this specific building functioned as a commercial space for the sale and/or manufacture of medical implements is less certain, though evidence recovered elsewhere in the city points to a robust commercial trade in medical products in addition to services. Baykan notes that small, individual use jars of medications were found in various rooms of several insulae located along the south side of the river. 461 Unfortunately, from the site plans it is impossible to tell whether or not these were recovered from the same room in which medical instruments were also found. However, the colocation of both types of objects seems likely in at least some of the rooms, particularly those rooms located in quadrants EXII and EXI (Fig. 1.7). 462 Interestingly, two large storage jars (pithoi) believed to have contained medicines were found in quadrant EXI (Figs. 3.8 and 3.9). 463 One of the large jars was inscribed with three lines 461 For a discussion of these objects and the comparanda that he uses to identify them, see Baykan 2005. 462 As previously noted, Baykan’s report unfortunately does not indicate the exact findspots for the medical instruments recovered from the insulae that comprise what I have designated the “south locus” (see Chapter 1 of this study s.v. “Allianoi”). I was able to pinpoint the general map quadrants in which the instruments were recovered from information given in the individual artifact reports. Baykan’s primary 2012 report is concerned only with medical instruments, and therefore excludes other, related medical items such as medicine jars, mortars and pestles, etc. However, an article he published in 2005 provides details of nine terracotta medicine jars found in various locations along the main, east-west street (likely the decumanus). It was by overlaying the findspots indicated on that map with the 2012 site plan that I was able to determine the two quadrants in which both medical instruments and medicine jars were recovered. See Baykan 2005, 451. 463 Yaraş 2010, 98. Yaraş’s text indicates that the pithoi were recovered in quadrant EXII, yet the map he provides depicts them in the quadrant EXI. Pending clarification in future publications, I have based my own text on the map. 163 of Greek lettering, indicating that it had contained a medicine called errhinon ioudaikon, a substance that included a combination of frankincense (olibanum) and onion. 464 Measuring approximately 90 cm wide and almost 110 cm high and with a capacity of over 50 liters, these vessels would have contained more medicine than a single practitioner could reasonably use. The large quantity of medicine, coupled with the fact that frankincense grows only in regions of Africa, India, and the Middle East and that its procurement would have required a relatively sophisticated trade network, indicates a robust trade in medicinal substances that must have comprised at least a part of Allianoi’s medical economy. Though they date to a later period (ca. fifth/sixth century C.E.), it is possible that the presence of these pithoi points to the continuity of Allianoi’s role as a medical treatment and commercial center. 465 If, after the severe flooding and subsequent destruction of much of the town in the third century C.E., efforts were made to re- establish the city as a center of commerce for medical supplies and trade that lasted into the Late Antique period, it seems likely that it had already been functioning as such during the Imperial period. While it is quite plausible to suppose that Allianoi was a center for medical commerce as well as for actual practices and treatments, we have no way of knowing to what degree the medical products and materials that comprised Allianoi’s medical commerce were manufactured locally. To date, there has been no comprehensive analysis of the metal objects recovered from the site vis-à-vis their origin of manufacture. However, in addition to the numerous metal surgical tools recovered from the site, Baykan notes the presence of an unusually high number of other types of high-quality metal objects, such as votives, that were recovered from the Allianoi 464 Yaraş 2010, 97. 465 The pithoi were dated to the fifth/sixthcentury C.E. based on the stylistic analysis of the inscriptions. Yaraş 2010, 97. 164 excavations. 466 It seems unlikely that there would have been a complete absence of metal-smiths working to produce such objects in the town itself, particularly since physicians were known to design their own tools or commission modifications to existing ones. In most cases, a surgeon would need a skilled metal worker to execute his design once he had conceived it. Galen describes such a process in his treatise Avoiding Distress, in which he laments the loss of the wax models of instruments he had crafted with the intention of turning them over to the bronze smiths to be executed in the fire that destroyed Rome’s Forum of Peace in 192. C.E. 467 Given the presence of so many physicians who required instruments, having no metal-smiths in the town to serve them would have been a lost economic opportunity indeed and seems an unlikely scenario. Allianoi’s popularity as a medical center and the numerous metal objects – both medical and non-medical – recovered from the site indicate instrument production likely comprised at least a part of the city’s economy. I suspect that further excavations would have revealed evidence of metal workshops, if not within the north locus, then certainly elsewhere in the city. The partial evidence that we have from Allianoi suggests to me that it functioned as a “medical marketplace” on two different levels: that of physicians and their patients, and that of the market in medical products and materials. Though the portrait of Allianoi’s medical supply industry is frustratingly incomplete, based on the evidence that we do have, I propose that the town was a vibrant medical marketplace with medical commerce beyond that which involved only the economy of physicians and their patients. The market created by the patients and their medical providers would have fueled the related market for the production and/or procurement of medical instruments and related materials. Thus, Allianoi may be our largest and most complete example 466 Baykan 2019b. 467 Gal. Ind. 3.5 (= Nutton 2013c, 79); See further discussion in Chapter 4 of this study. 165 of a medical market comprised of not only providers and their patients, but also a manufacturing and retail industry centered on medical instruments, medicines, and other related products. That Allianoi was a medical center during the Imperial period seems certain, but what do we know about the patients who sought treatment and the physicians who provided it? While a thorough study of Allianoi’s necropolis may have been able to provide some substantial clues as to the nature of the town’s population, such a project was unfortunately never undertaken. In his 2012 site report, Baykan makes reference to several skeletons from the Imperial period that were found “in Allianoi and nearby surroundings,” which exhibited injuries such as “defense breaks in the ribs and fingers.” 468 He cites this vaguely referenced evidence when he makes the assertion that Allianoi was the location in which one of the ancient Rome’s most famous physicians practiced for a time. Allianoi, he states, is where Galen treated the gladiators of Pergamon who fought in the city’s amphitheater. 469 Baykan’s proposal is a bold one. It is true that Galen held the position of Pergamon’s chief physician to the city’s gladiators from the fall of 157 through the summer of 161 C.E. 470 Furthermore, the site of Galen’s Pergamene practice has long been a mystery; evidence of it has never been found. 471 Baykan notes that surgical instruments used to treat wounds were identified among the numerous medical artifacts recovered from Allianoi. Such instruments, he suggests, could have been used to address the types of injuries frequently sustained by gladiators. 472 But his primary argument for the identification of Allianoi as the site of Galen’s gladiator practice is 468 Baykan 2012a, 166-7; Baykan references an osteological study of these skeletal remains, which was conducted by Yılmaz Selim Erdal and presented at a conference in 2006. The conference paper is unpublished, and Baykan offers no additional details concerning the number of skeletons studied, their precise locations or any other data that resulted from Erdal’s study. At the time of this writing I have been unsuccessful in my attempts to obtain a copy of this conference paper. 469 Baykan 2012a, 166-68. 470 Mattern 2013, 69. 471 Mattern 2013, xviiii. 472 Baykan 2019a, 43. 166 the similarity of the north locus complex to a military valetudinarium, which he observes were also often found in gladiator ludi (schools) for the treatment of injured gladiators. 473 There are several problems with this theory. From a purely geographical standpoint, a town located approximately 18km from Pergamon’s amphitheater seems an impractical location for a medical practice dedicated to addressing traumatic injuries, which by their nature are urgent and require intervention as soon as possible. Likewise, while the excavations of Allianoi were admittedly never completed, there is no evidence, archaeological or otherwise, to suggest that a gladiator ludus, or practice arena, was located in or near the town. Given how forthcoming Galen is on virtually all aspects of his life and profession, one would expect that if the site of his gladiator practice was elsewhere other than Pergamon that he would have mentioned this in his writings. However, Galen mentions Allianoi just once, briefly referring to it as the site of thermal waters. 474 An additional argument that Baykan offers in support of his theory that Allianoi was the site of Galen’s gladiator practice is that no comparable medical treatment facilities have been discovered in or near Pergamon’s amphitheater. This argumentum ex silentio is rather weak, however, given that the amphitheater’s structure is, by his own admission, quite damaged and has never been fully excavated. 475 And finally, while some skeletons from Allianoi and the surrounding area seem to show evidence of traumatic injury, these were not necessarily obtained in the arena, and paleopathology has its limits. As Nutton rightly notes, the skeletal evidence “cannot of itself determine who the patients were, or when, or where, a surgical intervention took place.” 476 Even if skeletal evidence indicates that a surgical procedure was conducted to address 473 Baykan 2019a, 40; Baykan readily admits that the military influence of the structure is only indirect, since Allianoi was hundreds of miles from any of the Empire’s military frontiers. Baykan 2012a, 166. Also see Nutton 2014, 123. 474 Gal. San. Tu. 6.9 (= Green 1951, 261). 475 Baykan 2019a, 40. 476 Nutton 2014, 384. 167 an injury, as is sometimes the case, no known osteological analysis has ever been able to tell us who conducted the surgery. 477 In the case of Allianoi’s mysterious and vaguely referenced skeletons, it is highly doubtful that it was Galen. While he may indeed have visited or even worked occasionally in Allianoi, the possibility that the town was the site of his practice during his service as Pergamon’s gladiator physician seems unlikely in the extreme. If the questions and possibilities raised by the excavations at Allianoi have left us with the depressing reality that whatever answers and remaining information it contained is now unattainable under several meters of water, there is no question that its excavators did the field a tremendous service by rescuing what they could. Additional reports by the excavators may yet be forthcoming. Moreover, new questions and possibilities brought to light by what has already been made available should provide us an intriguing picture of a town whose main economy seems to have been comprised of a variety of medical markets. In considering the organization of civilian healthcare in the Imperial era, it is clear that its development was a result of a variety of disparate forces that bore little resemblance to the intentional and more structured implementation of that which was instituted for the military. However, despite the relative lack of involvement by the Imperial administration, the medical profession in the civilian sphere came to have at least a degree of organization. The collegia, the medical competitions, the libraries (and the possible training opportunities they afforded), and even the laws governing public physicians all brought various degrees of structure and organization to the profession and its practices. Though certainly flawed as a mechanism for ensuring professional standards, the economic forces inherent in the medical market allowed at least a degree of discernment when it came to actual competence. A physician who regularly 477 For examples of the osteological evidence of surgical interventions in the Graeco-Roman world, see Jackson 1990, 2005 and Mariani-Costantini 2000. 168 killed his patients probably would not be able to maintain a good reputation indefinitely, no matter how adept at sycophancy he may have been. If Allianoi is any indication, the medical market that was comprised of highly specialized instruments, medicines procured from the furthest reaches of the Empire’s trade network, and the supplier/consumer dynamic represented by the physicians and their patients represented an entire economy in its own right and was likely duplicated in other Roman cities and towns. Such a market has thus far never been seriously examined for this period; it is a study that would be well-worth undertaking in the future. For now, I hope I have succeeded in signaling that such a medical economy not only existed but was possibly quite robust and merits future investigation. 169 Chapter 4: Physicians’ Expertise and the Tools of the Medical Trade When he exhorted his fellow physicians to “make a habit of two things—to help, or at least to do no harm,” Hippocrates of Cos (ca. 469-399 B.C.E.) could hardly have expected that his advice would reverberate through western medicine for the next 2500 years. 478 Though it is not uncommon for graduates of western medical schools today to swear a version of the Hippocratic Oath as part of their induction into the profession, there is no evidence that Graeco-Roman doctors took such an oath. Nevertheless, conscientious practitioners of the Imperial era viewed caution as a virtue when it came to the practice of medicine. 479 In an age in which the benefits of sterile operating conditions were completely unknown and infection and shock were common killers, scrupulous physicians would not have undertaken surgical interventions lightly. 480 They certainly would have been acutely aware and cautious of what Vivian Nutton drily observed almost two millennia later: “death…was an occupational hazard of being a patient.” 481 After all, a surgery can only be considered successful if the patient doesn’t expire from shock or infection, and the death of patients would have been bad for business. Despite the inherent risks of infection in an age that pre-dates the widespread acceptance of germ theory by over 1500 years, Ralph Jackson notes that in the Graeco-Roman period “a 478 OCD 687-8, s.v. “Hippocrates (2)”; Hippoc. Epid. 1.11 (= Jones 1923, 165). 479 Jackson 1997, 223. 480 Galen praises physicians who could treat conditions with medications rather than surgery. Gal. Opt. Med. Cogn. 10.2 (= Iskandar 1988, 117); Celsus acknowledges that the effects of surgical treatments are more obvious than prescriptions of dietary and medical treatments but seems to feel that such measures are best resorted to in the cases of wounds and bone injuries. Cel. Med. introduction to Book 7; While he was not a physician, Seneca’s observation that surgery is a last resort to be used only if “milder measures are unavailing” is presumably reflective of a more widely held opinion. Sen. De Ira 1.6.2 (= Basore 1928, 121); Likewise, it seems safe to assume that Livia’s comment to her husband, the emperor Augustus, that “physicians very rarely resort to surgery and cautery, desiring not to aggravate their patients’ maladies, but for the most part seek to soothe diseases by the application of fomentations and the milder drugs” is likely indicative of a more generally held philosophy when it came to medical treatment. Cass. Dio 55.17.1 (= Cary 1917, 437). Also see Bliquez 2015, 20. 481 Nutton 1986, 36. 170 sufficiently successful outcome to surgical treatment was evidently frequent enough to make it viable.” 482 By the second century C.E., Jackson continues, “medical and surgical equipment of diagnostic form was becoming increasingly numerous, varied and widespread throughout the Roman world.” 483 While Jackson does not speculate on why this may have been the case, the increasing prevalence of new and innovative surgical instruments we see from the second century onwards may be a result of several concurrent factors. First, while surgical intervention may well have been considered “last resort” options for many physicians, there are few alternatives when it comes to mitigating injuries of the type sustained in military conflicts. The increasing professionalization of the Roman army, which began with Augustus, enabled the Empire to reach its zenith of territorial expansion by the end of Trajan’s reign in 117 C.E. It seems likely that the injuries sustained by soldiers during the course of Rome’s trajectory from a republic to a sprawling empire would have presented surgeons with plenty of opportunities to advance their craft, developing specialized instruments and tools to fit their increasingly sophisticated surgical repertoire along the way. A second factor that contributed to the proliferation of medical technology was the increased ease of knowledge transmission. By the second century, the Roman army was a finely tuned machine, with military units – and their accompanying corps of medici – crisscrossing the Empire from one far-flung frontier to another along an ever-expanding series of secure roads and sea routes. The relative ease of mobility that enabled the efficient transport of men and goods would also have facilitated the transmission of medical knowledge. It is easy to imagine scenarios in which physicians posted to various military units were able to meet and share ideas for newly 482 Jackson 1997, 224. Jackson further notes that while the notion of infections resulting from unsanitary instruments was unknown to the Romans, that the “majority of instruments were made of iron or copper alloy or a combination of the two and…copper salts and corrosion products often inhibit the growth of bacteria.” 483 Jackson 1997, 224. 171 developed surgical techniques and instrument modifications as they moved from one post to another. Previous chapters of this study have sought to examine broader aspects of civilian medicine in the Imperial period, such as its relationship to military medical practices and the various external and internal influences that shaped the profession. This chapter seeks to zero in on the practitioners themselves: what we are now able to understand of their expertise and training, and how representative individual practitioners may have been of their profession as a whole. To what degree were Roman doctors “specialized,” i.e., what categories of expertise did they have, or at least claim to have, and how do we know? In order to begin answering this question, the first half of this chapter starts with an examination of the instruments themselves: what we know of their design and manufacture, and how their archaeological context affects what we can – and cannot – deduce about their owners’ expertise. I then move on to a brief analysis of what primary source literature and epigraphic evidence reveal about the various categories of medical specialization in the Imperial period. The second half of this chapter is concerned specifically with the sites of Rimini, Marcianopolis and Allianoi. My analysis of the medical instruments from these three sites has two objectives: 1) To understand what types of medical treatments and procedures would have been conducted by the Rimini, Marcianopolis and Allianoi physicians, (i.e., what types of medical expertise they possessed), and 2) To make the case that that though the archaeological sites themselves may be extremely rare in present times, the ancient medical paradigms that they represent are not. In other words, I suggest that the medical treatments, procedures, and categories of medical expertise characterized by the evidence from Rimini, Marcianopolis and Allianoi are, with some variations, representative of civic medicine more broadly. 172 As previously noted, the sites of Rimini, Marcianopolis and Allianoi are, like Pompeii, exceptionally rare in that they are part of a very small group of examples of in-situ civilian medical practices. 484 The medical implements from these sites were recovered within the context of their urban environments rather than from burials, a circumstance that provides more complete data than sepulchral contexts when it comes to the types of medical/surgical expertise that was available in the civilian sphere of Roman society (see discussion further on in this chapter). But if the archaeological sites and the evidence they contain are themselves rare and unique to us as contemporary scholars, does it stand to reason that the physicians and the medical skills they possessed were likewise rare and unique? I do not believe so. In fact, I think it is possible, even probable, that the Rimini and Marcianopolis surgeons and the skill sets they possessed are representative of the medical expertise available in similarly sized Roman towns from the same period, with possibly some differences (e.g., particular surgical skills) resulting from their geographical proximity to battle zones. Allianoi and Pompeii, located as they were far from the Empire’s conflict-prone frontiers, demonstrate a medical landscape that may perhaps have a slightly different emphasis when it comes to the types of medical conditions addressed and procedures performed. But I think it likely that this is more a result of the medical marketplace (i.e., patient demand) rather than a lack of available expertise. One of the primary ways in which we are able to gain a window into the lives and professional practices of Graeco-Roman medici is through the tools of their trade. The surgical 484 Though I suspect it is likely that physicians’ practices existed in Rhodiapolis in addition to the medical library and possible training center, the small number of medical instruments thus far recovered from the site, as well as their deteriorated state, do not allow for anything but the broadest of speculative hypotheses concerning the type of medical expertise that may have been represented in the city. For this reason, Rhodiapolis is largely left out of the discussion in this chapter, which centers on the evidence for the expertise and specializations of Imperial-era physicians.; The medically related objects from Pompeii and Herculaneum have already been comprehensively studied and published and will be referenced here only as comparanda to the primary data addressed in this study. Examples of publications concerning the medical material from Pompeii and Herculaneum include Bliquez 1994 and 2015, and Bon et al. 1997. 173 instruments and other medically related paraphernalia recovered from various archaeological contexts offer us testimonies of the practitioners who used them. These medical tools and objects help us understand the categories of skills Roman medici possessed and the types of procedures they performed. This type of information is not only useful in helping us piece together a more complete portrait of the types of practices and procedures in which Graeco-Roman physicians engaged, but it also offers us a great deal of information about the various illnesses and injuries that plagued Rome’s denizens. Of course, in order to properly assess a physician’s skill set as evidenced by his instruments, one must first accurately identify the instruments and their functions. In this we are generally fortunate, since a number of tools used by Roman physicians bear a striking resemblance to those employed by the surgeons of today. After all, while modern medicine is well ahead of its Graeco-Roman antecedent, the basic anatomy of the human body remains unchanged. This may be one reason why, as Jackson notes, “the basic design and quality of manufacture of instruments seem to have remained much the same from the 1 st to the 5 th century AD throughout the Roman world.” 485 As a result, many of the surgical instruments recovered in- situ from archaeological contexts “are identifiable even as single finds without a medical context.” 486 In the event that a tool may have other, non-medical functions and/or is less easily identified, Jackson observes that “the medical purpose of other, less diagnostic pieces is disclosed by their presence in sets of medical instruments found in secure dated contexts, principally sepulchral finds.” 487 This task has been made significantly easier by the catalogs of known medical tools and objects from the Roman period compiled by scholars such as Ernst 485 Jackson 1997, 227. 486 Jackson 2014, 133. 487 Jackson 2014, 133. 174 Künzl and Lawrence Bliquez, both of whom have masterfully gathered together extant examples of surgical instruments and other medically related objects from all over the Empire, cross- referencing them with descriptions of their design and use from primary source literature. 488 Instrument Design and Manufacture While there is certainly variation and degrees of difference when it comes to the quality of medical instruments from the Graeco-Roman world, we can say with some confidence that the majority of extant examples exhibit a high level of care when it came to their design and manufacture. In this, we may perhaps consider the instruments as the material counterparts to the detailed and carefully recorded accounts of surgical procedures provided by ancient medical writers such as Celsus and Galen. 489 The expert manufacturers of sophisticated medical instruments remain elusive figures, though a scene from a terracotta relief discovered at Ostia suggests that scalpels may well have been created by metalsmiths who specialized in blades. This first-century C.E. grave relief of L. Cornelius Atimetus seems to depict a shopkeeper and his customer perusing an impressive selection of various types of knives and sickle blades (Fig. 4.1). 490 A similar set of grave reliefs from Ostia come from the tomb of Verrius Euhelpistus. The reliefs, which date to the second century, depict similar scenes featuring a metalsmith at work in 488 Künzl 1983, 1991; Künzl and Riederer 2002; Bliquez 1980, 1981, 1982, 1986, 1988, 1994, 2015. Bliquez’s Tools of Asclepius: Surgical Instruments from Greek and Roman Times (2015) is the most recent and complete of these catalogs. It represents a skillful synthesis of his prior work as well as that of Künzl’s, grouping together known instrument examples according to type and function along with an exhaustive survey of corresponding primary source literature. 489 Jackson 2014, 133. Jackson’s 1994 article “The Surgical Instruments, Appliances and Equipment in Celsus’ De Medicina” is an excellent study that compares Celsus’ textual descriptions of medical paraphernalia to existing examples of the objects. Jackson 1994. 490 Krug 2008, 26-7. 175 his workshop (Fig. 4.2) as well as a prominent display of a variety of metal tools and blades (Fig. 4.3). 491 One such workshop has been identified in Pompeii. 492 First excavated in 1872, the workshop was attached to a residence located adjacent to the Porta Stabiana. 493 Within the workshop, a smelting furnace was identified as well as a number of bronze medical instruments in various stages of manufacture, including a probe and nine scalpel handles. 494 One of these scalpel handles was decorated with a bust of the demi-god Hercules and was identical to three other scalpel handles that were recovered elsewhere in Pompeii (Fig. 4.4). 495 This rather startling coincidence led Bliquez to conclude that all four pieces may have originated at this particular workshop, “because this sort of peculiar handle is unknown outside of Pompeii.” 496 In addition, two other shops in the immediate vicinity were identified as sites where metal tools were manufactured and sold, suggesting that the neighborhood surrounding the Porta Stabiana may well have been where the inhabitants of Pompeii, including its medici, came to purchase their metal tools. 497 How the metalsmith of Pompeii learned to craft specialized medical implements, and where he obtained the ideas for his designs, is something that we cannot know. Nor can we comprehend with any certainty the extent of the involvement of the metalsmith’s physician- customers when it came to the design and execution of the instruments that they purchased at the 491 Krug 2008, 28. 492 Bliquez 1994, 83-84; 1995, 219-21. 493 VIII. 7.5.6; The site was first reported in the Giornale degli Scavi di Pompeii NS II, 426 (1873); Bliquez 1994, 83-4. 494 Giornale degli Scavi di Pompeii NS II, 426 (1873); Fiorelli 1875, 348; Bliquez 1995, 220-1. 495 The exact provenance of these other three “Hercules handles” within Pompeii is unknown. See Bliquez 1994, 84. 496 Bliquez 1994, 84. 497 The shop where a M. Surus Garasenus manufactured and sold metalware was located immediately next door (VIII 7, 7.8). A second shop located across the street (I 1,19) also had a substantial inventory of such products. Bliquez 1994, 84 and 1994, 221. 176 Porta Stabiana. But while the dynamics of the customer/craftsman relationship at this particular workshop will likely always remain unknown, we do have some fragmentary literary evidence that suggests instruments – or at least some of them – were the result of collaborations between the metalsmiths who crafted the objects and physicians who designed them. 498 One of the more descriptive accounts of such collaborations comes to us from Galen’s letter titled Avoiding Distress, in which he responds to an inquiry concerning the loss of his medical instruments in the fire that swept through Rome’s Forum of Peace in 192 C.E. In this letter, he recounts how he had stored “a huge quantity of drugs of all sorts…and instruments of every kind” in a warehouse adjacent to the Forum that was destroyed in the fire. 499 Though he claims to have also lost books, loan documents, gold and silver, he particularly regrets the loss of his medical texts and instruments. 500 Of those lost instruments, Galen laments that “some, valuable for medical purposes, I said I had lost but still hoped to replace, but that other instruments I had invented myself, making models out of wax before handing them over to the bronze-smiths, these I cannot replace without a great deal of time and effort.” 501 From this text we can extrapolate two pieces of information: first, it is clear that Galen engaged in the practice of designing medical implements and commissioning a metalsmith to execute those designs, a practice we can reasonably assume would have been undertaken by other inventive physicians 498 Jackson 2014, 133; The closest we have to a study dedicated to the manufacturers of Roman medical instruments is Künzl’s brief 1984 article Einige Bemerkungen zu den Herstellern der römischen medizinischen instrumente. Künzl 1984. Though there is as yet no broader study that focuses on the design and manufacture of surgical implements in the Graeco-Roman period, there are a number of published studies on individual objects and collections that include investigations into – or at least mention of – their possible design and manufacture. Such studies include Jackson 1990a, 1991, 1994, 2005, 2010, 2014, Jackson and La Niece 1986, Bliquez 1992, 1994, 2015. For a metallographic analysis of two unprovenanced instruments from the Imperial period, see Jakielski and Notis 2000. 499 Gal. Ind. 2 (= Nutton 2013c, 78). 500 Gal. Ind. 3-6 (= Nutton 2013c, 78-9); For a discussion of Galen’s medical texts that were lost in the fire, see Chapter 3 of this study. 501 Gal. Ind. 3.5 (= Nutton 2013c, 79). Pier-Luigi Tucci has noted that wax models are more appropriate to bonze casting technology than iron, leading him to conclude that Galen had likely intended to turn his designs over to a bronzesmith to be cast, rather than over to a blacksmith to be forged. Tucci 2008, 141. 177 with the financial means to commission surgical tools of their own design. Second, though Galen may have been pained by the loss of wealth represented by the loan documents, gold, and silver, it is clear from his text that he considered the loss of his medical books, instruments, and medicines to be the greater blow. 502 This latter point underscores how valuable these objects were, both as examples of sophisticated craftsmanship that represented a significant financial investment as well as the essential tools of a physician’s craft. Another example of the inventiveness Galen applied to his instruments is found in his treatise On Anatomical Procedures, in which he refers to using “an instrument of my own devising” in a discussion of dissections that he performed on the spinal cords of pigs. 503 And though Galen’s accounts may be the most descriptive when it comes to the role a physician could play in the design of his own instruments, there were other examples. Celsus, when describing a lithotomy procedure, refers to a specialized scalpel devised by Meges for the removal of stones from the bladder, while the Pseudo-Galenic treatise Introductio Sive Medicus describes the improvements made to the male catheter by Erasistratus, which the author describes as resembling the shape of a “Roman sigma.” 504 We know of at least one case in which innovative medical instrument design was not only encouraged but lauded and – to a degree – institutionalized. Some of the second-century C.E. epigraphic evidence concerning the medical competitions held in Ephesus (see discussion in Chapter 3) tells us that the games included the design of new and inventive surgical implements as one of its categories. Physicians Publius Aelius, Publius Vedius Rufinus (who was also an 502 The quantities of medicinal compounds Galen had in storage, which included “some eighty pounds of the famous theriac, and more cinnamon than can be found in all the retail shops put together,” far exceeded that which he could have used as an individual practitioner. Gal. Ind. 6 (= Nutton 2013c, 79). It is possible that this represents a supply that he kept as part of the Imperial stores. See Nutton 2013c, 79 n.14. 503 Gal. Anat. Admin., 8.6.682 (= Singer 1956, 214). 504 Celsus Med. 7.26.2M-3 (= Spencer 1938b, 437); Pseudo-Galen Introductio Sive Medicus 13.35 and 19.12 (= Petit 2009, 64-5 and 96-7). Also see Bliquez 2015, 15-16. 178 archiatros) and P. Aelius Secundus were all winners of the Ephesian competitions for innovative surgical instrument design. 505 Though there is no mention of the winning instruments themselves, the existence of such a category is a testament to the role that physicians could play in the design of their own instruments. The archaeological record also attests to instances of instrument design modifications made by individual practitioners. Some examples of instruments that appear to have been modified at some point from their original form have been identified, including one from the Marcianopolis collection (see discussion further on in this chapter). One such example comes to us from the collection of surgical instruments in the National Archaeological Museum of Naples. Bliquez notes that its original form was that of a lithotomy scoop, but that at least one edge of the scoop had been modified so that it more closely resembled a sharp-edged spatula. 506 For what use it was modified is unknown, though Bliquez speculates that it may have been employed as a phlebotome, an instrument used to incise a vein for the purposes of bloodletting. 507 Another instrument adapted for a different use than its original intended design is in the collections of the Museum of Classical Archaeology in Cambridge, England. 508 In its original form, the slender, copper alloy instrument had two sharp, straight lancets at one end. The tool was modified by turning the ends of the lancets at right angles to effect a bifurcated blunt hook, an instrument commonly found in lithotomy sets (Fig. 4.5). 509 Jackson reports that another object in the collections of the Museo Nazionale Romano was, in its original form, a spatula probe. At some point “the oar-shaped spatula had been deliberately and carefully bent to form a strong curve, a 505 I. Eph. IV 1162, 1164, 1165 (= Samama 2003 nos. 211, 213, 214); Also see Jackson 2014, 133 and Bliquez 2015, 16. 506 Bliquez 1994, 37 and 123 no. 54. 507 Bliquez 1994, 123 no. 54. 508 Jackson 2010, 408-9. 509 Jackson 2010, 408. 179 modification perhaps intended to adapt it to use as a scoop.” 510 Such examples illustrate the inventiveness of various unknown medical practitioners who, using tools they may have already had on hand or could obtain easily, were able to fashion instruments they needed but had not acquired. Whether they adapted the instruments themselves or engaged the services of a metalsmith to execute their modifications is impossible to know, though both scenarios are possible. When it comes to the actual manufacturing of medical implements, the “what” has proven easier to discern than the “who.” Surgical instruments and other medical objects were made of a wide variety of materials, which seem to have been chosen carefully and thoughtfully in order to maximize both their effectiveness and their durability, though certain metals such as gold and silver were sometimes chosen as decorative elements. 511 Galen is on record as preferring scalpel blades made from steel obtained from Norcia, which he claimed could not be “blunted, bent or broken.” 512 This is consistent with Jackson’s observation that iron was generally the metal of choice when it came to instruments for which strength and durability were required, such as scalpels, bone saws and drills. 513 Bronze or other types of copper alloys were generally employed for intricate instruments with multiple moving and/or interlocking parts, as well as for purely decorative features. 514 Instruments of lead and tin are rare, but the two metals were frequently used as an alloy mixture to solder together separate components of certain instruments, such as the combination of bronze handles and iron blades commonly seen in 510 Jackson 2010, 414. 511 Künzl 1984; Jackson 1997. 512 Gal. De Anat. Admin. 8.6 (= Singer 1956, 214). 513 Jackson 1997, 225. 514 Jackson 1997, 225. 180 scalpels of the period as well as the similar, parallel configurations often employed for needles and small chisels. 515 Of those instruments that have survived, it is unsurprising that the majority are made of metal such as iron, steel, bronze, or some other type of copper alloy. Instruments and other medical paraphernalia that were made from more perishable materials rarely survive in the archaeological record. However, we know of their existence thanks primarily to Celsus, whose writings refer to items made from materials such as leather, cloth, papyrus, wood, reeds and even feathers. 516 Included among the instrumentarium of a Roman medicus would have been supplies such as bandages, slings, splints, straps, and sutures – items that generally do not survive in archaeological contexts. 517 Though incomplete, the medically related objects that have survived are able to tell us a great deal about the Roman medical practitioner both generally and – in cases such as Rimini, Marcianopolis and burial contexts – about particular physicians specifically. Physician burials, though they are far more numerous than other types of archaeological contexts from which instrumentaria have been recovered are, while valuable, also somewhat more limiting than non- sepulchral contexts (see discussion below). This is one more reason why rare sites such as Rimini, Marcianopolis, Allianoi and Pompeii are so important. When considered together, the instrumentaria from both burial and non-burial contexts provide us with a more profound 515 Jackson 1986, 133-4; 1997, 226; Celsus mentions tubes fashioned of lead or copper alloy used to drain internal wounds or infections, but the softness of the lead meant that it would have been an impractical medium for most surgical implements. Cel. Med. 7.15.1-2 (= Spencer 1938b, 383). All the surviving examples of such tubes are of the copper alloy type. Bliquez 2015, 207. 516 Jackson has put together an excellent set of tables demonstrating the Celsian passages that refer to the more perishable materials used to make tools and other types of objects used in therapeutic treatments, such as slings. See Jackson 1994, 198-200 (Tables 2-4). 517 Bandages and slings: Cel. Med. 5.26.24 and 8.10.3 (= Spencer 1938b, 89 and 1938, 545-6); Splints: Cel. Med. 8.10.1 (= Spencer 1938b, 541); Straps: Cel. Med. 8.10.1 (= Spencer 1938b, 539); Sutures: Cel. Med. 5.26.23 (= Spencer 1938a, 85). From Jackson 1994, 198-200 (Tables 2-4). 181 understanding of the Roman medical landscape, particularly when it comes to the expertise of practitioners. Instrumentaria from Sepulchral Contexts An important source of knowledge when it comes to examples of a Roman doctor’s instrumentarium comes to us from burial contexts, though this information can be somewhat limited. Physicians’ tombs – their decorative motifs and the items sometimes found within them – rarely provide us with collections of objects as extensive as those of Rimini, Marcianopolis or Allianoi. 518 However, they are nevertheless an important resource that provides us with a reasonably clear understanding of what typically comprised a Roman doctor’s most basic, core set of instruments. As a result, we are able to speculate with some confidence on the types of conditions that even a non-specialist physician may have been expected to treat. When it comes to tomb imagery, one of the most common representations of a Roman physician’s instrumentarium is a depiction of a folding instrument box containing various medical implements, which is frequently accompanied by images of bronze cupping vessels. While generally associated with tombs, such images may also be associated with votive reliefs. 519 This “standard,” core collection of surgical instruments generally consisted of scalpels, forceps, hooks, needles, probes and perhaps a cautery tool, though Jackson notes that in the absence of a cautery tool scalpels, needles and probes were frequently used to cauterize wounds. 520 These basic tools of the medical trade were generally kept in rectangularly shaped, 518 One of the exceptions to this is a collection of instruments recovered from a burial in Bingen (Germany), which will be addressed later on in this chapter. 519 Jackson 1988, 113 and 1995, 191. 520 Jackson 1997, 228; Künzl 1983, 8-9; The use of various medical implements as cauterization tools would also have mitigated the risk of introducing infectious agents to wounds via non-sterile instruments. 182 hinged, wooden or leather cases that not only kept the instruments contained and organized, but had the additional benefit of being inherently portable (Fig. 4.6). 521 These medical kits were often accompanied by bronze cupping vessels, which were used to draw infected fluid from a wound or, in the case of a blood-letting procedure, to collect blood (Fig. 4.7). This basic type of collection of medical tools is referred to in the Hippocratic texts, which advised physicians to keep these tools prepared, in order and with them at all times. 522 Such kits are well-attested to in the archaeological record, an organized reporting of which was presented by Künzl in his 1983 publication Medizinische Instrumente aus Sepulkralfunden der Römischen Kaiserzeit. 523 As the title suggests, Künzl’s study was concerned with those instruments that were recovered from burial contexts, though examples have also been found in other, non-sepulchral contexts, such as the one recovered from the “Piazza dell’Anfiteatro” in Pompeii and another in Herculaneum. 524 Basic though it may have been, in the hands of a skilled surgeon the tool kits that formed the foundational - or even the exclusive – pieces in a physicians’ instrumentarium could enable him to be prepared for a relatively wide variety of surgical procedures. For example, Celsus makes no mention of the need for specialized instruments when he describes operations to address fistulas and aegilops (an abscess or ulcer of the inner canthus of the eye). Procedures such as tonsillectomies, uvulectomies, and hemorrhoidectomies likewise do not seem to have 521 Jackson 1988, 114-5 and 1997, 228. 522 Hippoc. Decent. 8 (= Jones 1923, 291). 523 For a breakdown of instruments by type identified from the various burials discussed in Künzl, see Künzl 1983, 8-9 (Tables 2a and 2b). Also see Jackson 1995, 196-200 (Tables 1-3) for the inclusion of objects discovered/identified after Künzl’s 1983 publication. 524 Bliquez 1994, 87-8; De Carolis 1993; The instrumentarium discovered in Pompeii was discovered under a group of skeletons, one of whom was presumably the owner. I agree with Bliquez’s suggestion that the case was most likely carried into the Piazza dell’Anfiteatro by its owner from a nearby dwelling and “has no association with the nearby Palaestra, even though it is often referred to as the ‘Palaestra’ instrumentarium” (Bliquez 1994, 87-8). The fact that the instrumentarium was found with four other cases, all of which contained medicines, attests not only to the portability of such objects but also to their value to their owner since he was carrying the cases with him when he and his companions fled to, and were eventually overwhelmed at, the amphitheater. 183 required highly specialized or sophisticated implements. 525 The versatility of such a relatively modest instrument collection was increased because many of the implements usually identified in these kits were designed as multi-purpose tools. For example, it was common practice to mount two different instruments on either end of a single handle. We have many examples of this technique that represent a variety of combinations, such as scalpel blades of two different sizes, double needles, double probes, blunt hooks/sharp hooks, lithotomy knives/lithotomy scoops and forceps/probes (Fig. 4.8). 526 Jackson points out that this was practical not only in terms of saving on the cost of manufacture and materials by essentially having two instruments in one, but that it also allowed for a greater number of instruments to be included in a portable case. 527 While these medical toolkits represent the basic, core pieces of a physician’s collection, the evidence from sites such as Rimini and Marcianopolis make it clear that doctors could and did have other, more specialized instruments in their instrumentaria. While it is possible – even probable - that less wealthy or specialized medici may have only possessed a single, basic kit such as those that appear with relative frequency in burial contexts, Jackson cautions us against interpreting this as representative of the norm for most physicians. 528 It is the very context in which many of these kits have been identified that necessitates restraint in approaching this conclusion, since the “dedication of grave goods was a controlled action, a conscious decision to take out of circulation a group of objects.” 529 In this case, the decision to include these objects as 525 Cel. Med. 7.4 (fistula), 7.7.7 (aegilops), 7.12.2 (tonsillectomy) 7.12.3 (uvulectomy), 7.30.3 (hemorrhoidectomy) (= Spencer 1938b, 311-5, 335-7, 371-3, 373, 463-7); Bliquez 2015, 12; Jackson 1997, 228; Jackson 1995, 193. 526 Jackson 1997, 227. 527 Jackson 1997, 227. 528 Künzl’s 1983 study, Medizinische Instrumente aus Sepulkralfunden der Römischen Kaiserzeit, surveyed 78 medical instrumentaria recovered from burial contexts and remains the most comprehensive study of its kind to date.; Jackson 1995, 192. 529 Jackson 1995, 192. 184 part of a burial eliminates the possibility that they can be given or sold to another practitioner. In other words, it is rare that the more highly specialized, complicated, and therefore more expensive implements were consigned to a burial context; their value made it more likely that they stayed in circulation. As a result, while burial finds have been able to attest to the relative uniformity of a physician’s basic tool kit, it is impossible to know if these kits represent the deceased’s entire instrumentarium. 530 Therefore, when trying to assess the expertise of a particular surgeon, it is the instrument sets recovered from non-sepulchral contexts that are more useful in determining the breadth and scope of a physician’s skills. An exception to this is an instrumentarium recovered from a first-/second-century C.E. burial in the ancient spa-town of Bingen, located near Mainz, Germany. Prior to the discoveries of the medical instrumentaria at Marcianopolis, Rimini and Allianoi, the Bingen collection was considered to be one of the most significant sets of surgical tools from the Imperial era ever discovered. Unlike the majority of instrumentaria recovered from burial contexts, which are frequently limited to the basic kit described above, the Bingen collection contains over 50 separate pieces. 531 It is not only the largest such instrument set to be recovered from a sepulchral context, but it is also one of the few extant collections that represents a more specialized expertise on the part of its owner, who, if his instruments are any indication, seemed to have had considerable familiarity with various types of bone surgery. The set included several bone elevators and chisels, a bone gouge and two crown trephines (modioli), which were employed by 530 Jackson 1997, 232-3. 531 Como 1925; Künzl 1983, 80-5; Jackson and La Niece 1986, 120; Jackson and La Niece are dubious that all the objects considered to be part of the Bingen instrumentaria had medical use. The tomb and its contents were discovered in 1925, and the lack of more modern, systematic excavation techniques is one reason why they urge caution in assuming that all the objects were grouped together as a single collection used for medical purposes. Jackson and La Niece 1986, 120. 185 doctors in trepanation procedures. 532 This is consistent with Jackson’s observation that “instruments for bone surgery are the commonest identifiable ‘specialist’ component in the largest apparently complete Roman instrumentaria.” 533 Bone surgery, along with dentistry, were likely more common “specializations” since they involve more straightforward, mechanical manipulation (or, in the case of teeth, extraction) of bone as opposed to the more delicate and perilous procedures involving the internal organs and primary blood vessels. 534 And yet the various types of procedures could and did overlap, such as in the case of amputations or the very risky trepanation operations. The latter procedure was a dangerous (and frequently fatal) surgery that was undertaken as a last resort effort to relieve intracranial pressure caused by severe trauma to the head or to remove diseased (i.e., infected) bone, described in dramatic detail by Celsus: “When the disease is so limited that the modiolus can include it, this is more serviceable; and if the bone is carious, the central pin is inserted into the hole; if there is black bone, a small pit is made with the angle of a chisel for the reception of the pin, so that, the pin being fixed, the modiolus when rotated cannot slip; it is then rotated like a trepan by means of a strap…But if disease is too extensive for the modiolus to cover, the operation must be carried out by the trepan. With this a hole is made exactly at the margin of the diseased and sound bone, then not very far off a second, and a third, until the whole area to be excised is ringed round by these holes; and here also the bone dust shows how deep the trepan is to go. Next the excising chisel is driven through from one hole to the other by striking it with a mallet, and cuts out the intervening bone, and so a ring is made like the smaller one cut by the modiolus.” 535 The application of the trepanation surgical procedure is considered a drastic measure even today; the risk to the patient would have been considerably higher in a pre-antibiotic age. Nevertheless, 532 Crown trephines are the smaller of the two known trepanning devices from antiquity. Jackson 1995, 194; 2005, 104. 533 Jackson 2005, 103. 534 In his 1995 study of Roman medical instrumentaria in which he categorized various extant surgical instruments by type and number, Jackson concluded that bone surgery and dentistry seem to have been two of the most common specializations of Roman practitioners. See Jackson 1995. 535 Cel. Med. 8.3.2-4 (= Spencer 1938b, 497-9). Also see Jackson 1988, 118; 1993, 92 and Bliquez 2015 38-9 and 185-6. 186 in the Imperial era it seems to have been performed regularly enough that a number of surgical instruments were devised to facilitate the procedure. 536 In the case of trepanation or other types of drastic surgical interventions, it seems unlikely that such procedures would be attempted with any regularity by someone lacking the necessary surgical skills. As noted previously, expiring patients are bad for business; it seems reasonable to presume that most physicians would have preferred to avoid extreme surgeries if at all possible. Certainly, some physicians would have been more skilled at certain procedures than others, but to what degree doctors of the Imperial era could be “specialized” is a question we are still answering. However, the evidence from Rimini, Marcianopolis and Allianoi thus far seems to align with other existing evidence concerning medical specialization and expertise in the Imperial era. Medical Specialization The concept of medical specialization as it is understood in our contemporary era, with its associations of extensive training and highly specific areas of expertise did not – as far as we know – exist in antiquity. By today’s standards, medical practitioners of antiquity could probably be more accurately compared to generalists, some of whom had particular affinities for, and skills adapted to, certain types of medical practices and procedures. However, there is plenty of evidence, both textual and archaeological, that at least some Graeco-Roman physicians developed expertise in and collected instruments suited to specific types of procedures. And in their own time, there is at least some evidence that certain practitioners were identified as 536 For a discussion of the various instrument types involved in trepanation from the Roman period, including the function of bow drill handles and their identification as well as additional extant examples, see Bliquez 2015, 185- 189 s.v. “drills,” Jackson, 2005, 101-10 and De Carolis 2009b, 50-2. 187 medical specialists by their communities. For example, Galen refers to practitioners that conducted procedures in ophthalmology, dentistry, otology and proctology. 537 Celsus references a physician named Euelpides, whom he calls “the most famous oculist of our time.” 538 A first- century C.E. funerary inscription from Assisi dedicated to a physician named Eros Merula specifies that one of his specializations was as a medicus ocularius (eye doctor); a second funerary inscription from the same period records that a physician from the city of Rome, one D. Colius Arsaces, also claimed the specialization of a medicus ocularius. 539 Other epigraphic evidence attests to doctors who were known specifically as surgeons (medici chirurgi), such as the first-century C.E. physician Celadus Antoniae Drusi, ear specialists (medici auricularii) like the first-century medicus T. Iulius Secundus and the second-century medicus T. Aelius Aminias, as well as specialists in the preparation of curative ointments (iatralptes), such as the second- century medicus P. Aelius Epaphroditus. 540 In light of the evidence, it seems that medici ocularii were a broadly recognized category of doctor. 541 Certainly the military seems to have acknowledged this specific distinction in medical expertise, as evidenced by Axius, referred to by Galen as the medicus ocularius for the classis Britannica (British fleet). 542 While the tools of a physician such as Rimini’s Eutyches indicate a specialty in what we may consider trauma and bone surgery, there’s no evidence to suggest that such precisely 537 Gal. Opt. Med. Cogn. 10 (= Iskandar 1988, 116-9). 538 Cel. Med. 6.6.8 (= Spencer 1938a, 196). 539 Eros Merula: CIL XI, 5400 (= Alonso 2018, no. 249); D. Colius Arasces: Alsonso 2018 no. 112; Korpela 1987 no. 31. Other epigraphic examples of medici ocularii include CIL VI 3987, 6192, 8909, 9606, 9607, 9609, 33157 (from Korpela 1987, 82 n. 274). 540 Surgeons (medici chirurgi): CIL VI 4350 (=Alonso 2018, no. 4). Other examples include CIL VI 3986 and 33882 (from Korpela 1987, 82 n. 273); Ear specialists (medici auricularii): T. Iulius Secundus CIL VI 37752 (= Alonso 2018, no. 86) and T. Aelius Aminias CIL VI 8908 (= Alonso 2018, no. 160); Ointment specialists (iatraliptes): CIL VI 8981 (= Alonso 2018 no. 159). For discussions of the epigraphic evidence for these various specializations in the Imperial period, see Alonso 2018, 89-113, Korpela 1987, 81-5, 97-9, 123-5, 135-6, 143-5 and Künzl 1983, 35-7. 541 Whether or not Eros Merula’s skills were commensurate with the specialty he claimed for himself is a question we have no way of answering. 542 Gal. Comp. Med. Loc. 4.8 (= Kühn 12.786 https://scaife.perseus.org/reader/urn:cts:greekLit:tlg0057.tlg076.1st1K-grc1:4.8, accessed 12-17-20). 188 defined categories of specialization were indicated by title. Beyond the delineation between a medicus clinicus (clinical doctor, i.e., one who relies on primarily diet, medicine and regimen prescriptions) and a medicus chirurgus (surgical doctor) that we see in some epigraphic evidence, there’s little to suggest that a surgeon of Eutyches’ skill would have been known as anything other than a medicus or, at most, a medicus chirurgus. 543 From a more pragmatic point of view, the nomenclature used to connote a medical specialty was likely less important to a Roman patient seeking treatment than the practical skills of the physician in question. Rimini Physician As previously discussed in Chapter 2, the astonishingly large collection of medical implements from the Domus del Chirurgo indicates that the Rimini physician, whatever title he claimed for himself, specialized in bone and wound surgery. Included in his extensive instrumentarium were tools used in the difficult and dangerous trepanation procedures described above. In total, nine different trepanation instruments – representing four different types – were identified. These include two folding, copper alloy handles used to operate the bow drills, or trepans (Figs. 4.9, 4.10). 544 The terminal, or handle, of one of these takes on the form of a stylized snake, the symbol of Asklepios, a decorative element that has also been found on a tri-valve uterine speculum and a few other known surgical instruments from the Imperial period (Fig. 4.11). 545 Whether the decorative snake element was meant to call upon the deity’s healing powers or was 543 Maria Ángeles Alonso’s 2018 epigraphic study provides multiple examples of physicians who were referred to as either clinical or surgical specialists. See Alonso 2018, 89-96 (medicus chirurgus) and 103-7 (medicus clinicus); Roy Davies notes that epigraphic evidence from Roman military forts not only testifies to the presence of clinical, surgical and oculist medici, but that it also delineates the various roles of their assistants, such as that of a miles medicus (comparable to a medical orderly) and capsarii (wound dressers/bandagers). Interestingly, some military medical units, such as the First Praetorian cohort, also included a veterinarian (medicus veterinarius). Davies 1989, 214. 544 Jackson 2003, 317. 545 Jackson 2003, 317; Bliquez 2015, 189; Bliquez 1994, 188-9. 189 simply a conceit on the part of the instrument’s creator or commissioner it is impossible to know, but the refined decoration is both functionally unnecessary and more costly, thus reflecting a degree of investment beyond that which would have been necessary for a more basic version. It may perhaps speak to Eutyches’ desire to visibly demonstrate his association with the deity. Three sequestrum (bone) forceps, one with straight and two with curved jaws, were among the trepanation instruments recovered from the Domus del Chirurgo. 546 These devices were primarily used to remove detached or partially detached cranial fragments, though Jackson notes that they could have been used for additional purposes such as the removal of foreign objects from wounds and the clamping of blood vessels. 547 Interestingly, two of the sequestrum forceps (the straight-jawed and one of the curved-jawed types) are believed to have come from the same workshop, as they have identical handle decorations (Fig. 4.12). 548 All three forceps are made of copper alloy, and comprise a very small set of surviving examples of this instrument type. 549 Also believed to have been employed in trepanation procedures were three iron surgical gouges of a type known to us from Galen’s texts but that had never before been identified in a Roman instrumentarium. 550 Similar to standard bone chisels, these gouges have the unusual feature of a very smooth and slight curved outer surface. Jackson identified these as lenticulars, guarded chisels of the type described by Galen for use in a particular method of trepanation. 551 In 546 Jackson 2003, 217-8; 2009, 88. 547 Jackson 2003, 318; Bliquez 2015, 241-2. 548 Jackson 2003, 318. 549 Jackson 2003, 318; Bliquez notes that a small number of other known examples come from Pompeii, Luzzi and Colophon. See Bliquez 2015, 242 n. 688. 550 Jackson 2003, 318; 2009, 88. 551 Gal. Meth. Med. 6.6 (= Johnston and Horsley 2011, 215-23); Jackson 2009b, 88. Also see Jackson 2003, 318 and 2005, 116-7. Paul of Aegina, the seventh-century Byzantine physician whose seven-volume medical encyclopedia has survived, also describes the same procedure being performed by surgeons in his time using the same tools. Paul Aeg. 6.90 (= Adams 1847 vol. 2, 429-33). 190 this procedure, the smooth, curved surface of the guarded lenticular gouge protected the brain as it separated the dense, connective tissue surrounding the brain (dura matter) from the cranium while the cutting edge of the instrument divided the bone. 552 The discovery of these gouges at Rimini is an example of ancient medical texts corroborated by archaeological evidence, an occurrence that is rare enough to be considered extremely fortunate. However, there is yet a third piece of evidence for this particular surgical practice that is rarer still: that of paleopathology. In 1995, a second-century C.E. skeleton of a child, aged 5-6 years and in an excellent state of preservation, was discovered in Castel Giubileo (ancient Fidenae), approximately 10km north of Rome. 553 A forensic osteological analysis of the skull determined that the child had likely suffered from hydrocephalus, a condition which was almost certainly the reason for the trepanation procedure performed as a last resort effort to alleviate the pressure on the child’s brain caused by the excess buildup of cerebrospinal fluid. The procedure was ultimately a failure, as it is clear that the child perished soon afterwards. However, the excellent state of the skull’s preservation allowed scientists to determine that the trepanation procedure undertaken by the local surgeon was the same described by Galen involving the use of lenticular gouges of the type discovered at Rimini. 554 The final item in the Rimini collection believed to have been used as an instrument in trepanation procedures is also the only example of its kind from the Roman era. It is “a composite instrument with a central bronze grip mounting a small, strong, ivy-leaf-shaped iron blade at one end and a broken elevator at the other.” 555 Though nothing like it has ever been 552 Jackson 2009b, 89; De Carolis 2009b, 52; Bliquez 2015, 195-7. 553 Mariani-Costantini 2000. 554 Mariani-Costantini 2000; Jackson 2003, 319; 2005, 116-8; 2009, 89. Two skeletons from Pompeii also exhibited evidence of trepanation procedures, though no trepanning devices have thus far been identified in Pompeii or Herculaneum. Lazar 1996; Bliquez 2015, 187; For a summary of skeletal evidence for trepanation procedures in the Roman era, see Cruse 2004, 187-92. 555 Jackson 2009b, 88; Bliquez 2015, 205. 191 discovered from the Roman period, Jackson notes its similarity to a 17th-century instrument that was used at the beginning of a cranial trepanation procedure, and speculates that the Rimini instrument had a similar function. 556 Though it is impossible to be certain, I see Jackson’s interpretation of the instrument’s use as a reasonable one. The archaeological conditions of the Domus del Chirurgo were optimal in the sense that all the instruments were discovered in-situ and carefully documented. The instruments themselves were recovered in bundles, most of them organized according to type, a circumstance that indicates the Rimini physician stored his instruments in bundles according to function. 557 The site’s excavator, Jacopo Ortalli, reports that the various instruments had “once been grouped inside wooden boxes covered in bronze sheet and tubular specillothecae [cases] found in fragments, or otherwise wrapped in cases of which no trace remains.” 558 The fact that the composite instrument bearing such a striking similarity to the known 17th-century version instrument was recovered in the same bundle with the other eight trepanation tools lends further support to Jackson’s interpretation of the instrument’s function. Including the nine trepanning instruments, the Rimini instrumentarium contained at least 40 surgical tools associated with bone surgery, the comprehensive composition of which gives “the appearance of very careful selection,” implying a determination on the part of Eutyches to assemble a collection that would enable him to address all manner of bone injuries. 559 These include nine bone levers, used for the setting of fractures or dislocated bones, twelve bone chisels of varying size and three double blunt hooks (used to hold skin, muscle and tissue out of 556 Jackson 2009b, 88 and 2014, 141. 557 Jackson 2003, 314; 2009, 86; Ortalli 2009, 33. 558 “…un tempo raggrupati all’interno di cassettine lignee rivestite in lamina bronzea e in specillothecae tubolari, rinvenute in frammenti, o altrimenti avvolti in astucci dei quali non è restate traccia.” Ortalli 2009, 33. 559 Jackson 2009b, 88; Jackson’s 2005 study of bone surgery in the Roman period is particularly useful as it takes into account surgical instruments found in a variety of contexts from across the Empire. It should be noted that some of his provisional assessments of the Rimini assemblage made in this article were revised and/or refined in his 2009 publication, which focused specifically on the Rimini instrumentarium. Jackson 2005, 2009. Also see Bliquez 2015, 14. 192 the way during surgical procedures). 560 Some of these instruments, such as one of the double blunt hooks and one of the chisels, feature very ornate and finely detailed decoration on the handles. Also present in the collection were a total of 19 spring forceps in a range of sizes with jaws of varying types. 561 While these were primarily used for grasping and removing foreign objects from wounds, they could also be employed as arterial clamps to prevent hemorrhaging. 562 Of the 19 examples, only one was made of iron, a rare example of its type since most of the known examples of its type are generally made of bronze. 563 Jackson notes that many of the forceps still had their sliding lock-ring, a circular metal ring that could be slid along the handles to lock the jaws of the forceps closed, thus enabling protracted use or, when not in use, facilitated more orderly storage. 564 Many have fine, interlocking teeth in order to secure a firm grip. 565 Such a feature is essential when trying to extract a projectile point embedded in bone, for example, as the procedure would have necessitated a great deal of applied force. One of the most notable instruments recovered from the Domus del Chirurgo was the device identified as a “Diocles’ Spoon,” a highly specialized instrument for extracting arrow and spear points from tissue and bone (Fig. 2.1). 566 This particular device had long been known from ancient medical literature. Celsus gives us a detailed description of the instrument, which was designed to prevent barbed projectile points from causing further tissue damage in the course of their extraction: 560 Jackson 2009b, 88. 561 Jackson 2009b, 88; For a discussion of forceps, their designs, uses and various extant examples from the Roman period, see Bliquez 2015, 233-49. Also see Chapter 2 of this study for additional discussion of these types of instruments. 562 Jackson 2009b, 88; Bliquez 2015, 235-238. 563 Jackson 2009b, 88; Bliquez 2015, 238. 564 Jackson 2009b, 88; Bliquez 2015, 233. 565 Jackson 2003, 316. 566 De Carolis 2008, 2009a, 2015; Jackson 2005, 98; 2009b, 89; Bliquez 2015, 142-3; Ortalli 2007, 114-5; 2009, 33. 193 “But if it is a broad weapon which has been embedded, it is not expedient to extract it through a counter opening, lest we add a large wound to one already large. It is therefore to be pulled out by the aid of some such instrument as that which the Greeks call the Dioclean cyathiscus…The instrument consists of two iron or two copper blades, one blade has at each angle of its end a hook, turned downwards; the other blade has its sides turned up so that it forms a groove, also its end is turned up somewhat, and perforated by a hole. The latter blade is first passed up to the weapon, and then underneath it, until the point is reached, the blade is then rotated somewhat until the point becomes engaged in the perforation. After the point has entered the perforation, the hooks of the first mentioned blade are fitted by the aid of the fingers over the upturned end of the blade already passed, after which simultaneously the cyathiscus and the weapon are withdrawn.” 567 While scholars of Graeco-Roman medicine had long been aware of Celsus’ text concerning this elusive instrument, an authentic example had never been recovered until the excavation and analysis of the Rimini instrumentarium, when Jackson and his colleague, Stefano De Carolis, positively identified an instrument as being one half of the Diocles’ Spoon device described by Celsus. 568 In his 2009 study of the object, De Carolis notes that though the second half of the instrument (a blade with a hook on either end) is missing and was likely destroyed in the fire that collapsed the building, the extant piece conforms to the description given by Celsus “almost to the letter.” 569 I suggest that the fact that the Rimini collection represents the first archaeological confirmation of the Diocles’ Spoon known from Celsus’ text is more an indicator of the myriad destructive circumstances that could befall small iron or bronze artifacts from antiquity, as well as the general dearth of medically related, non-sepulchral archaeological sites, than it is of the instrument’s rarity in the Roman era. The tool and the procedure performed with it was evidently common enough in the first century C.E. that it warranted an entry in Celsus’ medical encyclopedia. The fact that a frontier surgeon was employing the same instrument to 567 Cel. Med. 7.5.3 (= Spencer 1938b, 319-21). 568 De Carolis 2008, 2009a, 2015; Jackson 2005, 98; 2009, 89. 569 “…la conformazione generale dello strumento si adatta pressoché alla lettera descrizione fattane da Celso.” De Carolis 2009a, 45-6. 194 perform the same procedure almost 200 years later suggests that the practice was fairly widespread, particularly given that the martial volatility of frontier life would have offered surgeons ample opportunity to develop an expertise in projectile point removal. In fact, given the types of injuries that military surgeons in particular would have addressed on a regular basis, it is hardly surprising that bone surgery in general seems to be the most common type of specialist medical expertise. 570 While I suspect that Eutyches was probably not unusual when it came to his use of a Diocles’ Spoon, the extraordinary number of surgical instruments in the collection used in bone surgery does seem to indicate an unusual depth of surgical expertise; there is no evidence that trepanation, and the tools to perform it, were part of the standard repertoire of the average Roman medicus. Likewise, the extraordinary number and variety of scalpels in the Rimini instrumentarium indicate a surgical skill set beyond the mitigation of bone injuries. Over 30 intact scalpels with bronze handles and iron blades were recovered from the Rimini site, in addition to 10 bladeless handles and 17 detached iron blades. 571 Jackson observes that this collection represents “at least ten distinct forms, few of which have been encountered before.” 572 Among these is a scalpel of the type described by Galen to be used in the opening of the vertebral canal, which, according to his text, was an instrument that he invented himself. 573 If this is indeed an example of the type of scalpel Galen devised for spinal dissections, then this indicates that not only did the knowledge of such procedures and their related instruments transmit from Galen in the second-century C.E. to his professional descendants a century later, 570 Jackson’s 1995 and 2005 surveys of the known Roman instrumentaria demonstrate that “instruments for bone surgery are the commonest “specialist” component in the largest, apparently complete Roman instrumentaria.” Jackson 2005, 103. Also see Jackson 1995, 196-9 (Tables 1 and 2). 571 Jackson 2009b, 87. 572 Jackson 2009b, 88. 573 Gal. De anat. admin. 8.6 (= Singer 1956, 214-5); Jackson 2009b, 88 and 2014, 141. 195 but that the Rimini surgeon himself may have performed such procedures. It is not difficult to imagine that the types of injuries sustained in armed conflict could have necessitated the delicate procedure to remove spear or arrow points from the spinal column of unfortunate soldiers. Though the majority of the instruments from the Rimini collection indicate extensive expertise in bone surgery, other scalpels in the instrumentarium indicate that the medicus most likely performed other, unrelated surgical procedures to address common conditions that could affect soldiers and civilians alike. Three very small, fine blades were identified as instruments used to remove pterygium growth from the eyes as well as to address trichiasis (a condition in which eyelashes grows inwards toward the eye). 574 Two other blades were identified as being of the type “called from its shape ‘the raven’” that were recommended by Celsus to open the scrotum in order to repair severe hernias. 575 Another pair of scalpel blades are believed to be of the type described by Paul of Aegina for use in tonsillectomies, while two others fit Galen’s description of the types of scalpels he recommends for the dissection of the thorax, which feature a convex blade on one side and a concave blade on the other. 576 A total of eight dentistry tools were identified in the collection, seven of which were specialized iron dental forceps of graded size, each with extremely strong offset jaws, the ends of which were found to be very precisely notched in order to grip a tooth as firmly as possible. 577 The eighth dental tool was a small iron file with very fine striations. 578 Such instruments were used to remove tarter, file down projecting teeth and smooth the jagged edges of broken teeth. 579 574 Jackson 2009b, 88; Bliquez 2015, 91-2. Bliquez notes that these very small, fine blades could also have served as suture knives, employed to sew the edges of a wound together. Bliquez 2015, 90. 575 Cel. Med. 7.19.7-8 (= Spencer 1938b, 404-5); Jackson 2009b, 88 and 2014, 141; Bliquez 2015, 87-8. 576 Paul Aeg. 6.30 (= Adams 1847 vol. 2, 297); Gal. De anat. admin. 8.4 (= Singer 1956, 210); from Jackson 2009b, 88. Also see Jackson 2014, 141 and Bliquez 2015, 78 (concave/convex blades) and 102-3 (tonsillectomy scalpels). 577 Jackson 2003, 319-20; 2009, 89. 578 Jackson 2009b, 89; Bliquez 2015, 201. 579 Jackson 2009b, 89; Paul Aeg. 6.28 (= Adams 1847 vol. 2, 294). 196 Other instruments used to conduct lithotomies, hemorrhoidectomies and uvulectomies were also identified in the Rimini assemblage, as well as spoons for debriding wounds, needles for wound suturing, a variety of hooks used to retract skin, muscle and/or tissue during surgeries and a number of probes, used to assess the nature of a wound or injury. 580 In an instumentarium of approximately 150 surgical implements, one might expect that there would be some duplication, particularly if there were more than one practitioner working in the medica taberna. Given the size of the collection, the possibility there were two or more medici working together is not unreasonable. However, Jackson’s observation that there are “virtually no duplicates” in the Rimini collection seems to indicate that the entire set belonged to a single practitioner who not only had the financial means to acquire such an extensive set of tools, but who was also meticulous and deliberate in choosing the pieces he assembled and took care to store them in an orderly and organized manner. 581 He was wealthy, but not wasteful; the Rimini instrumentarium is no haphazardly acquired collection, but rather reflects a practitioner who invested significantly but also strategically in order to maximize the range of procedures he was able to perform. The variation and broad range of sizes and designs represented in the collection of scalpels and forceps, for example, suggest a deliberate effort to be prepared for almost any surgical contingency. In addition to surgical expertise, it is clear from the evidence recovered from the Rimini site that this practitioner also relied on medicines to address his patients’ conditions. To call him by the modern term “pharmacist” risks giving the impression that the practice of medicine and the practice of pharmacology were fields as distinct from one another in antiquity as they are 580 Jackson 2003, 320; 2009, 87-9; Bliquez 2015, 100 581 Jackson notes that the instruments were stored in groups or bundles according to their function, and the care taken by their owner is evident in details like the fact that the spring forceps were all in their “closed” position with their lock rings (those that survived) engaged. Jackson 2003, 316. 197 today. However, the number and types of objects recovered from the Domus del Chirurgo that relate to the manufacture and dispensing of medicinal substances make it clear that Eutyches employed pharmacological treatments as part of his practice. Seven mortars and pestles of graded sizes and two copper scales used for the preparation and weighing of drugs were among the objects identified at the site, as well as a number of scoops and spoons used to dispense and/or apply them. 582 Also identified were the remains of several metal drug boxes as well as the fragments of ceramic containers. Two of the latter category were inscribed in Greek lettering with the names of known medicinal substances (ΧΑΜΑΙΔΡΥΕ, ΑΒΡΟΤΟΝΟΥ, Fig. 4.13). 583 The first (camedrium in Latin) was recommended by Dioscorides used as an astringent, an antivenom, to alleviate chest congestion and to stimulate healing in torpid ulcers. 584 The second (abrotonum in Latin), was recorded by Dioscorides and Pliny the Elder as somewhat of an all- purpose medication that had a wide variety of therapeutic uses and was employed to treat inter alia asthma, convulsions, constipation, sciatica pain, eye inflammation, coughs, parasitic infections and as an anti-venom treatment for certain types of snake and spider bites. 585 In the context of surgery, De Carolis, himself a medical doctor, notes that camedrium (classified today as Teucrium Chamaedrys) has demonstrated antibacterial properties and is a component in medications used to treat septic sores and ulcers as well as skin infections, while abrotonum (Artesmisia Abrotanum) has properties that would have been useful for helping to stimulate healing of lesions and abscess, and that it is used today in the treatment of some conditions associated with tuberculosis and rheumatism. 586 582 Jackson 2003, 321; Ortalli 2000c, 516; 2009, 32-3; 583 De Carolis 2009b, 55. 584 Dsc. 3.98 (= Beck 2017, 225-6); De Carolis 2009b, 55; Jackson 2003, 321. 585 Dsc. 3.24 (= Beck 2017, 189) Plin. HN 21.92 (= Jones 1951 vol. 6, 275-7). 586 De Carolis 2009b, 55-6. De Carolis also notes that the plant (Artemisia abrotanum or “Southernwood”),which is a species in the sunflower family, contains an alkaloid that has a therapeutic function similar to quinine. De Carolis 2009b, 55 n. 52. 198 In addition to the ceramic jars, a number of glass containers were found in the Orpheus Room. Based on their size and archaeological context, these glass vessels, most of which had been melted by the heat of the fire that destroyed the domus, are presumed to have been medicine jars in which ointments and medicinal substances were stored. 587 The presence of a substantial number of objects used in the preparation and storage of medicines, in addition to the foot- shaped ceramic vessel used to alleviate the symptoms of foot ailments such as joint disease or gout, demonstrates that the Rimini physicians considered medicinal substances and other therapeutic treatments to be an important part of his medical arsenal. Given the range of conditions that the two known medications in his dispensary could be used to address, it seems likely that he treated other medical conditions in addition to those that required surgical interventions. As a collection, the surgical and pharmacological objects recovered from the Rimini site represent the most comprehensive medical assemblage belonging to a single practitioner ever discovered from the Roman period and demonstrates the physician’s ability to address a wide variety of medical conditions. They also suggest a very deliberate and thoughtful acquisition process, conducted with an eye toward maximizing the types of treatments that could be performed by selecting tools and substances that were versatile in their uses when possible while avoiding duplications. When considering the methodically assembled instrumentarium of finely made instruments acquired by Eutyches, as well as the undisturbed archaeological context in which they were found, it seems likely that the absence of gynecological instruments reflects a 587 Jackson 2003, 321; De Carolis 2009b, 58. Small glass vessels were common containers for ointments and medications as well as perfumes. In the absence of analyzable residue, it is often archeological context that determines their functional interpretation. In the case of the Domus del Chirurgo, I believe we are on solid ground in assuming that these containers were used for medicine storage. For comparable examples from Pompeii, see Ciarallo 2004, 96. 199 deliberate choice on the part of the practitioner rather than an inability to acquire the relevant tools. Why he chose not to practice gynecology is a matter of pure speculation, but it is evident from his refined and expensive domus that this physician had no financial need to increase his medical repertoire beyond the skills represented by his instrument collection. Whether he did not know how to practice gynecology or did not care to is something we cannot know, but it is clear that he had no economic need to expand his practice to include this particular medical specialty. The town’s population evidently provided him with enough business within his area of expertise that he had no need to extend his practice into other areas. As a surgeon specializing in traumatic injuries who likely had spent at least some part of his career in the military medical corps, with an established practice in a city that was relatively close to the Empire’s northern frontier, it seems probable that Eutyches would have had soldiers among his patients as well as civilians. As discussed in Chapter 2, though Ariminum was technically well south of Rome’s cartographical frontier, the border instability of the third- century C.E. meant that the incursions of the Germanic tribes into Rome’s territory brought the fighting perilously close to Ariminum in the years prior to the city’s ultimate destruction around 258-260 C.E. Though they may well have received provisional medical treatment closer to the battle locations, it is not difficult to imagine that wounded soldiers retreating from the front along the Via Flamina would have sought more extensive treatment once they reached the relative safety of Ariminum, particularly in cases of infection, broken or fractured bones, or wounds that needed additional treatment. Furthermore, Ariminum’s role as a bustling port city meant that a portion of its urban population would have been involved in agricultural, manufacturing and transport activities, while still others would have worked at the port itself, loading and unloading goods, repairing ships and any number of other related tasks involving heavy machinery, tools 200 and animals. 588 All of these various occupations entailed the risk of serious accidents and injuries that would have required the attention of a physician with Eutyches’ skills. 589 The occasional accident at sea meant that an incoming foreign sailor may have sought out the expertise of the Rimini physician, who in all likelihood was able to speak both Latin and Greek and may well have spoken other languages and dialects learned in his travels. 590 These skills may have given him a professional advantage in the cultural melting pot of a Roman port city. Marcianopolis Physician The Marcianopolis physician likewise may have earned at least some of his income treating gladiators, though again we know little about the city’s amphitheater beyond its general capacity, which at approximately 3500 spectators was less than half the size of the one in Rimini. 591 Like Rimini, we have no information concerning the types of games or the frequency with which they were held around the era of the city’s destruction in the mid-fifth century C.E. 592 Furthermore, by the time the Marcianopolis physician was practicing, gladiator games had been officially prohibited for over 100 years, so it is unlikely that events in the arena would have provided a steady stream of patients to his practice. 593 However, also like Rimini, Marcianopolis’ geographical location and its function as a staging area for many of the region’s military campaigns in the fourth and fifth centuries meant that the city would have seen its fair share of 588 Jackson 2009b, 89. 589 Gladiator games, if indeed they occurred in Rimini in this period, may also have been a possible revenue source for a surgeon such as Eutyches. See Chapter 2 of this study. 590 Ortalli makes an excellent case for the Rimini physician’s origins in the Greek East. See Ortalli 2009, 37-8; 2000c, 517-8. That fact that the grafitto found in the cubiculum was written in Latin indicates that that language was the one used by at least some of his patients, with whom he was presumably able to effectively communicate. 591 See Chapter 2 of this study. 592 Gladiator games were officially banned by the Emperor Constantie in 325 593 The emperor Constantine first prohibited gladiator games in 325 C.E. Cod. Theod. 15.12.1; Cod. Iust. 11.44. OCD 617-8, s.v. “gladiators.” 201 wounded soldiers coming back from the front. A physician with expertise in addressing traumatic injuries and broken bones would have likely found that his skills would have been much sought after in fifth-century Marcianopolis. Compared with the extensive Rimini instrumentarium, the Marcianopolis collection does not contain a comparable number, or range, of surgical implements specifically adapted to bone surgeries. Nevertheless, it is clear that its owner had experience in this area of medicine as well as several others, and that he was financially successful enough to acquire not only a number of sophisticated, difficult-to-make objects, but also invest in instruments that were expensively decorated. Thus, the frustrating lack of archaeological context for the instrumentarium can be partially made up for in an examination of the objects themselves. We may never know the complete story surrounding the Marcianopolis physician and his practice, but his instruments allow us to reach at least a few conclusions concerning his expertise and socio-economic status with a reasonable degree of confidence. The inventory of the instruments reported by the site’s excavator, Alexander Minchev, represents at least some expertise in ophthalmology, gynecology and the treatment of wounds and bone injuries. 594 Furthermore, at least three of the instruments were identified as those used in lithotomy procedures to remove stones from the bladder and kidneys. One of these, a bifurcated lithotomy scope, shows evidence of having been modified after its initial manufacture; the tool has an additional curve that was added to the handle, possibly to facilitate insertion into the urethra by the practitioner according to his own technique, or to conform to a specific patient’s anatomy or condition. 595 Also recovered were the remains of at least two pair of 594 Minchev 1983, 2016. 595 Minchev 1983, 145. This is an example of a specially modified tool, though of course we cannot know if the modification was done by the Marcianopolis physician (or at his request) or if he acquired the instrument in its modified state. 202 forceps, three bronze scalpels/dissectors, a hook, two needles, a bone lever, a bone drill and at least two fragments from instruments known to have been used in trepanation procedures: a bronze bow, employed as the lever with which a cranial drill was rotated, and a ruler to determine the size of the hole needed for the procedure (Figs. 4.14 and 4.15). 596 Several of these instruments likely had a variety of uses. For example, Nadejda Kirova, who published a study of some of the Marcianopolis instruments in 2002, suggests that the large hook, which measures 17cm in length, could have been used as a retraction tool during surgeries but also as an extraction device to remove stones during lithotomy operations. 597 Finally, a number of objects associated with the preparation and storage of medicines were also recovered. These include a bronze pestle used to grind mineral substances into powders, a cylindrical box with a lid used to store drugs, a large, bronze carafe-shaped bottle (used to store solid and liquid medicines, respectively) and two whetstones, which were used to sharpen scalpels and needles. 598 While the Marcianopolis collection may not be nearly as large as that of Rimini, the quality and decoration of many of the instruments, in addition to being superlative examples of metallurgical craftsmanship, attest to the physician’s penchant for objects of beauty as well as function. For example, the bronze trephine bow features an intricate decorative motif composed of “shaped balls and rings and an elegant spiral curve on the short plate.” 599 The workmanship of another trepanation instrument, a long, slightly curved drill is described by Kirova as 596 Minchev 2016, 232-3; See discussion in Chapter 2 of this study for further details of the surgical instruments specifically designed to address traumatic injuries. 597 Kirova 216, 76. 598 Minchev 2016, 233. The functions of these and other objects from the Roman Imperial period have been thoroughly studied and reliably attributed. The most comprehensive and up-to-date study to date is Lawrence Bliquez’s impressive compendium of all the known types of medical and pharmacological tools and objects from the Graeco-Roman period (Bliquez 2015). 599 Kirova 2002, 86. 203 “exquisite.” 600 The two needle handles recovered from the site were found to be decorated with inlays of precious metals. One bronze handle of an ophthalmic needle was noted to be “inlaid with floral and geometric-shaped gold thread,” while the second, the bronze handle from a double needle instrument (of which the iron needles themselves were not recovered) is “a masterpiece of Roman bronze work.” 601 The delicate piece was incised with a finely wrought floral motif, which was then inlaid with silver. 602 A third instrument decorated with precious metals is that which had been tentatively identified by Minchev as the aeneum spiculum, a rare gynecological tool mentioned by Tertullian as being used to assist in medically necessary abortions. 603 According to Tertullian, an aeneum spiculum was a highly specialized tool that was used to puncture the cranium of an impacted fetus in the event that it could not be safely delivered. 604 While the instrument’s fragmentary nature precludes a definitive consensus as to its exact function, the elaborate inlay decoration of silver and electrum rings attests to its unquestionable value and craftsmanship. 605 The Marcianopolis physician’s expertise in gynecology evidently was such that it justified the inclusion of such sophisticated instruments. While gold and silver inlays are indisputable signs of value, instruments lacking elements made of precious metals could nevertheless be finely decorated, and even an object with no visible decoration at all can be safely recognized as valuable by the high-quality of the craftsmanship. An example of this from the Marcianopolis instrumentarium is the three- 600 Kirova 2002, 86. 601 Kirova 2002, 91; Minchev 2016, 232. 602 Minchev 2016, 232. 603 Tert. De Anim., 25. 604 Tert. De Anim., 25. Lawrence Bliquez notes that while Tertullian does not offer a description of the aeneum spiculum, its name is indicative of its form. Since the spiculum at Marcianopolis was found accompanied by a gynecological speculum, Bliquez concedes that it may have had the gynecological applications suggested by Minchev. However, Bliquez goes on to suggest that “Tertullian’s aeneum spiculum was not a special tool at all but merely an appropriate lancet or scalpel,” of which the Marcianopolis tool is an example. Bliquez 2015, 256. 605 Minchev 1983, 146; 2015, 233; Kirova 2002, 84. 204 component (tri-valve) vaginal speculum, described by Minchev as “highly elaborate” in its construction, and a “masterpiece of the Roman bronze craft” (Fig. 4.16). 606 Specula, while well- attested to in primary source literature as valuable diagnostic instruments, are very rarely found in archaeological contexts. 607 The complexity of their construction meant they were difficult objects to make. Locating a craftsman skilled enough to manufacture one would have been a significant obstacle for a physician, as would the cost of its purchase. As a result, vaginal and rectal specula as well as other complex instruments were likely handed down from generation to generation and are rarely found among the medical implements recovered from physicians’ tombs. 608 Like the example at Marcianopolis, the known extant examples of specula come primarily from archaeological contexts in which cataclysmic events presumably prevented their owners from retrieving them, such as the three examples recovered from Pompeii. 609 Given the seemingly rare and expensive nature of specula, it is possible that less well-off physicians and midwives who treated women for gynecological issues did so using more rudimentary methods and devices to facilitate dilation. There is some uncertainty as to the function of a second, bi-valve speculum (catopter) recovered from Marcianopolis. In his evaluation of the instrument’s short shanks, Minchev concluded that it could be a rectal speculum, known from primary source literature as a device recommended for use in the treatment of hemorrhoids and fistulas (Fig. 4.17). 610 However, Minchev also speculated that it may have been used as a wound dilator, a device described by 606 Minchev 2015, 232-3 607 The earliest known reference is found in the first/second century physician Soranus of Ephesus’s treatise on gynecology. While much of the text survives, the relevant chapter is missing. However, it is paraphrased by the fifth century Latin writer Muscio. Rose 1882, 117-119. 608 Kirova 2002, 82. 609 To date, there are only eleven known examples of gynecological specula from the Roman period, including the one from Marcianopolis. Three of these are from Pompeii. See Bliquez 2015, 253. 610 Paul Aeg. 6.78 (= Adams 1847 vol. 2, 399-401); Minchev 1983, 119; 2016, 232. 205 Celsus for use in the extraction of weapon points, an example of which has yet to be conclusively identified. 611 Kirova argues against Minchev’s interpretation, asserting that the speculum’s function as a wound dilator is “impossible,” and that the object’s smaller size alone cannot be proof of its function as anything other than a vaginal speculum. 612 She asserts that this second speculum is simply a vaginal speculum of a different size and type, stating that “all of the instruments of the Marcianopolis set speak for a physician [who is] a specialist in healing gynaecological and urinary system diseases and not for a specialist of bone traumas.” 613 This is a puzzling position to take, since her own study includes a mention of the trepanation bow and bone drill from the Marcianopolis instumentarium. 614 These instruments, along with the bone lever identified in the collection, clearly indicate that while he may not have had the level of expertise – or at least the range of instruments – of the Rimini physician, the Marcianopolis physician did indeed treat bone injuries in addition to other types of conditions. 615 Rather than siding with Minchev or Kirova, I see no reason why this speculum could not have been used in a variety of ways, depending on the necessity of the situation. After all, as Jackson points out, “the function of the speculum was simply to hold apart the walls of a cavity, and, as with so many other Roman surgical instruments, that function might be adapted to a number of different operations.” 616 Both specula could have been employed as vaginal, rectal, or wound dilators as the patient’s condition and physiology warranted. The inclusion of two 611 Cel. Med. 7.5.2 (= Spencer 1938b, 317); Minchev 1983, 119; 2016, 232. For a study of Roman bivalve studies and the literary evidence for the wound dilator described by Celsus, see Jackson 1991. 612 Kirova’s explanation of why she believes Minchev’s identification to be impossible is somewhat unclear. She supports her argument by stating that “no ancient author speaks for utilization of a specialized instrument with unspecified function [sic].” She may have been unaware of the description of such an object in Celsus’ writing, though this seems unlikely since Minchev refers to it in his report. Kirova 2002, 78. 613 Kirova 2002, 80. 614 Kirova 2002, 86. 615 Kirova’s study makes no mention of the bone lever that Minchev clearly indicates was present in the instrumentarium. See Minchev 1983, 120; 2016, 233. 616 Jackson 1991, 105. 206 different types of dilators suggests that, similar to the Rimini physician, the owner of the Marcianopolis instrumentarium carefully selected his instruments with an eye toward maximizing the versatility and range of procedures he was able to perform. Though neither of the specula were reported as having decorative features, the presence of such sophisticated instruments in the instrumentarium indicates a significant investment, as does the precious metal inlay decoration of several of the other pieces. Interestingly, several of the high-quality pieces in the collection date from the third and fourth centuries, which would have made them approximately 100-200 years old at the time they were buried by the mid-fifth century collapse of the building from which they were recovered. 617 This, along with the “diversity, complexity, technical and artistic craftsmanship, and the sheer number of objects” from Marcianopolis has led Dan Aparaschivei to conclude that “we are dealing with a medical practitioner’s office that had functioned at least since the third century” and that “this place probably facilitated the professional activity of numerous physicians, under the tutelage of the city.” This, he concludes, “would explain the transmission of objects over several generations, the variety of operations that could be made (from ophthalmologic to gynecological operations, from very simple to very complex surgery) and, last but not least, their high material value for the period in question.” 618 While the collection is indeed impressive, the available evidence is simply insufficient to support Aparaschivei’s thesis that the structure in which the instruments were recovered was the site of a medica taberna that had been in continuous operation from the third century until its 617 Minchev’s reports are not specific as to which objects have been precisely dated. He mentioned only that though they were recovered from a site that dates to the mid-fifth century, “most” of the instruments “were produced much earlier – in 3 rd or 4 th c. AD.” Minchev 2016, 233. Aparachivei likewise does not give specifics but states that “the instrumentation is typical of the third century AD.” Aparaschivei 2010, 147. Kirova dates the scalpels and the larger speculum in the Marcianopolis collection to the fourth century C.E. Kirova 2002, 74, 83. 618 Aparaschivei 2010, 147-148. 207 destruction in the middle of the fifth. My view is rather the opposite: given the dynamics of the region, and the regularity with which Marcianopolis was impacted by Gothic invasions, it is highly unlikely that the same building would have served as a medical practice for 200 years. There is no supporting epigraphic or primary source evidence for the notion that there was any sort of school or physician’s training center in the city and no evidence for these institutions being in continuous operation for such a long period of time. It seems probable that this particular physician acquired the older instruments, either through purchase or perhaps as heirloom objects passed down through his family if he was a member of a family for whom the medical profession was an established family trade. However he may have acquired them, the high-quality of these instruments made them useful and valuable additions to the instrumentarium of a skilled general practitioner. Based upon his examination of these finds, Minchev believes that Marcianopolis was an important medical center, where “there lived and practiced highly educated professionals, who performed very sophisticated and surgical operations [sic].” 619 Minchev’s and Aparaschivei’s conclusions regarding the relatively sophisticated nature of surgical interventions represented by the instruments are reasonable. Certain instruments, such as those used for trepanning procedures, are easily identified. Not only are they described in extant primary source literature, but also, they are clearly the antecedents of instruments still used in modern operating theaters. 620 Furthermore, such instruments are generally not found among the smaller, portable medical kits such as those recovered from the Piazza del Anfiteatro in Pompeii and Herculaneaum, and which are generally associated with the most basic of practitioners. 621 619 Minchev 2016, 232. 620 Celsus, Med. 8.3-4; Galen MM; Oribasius Coll. Med. 46.11.11; Bliquez 2015, 185-89. 621 Bliquez 87-8; De Carolis 1993; Manjo 1975, 355. 208 Could it be that Marcianopolis, with the Asklepian associations of its bath complex and the presence of physicians, was a smaller version of Allianoi, functioning as a center of healing and treatment? With the scant evidence from Marcianopolis that we have on hand, it is impossible to know. There is no reference to Marcianopolis in primary source literatures that would indicate it had a reputation as a health center, though admittedly there is little extant primary source literature that mentions Marcianopolis at all. The same is also true of Allianoi and yet it is clear that Allianoi did have a rather robust medical culture. However, as intriguing as the suggestion may be, I believe that such a scenario is improbable for Marcianopolis. After all, as discussed previously in this study, many bath complexes featured images of, and even temples dedicated to, Asklepios and Hygieia. Like these bath complexes, I would suggest that the degree of surgical and medical expertise represented by the Marcianopolis finds were possibly the norm, rather than the exception, for similarly sized towns in the Imperial period. Certainly, there’s no indication that Rimini was particularly known for its medical culture, and the Rimini medicus was even more well-equipped for his craft than his counterpart in Marcianopolis. Caution should therefore be exercised when considering the overall scarcity of civilian, non-sepulchral sites with medical finds and associations. I suggest that this scarcity is far more likely to be a result of historical and archaeological circumstances (and luck) than it is an indication of the general paucity of specialized, skilled practitioners in the Imperial period. When we are lucky enough to find such a site, it is not necessarily an indication that such practitioners and the places where they worked were as exceptional and rare as the small number of such sites might suggest. Evidence of such practitioners need not indicate that the town in which they practiced had any particular medical associations or economies. For example, of the 11 known examples of uterine specula from the Roman period, three of these are from Pompeii, 209 a city that has been extensively studied. 622 Yet there is no evidence to suggest that Pompeii was particularly noteworthy as a site frequented by patients seeking healing for illnesses or injuries – the presence of the specula are more easily explained by the fact that they likely represent the types of instruments that were typically to be found in the collections of at least some of the medici practicing throughout the Empire. The rarity of such objects in contemporary times may be more easily explained by several different factors. Bronze objects from antiquity are relatively rare in general, since such objects were often melted down and the bronze re-used for the manufacture of other objects. 623 Furthermore, high-quality medical implements that required particularly skilled craftsman to fabricate them were undoubtedly difficult to come by, particularly in the later Imperial period when the Empire’s socio-political instability seems to have had a deleterious effect on workshops and production. 624 This latter circumstance may explain why the Marcianopolis instrumentarium contained objects that were 100-200 years older than the site at which they were found; a physician who valued quality craftsmanship may have deliberately sought older objects in the event that contemporary versions of equivalent quality were difficult to obtain. In cases such as the Rimini and Marcianopolis sites, I suggest that we have examples of what may have been the norm in terms of medical practices, expertise, and tools in the Imperial period. Without additional evidence, I see no reason to presume that these cities represent major medical centers or destinations for health-seeking travelers. Nor do I think it likely that either city, unlike 622 Bliquez 2015, 251-5. 623 The practice of melting down metal objects from the Graeco-Roman period and reusing the material is well documented and occurred even in antiquity. Plin. NH 34.30 (= Henderson 1952, 150-1). Greenhalgh 1989, 234-6; Mattusch 2014, 14-7; Heinzelmann et al. 2018. 624 Jongman 2007; McCormick 2003, 25-119. 210 Rhodiapolis, featured medical “schools” or had particular reputations as centers of medical learning, as has also been suggested. 625 Allianoi Compared to Rimini and Marcianopolis, in the case of Allianoi, we are both more and less fortunate when it comes to evidence. We are more fortunate because of the sheer number of recovered objects that the site’s excavators have suggested are medical in nature; in total, Daniş Baykan’s 2012 report lists 348 surgical implements and other medically related items. 626 As significant as the Rimini and Marcianopolis collections are in number and quality, the Allianoi collection has the potential to dwarf them both when it comes to the quantity of medical instruments recovered from a single site. We are also fortunate in that the site of Allianoi effectively contains multiple “sub-sites” of medical loci, as opposed to a single domus or medica taberna. In other words, with Allianoi there is the potential not only to understand the expertise of a particular physician or groups of physicians, but also gain some insight into an entire medical economy (see discussion in Chapter 3 of this study). Unfortunately, the lack of detailed site plans in the report make it difficult to assess the exact provenance of many of the objects listed in the catalog and this type of contextual information can be critical when it comes to the accurate identification of the objects. Some of the items listed in Baykan’s catalog are in such fragmented condition that it seems impossible to identify them without their contexts. These include the five bronze fragments identified as 625 For the assertion that Marcianopolis was a “leading center of practical and theoretical medicine,” see Minchev 1983, 148; For similar arguments, see Minchev 2016, 232-3 and Aparaschivei 2010, 147-8; Lorenzo Braccesi asserts that Rimini was the site of a renowned school of medicine, a position that Ortalli convincingly argues against. See Braccesi 2008, 39-62 and cf. Ortalli 2008. 626 Baykan 2012a. 211 “probe covers,” but which, judging from the limited descriptions, photographs, and drawings, could be fragments from almost any bronze object. 627 The object identified as a “cupping container” is likewise suspect. Its fragmentary condition notwithstanding, the lip of the bronze vessel does not slope decidedly inwards like the vast majority of extant examples (Fig. 4.18). 628 Though the possibility that this particular object was used as a cupping vessel cannot be definitely ruled out, it seems at least equally likely that this particular object could have had any number of uses unrelated to medicine. Other objects, such as those identified as needles as well as a significant number of spoon-probes and hook-shaped tools, are typical of basic medical implements but could also have had a variety of non-medical uses. 629 It is in cases such as these that understanding the precise archaeological context in which they were recovered plays such an important role in their correct identification. Small, slender spoons were indeed used in medical procedures, as were hook-shaped tools and needles, but all of these objects could have also been employed in a variety of other household and commercial activities, such as cooking, sewing, the mixing or applying of cosmetics, etc. Information such as what other types of objects were found with or near these items and the type of structure or space in which they were discovered is missing completely from the description of most of these artifacts. If, for example, a needle, a spoon, and a hook were found grouped together with a pair of forceps and a scalpel, then this significantly increases the likelihood that they may have been pieces in one of the basic medical toolkits discussed earlier in this chapter. On the other hand, if the same items were recovered in a room in which other objects related to sewing, weaving, cooking or cosmetics were also identified then 627 Baykan 2012a, 156-7 nos. 345, 346 and 347. 628 Baykan 2012a, 157 no. 348. For securely identified comparanda see Bliquez 1994, 108-12 and 2015, 386-7. 629 Baykan 2012a, 71-88 nos. 1-69 (spoon probes), 100-16 nos. 112-181 (hook-shaped tools), 140 nos. 277 and 278 (needles). 212 the interpretation of their function would change significantly. It is for this reason that the lack of detailed sites plans and descriptive information concerning the archaeological context of each of the 348 objects listed in the catalog is so problematic. Such circumstances make it impossible to independently confirm or dispute Baykan’s assertion that all of these items are medical in nature. As a result, until such a time as additional information is made available, we cannot say with certainty the true number of medical implements recovered from Allianoi by the team from Trakya University; it is almost certainly less than 348. However, there are enough clearly identifiable tools and archaeological contexts that Allianoi can still be considered one of the most remarkable sites of civilian medicine from the Imperial era. And though we may not have as complete a picture as one might like for the medical activities at Allianoi, Baykan has provided us with enough information that we are able to understand at least some of the various types of medical expertise represented by the town’s physicians in the middle of the third century C.E. As noted in Chapter 1 of this study, the information provided by Baykan’s site report is more detailed when it comes to the northern locus, a building located immediately west of and adjacent to the thermal bath complex in the northern quarter of the town. It was in this building where approximately 65 medical implements were recovered, many of which were distributed throughout several rooms according to type. For example, the instruments from room B4 include forceps, spatula probes and an rectal speculum, all of which indicate procedures such as uvulectomies and hemorrhoidectomies. 630 The small and finely crafted hooks, spatulas, scalpels and needles recovered from room B5 are indicative of ophthalmology, while the lithotomy instruments identified in room B7 make it clear that those types of procedures must have taken place with some degree of regularity. 631 And while the suture forceps and needles found in room 630 See page 37 of this study. 631 See page 37 of this study. 213 C1 (north of and immediately adjacent to B7) could have been used in other, non-medical contexts, the room’s proximity to the other chambers in which the objects were clearly medical in nature make it likely that objects recovered from C1 were likewise employed by medical practitioners. Though other, more identifiable objects in the vicinity were not recovered in such neat and precise groupings and contexts of those in rooms B4, B5, B7 and C1, their presence is representative of certain other types of medical expertise. For example, the small, bronze double- sided serrated saw (serrula) and the bronze and iron bone elevator handle recovered from the vicinity of the rooms in which the other instruments were found are indicative of bone surgeries (Fig. 4.19). 632 Oribasius describes a saw like the one identified in Allianoi as a tool employed by physicians to remove diseased sections of bone, while Celsus indicates its use in amputation procedures. 633 Bone elevators were commonly used to set fractured and broken bones, functioning as levers that allowed the physician to manipulate the displaced bones into the correct position before applying a splint and/or bandages. 634 Located near these objects, excavators also recovered a pair of hemostatic forceps, one of the few known examples from the Roman period (Fig. 4.20). 635 Though the exact location where these instruments were recovered is unknown, their presence in the vicinity seems to indicate either that surgical interventions took place here, or that tools for such procedures were sold - and perhaps also manufactured – in this complex. Of course, it is also possible that both circumstances existed simultaneously. 632 Both objects were recovered in the northern building complex. Baykan 2012a, 152 no. 323 and 154 no. 335; Baykan does not identify the bone elevator handle as such in his catalog. This interpretation was assigned by Bliquez. (Bliquez 2015, 204 n. 518); For examples of comparanda and primary source literary references see Bliquez 2015, 184 (saw) and 202-5 (bone elevator). 633 Oribasius Coll. Med. 44.20.18; Cel. Med. 7.33 (from Bliquez 2015, 183). 634 Bliquez 2015, 202. 635 Baykan 2012a, 145 no. 297; Bliquez 2015, 245-6. 214 Instruments used for bone surgeries and treatments were also recovered from the south locus, which was comprised of the group of insulae in which many medical instruments were located. Unfortunately, we are provided with only very general locations for their findspots. Nevertheless, Baykan records that a total of seven bone elevators were found in or near the southern locus, though Bliquez only confirms the single bone lever recovered from the north locus. 636 It is unclear if this is because Bliquez did not believe that Baykan had correctly identified the additional seven from the south locus or if he was simply unaware of Baykan’s identifications. Baykan does provide drawings of all seven. Based on these I am of the opinion that at least one example (catalog no. 336) can be confidently identified as a bone lever, as it is consistent with known comparanda. 637 The available information and images of the remaining six provided by Baykan are insufficient for definitive conclusions to be drawn about their function. Other tools related to bone surgery recovered from the south locus include a meningophylax (an instrument used to protect the dura matter of the brain during cranial surgery), a bow trephine and a possible bone chisel/gouge. 638 These identifications can only be said to be provisional, as the instruments have not yet been subject to the kind of careful analyses undertaken by Jackson on the Rimini collection. Hopefully the Allianoi instruments will eventually be subject to a comparable evaluation. For now, however, we can be reasonably confident that some types of bone surgeries, and surgeries in general, did take place at Allianoi, likely in more than one location within the town. 636 Baykan 2012a, 154-6 nos. 336-342; Bliquez 2015, 204 n. 518. 637 Baykan 2012a, 154 no. 336; Bliquez 2015, 413-5 figs. 50-54. 638 Baykan 2012a, 139 no. 271 (meningophylax), 136 no. 261 (bow trephine), 121 no. 200. Also see Jackson 2005, 111-3 (meningophylax), Bliquez 2015, 410 no. 46 and Krug 1985, 98-9 (bow trephine), Bliquez 2015, 191-4 (bone chisel/gouge). 215 Interestingly, given the significant number of medically related instruments identified at Allianoi, there seems to be a relative dearth of implements specifically used to treat women. For example, all three sets of catheter fragments recovered from Allianoi indicate that the three catheters were of an S-shaped design that was designed specifically for men (Fig. 4.21). 639 These are consistent with the broader set of extant catheters from the Roman period: of the 17 known examples, 15 are adapted for males while only two examples are of the female type (Fig. 4.22). 640 This particular discrepancy is perhaps easily explained by noting that modern medical data concerning obstructions of the urinary tract (the most common condition for which a catheter was employed in antiquity) shows that these obstructions affect males more than females. 641 So while there were no female catheters recovered from Allianoi, this does not necessarily indicate that the town’s practitioners did not include women among their clientele. It is probable that, like today, the specific conditions for which catheters were employed were simply not as common among woman in antiquity, and that such female-specific instruments were correspondingly less common. It is also possible that examples of female catheters may have been present at the site but that the incomplete excavations preluded their discovery. Gynecological specula likewise were not identified among the recovered medical instruments of Allianoi, though this is hardly conclusive. As noted previously, surviving examples of such instruments are known to be rare, and in any case the excavations at Allianoi were unable to be completed; there may yet be many more instruments now lying under several 639 Baykan 2012a, 134 nos. 252-254; This type of catheter is described in the Pseudo-Galenic text Introductio Sive Medicus 13.35 (= Petit 2009, 64-5); Bliquez 2015, 220-4. 640 Bliquez 2015, 223-4. 641 In addition to describing the conditions for which a catheter is used, Celsus also recommends that a fully prepared surgeon have five catheters made of copper alloy in various sizes on hand, three for men and two for women. Cel. Med. 7.26.1 (= Spencer 1938b, 425); The chemical composition of urine in males, in addition to the presence of the prostate and the variety of inflammatory conditions to which that organ is subject, result in a higher incidence of bladder and kidney stone formations as well as urinary tract obstructions among men as compared to women. Lieske et al. 2014. 216 meters of water. Absent instruments notwithstanding, one conclusion we may draw with relative confidence is that lithotomy and urological specializations were likely claimed by more than one practitioner in the town. While the lithotomy instruments and catheter identified in the northern locus indicate that such implements were sold and/or used in the building adjacent to the thermal baths, the remaining two catheters were recovered from the group of insulae in the southern locus (in quadrants FXI and GX) across the river, as were a number of clearly identifiable scalpels, needles, probes and forceps. 642 It would require more data than are currently available to draw definitive conclusions about the complete range of medical activities that took place at Allianoi as well as where they took place. We do, however, have enough information to conclude that the types of medical expertise indicated by the instrumentaria of Allianoi are similar to those known elsewhere in the Empire, including Rimini and Marcianopolis. From the available evidence, we can conclude that the practitioners of Allianoi performed uvulectomies and hemorrhoidectomies as well as procedures to address kidney, bladder, and urological conditions. Also represented among their collective expertise are specialties such as ophthalmology, wound care, bone setting and surgery, phlebotomy, and pharmacology. 643 In terms of the design and manufacture of the instruments received from Allianoi, further study is needed to determine if any of the tools were manufactured locally or if there are any that indicate they may have come from the same workshop. It is likewise difficult to understand from the available information exactly how many of them have evidence of refined or costly decorative elements, such as some of the implements from the Marcianopolis instrumentarium. However, Baykan does provide information on a small number of instruments that have finely decorated elements, such as a pair of bronze caustic forceps and a pair of tweezers, both 642 Baykan 2012a, 134 nos. 253 and 254; 165. 643 See discussion in Chapter 1 of this study. 217 recovered from the north locus (Fig. 4.23). 644 A needle grip, also from the north locus, exhibits a finely detailed, pattern decoration on the lower section of the handle. 645 Future studies on the medical material retrieved from Allianoi would be invaluable, as there is undoubtedly more that these objects have to tell us. Though one may hope for more details concerning Allianoi in future publications, the picture thus far provided by the available studies is an intriguing one: a spa-town whose economy was founded, at least in part, on a medical “market” that served visiting patients who came in search of more secular cures and treatments, perhaps before or following a side trip of a more religious nature to the Asklepeion located 18 kilometers to the southwest. Such places are not unique in the Graeco-Roman world. The availability of medical treatments seems to have been a natural complement to thermal baths, at least in some Roman towns. 646 The presence of the skilled surgeon with an impressive instrument collection at the spa-town of Bingen may indicate a somewhat analogous arrangement, and Künzl has identified the presence of medical and surgical services in the context of other hot springs and baths. 647 Unlike Rimini and Marcianopolis, Allianoi was located far from the Empire’s frontiers and conflict zones. Also, as discussed previously, Allianoi was almost certainly too far for Pergamon’s gladiators to travel to receive treatment for any injuries sustained in the arena, at least initially. How, then, might we explain the presence of instruments such as trepanning devices in this spa-town? Thus far we have examined these trepanning tools primarily in the 644 Baykan 2012a, 144-5 no. 293 and 296 (tweezers and forceps); 205-6 Plates 17 and 18 (forceps); Baykan has interpreted this instrument as an rectal speculum, while Bliquez and Jackson believe that it is a pair of forceps, albeit of a rare type. Baykan is an experienced and skilled archaeologist, but is not a specialist in medical material culture. Since Bliquez and Jackson are unparalleled when it comes to expertise concerning Graeco-Roman medical instruments, I am inclined to agree with their identification of this object. Bliquez 2015, 247 n. 706. 645 Baykan 2012a, 137 no. 263, 204 Plate 14. 646 Künzl 1986; Jackson 1990b and 1999; Ginouvès 1994. 647 Nutton 2014, 387; Como 1925; Künzl 1986. 218 context of traumatic cranial injuries that, while not exclusive to the domain of soldiers and gladiators, almost certainly occurred with greater frequency among those two specific populations than the general civilian population. But trepanation was not a procedure that was limited to the treatment of cranial damage sustained in conflict situations. The skeleton from Fidenae demonstrates that the procedure was also employed in an attempt to relieve the symptoms of hydrocephalus. But primary source literature attests to trepanation procedures used to treat other conditions as well. For example, Celsus records its use to remove bone that has become carious as a result of wound infection as well as to drain abscesses from the skull. 648 Oribasius records it as a procedure to remove osteomas (benign bone tumors), while Galen suggests it as a treatment for aching teeth caused by fever. 649 The fact that trepanation was evidently used to treat conditions that did not necessarily result from combat injuries explains the presence of such instruments at Allianoi. 650 Broken and fractured bones are likewise not exclusive to soldiers and gladiators. As such, the presence of instruments adapted to bone surgery at Allianoi is likewise unsurprising. From the evidence available to date, it would seem that the types of medical expertise represented by those instruments from Allianoi that have been securely identified are reflective of the types of medical conditions that affected civilians and soldiers alike. And while Allianoi may have differed from a typical Graeco-Roman town of similar size as a result of its thermal baths and accompanying medical industry, there is no reason to assume that the specific types of 648 Cel Med. 8.2.4 and 8.4.13-15 (= Spencer 1938b, 495 and 511-5). 649 Oribasius Coll. Med. 46.29.8; Gal. Cmpds. by Place 12.821K (from Bliquez 2015, 185); I suspect that Galen’s “aching teeth caused by fever” is almost certainly a description of a sinus infection, a condition for which trepanation would likely have been a disastrous case of excessive intervention. 650 An analysis of one of the skeletons in Pompeii that exhibited evidence of a cranial trepanation procedure indicated that the individual suffered from a condition known as Hyperostosis Frontalis Interna (HFI). This is an overgrowth of bone inside the frontal bone of the cranium that causes severe headaches. The authors of the study hypothesize that these headaches were the reason for which the trepanation procedure was undertaken. Lazar et al. 1996, 623. 219 medical expertise represented by the instruments were particularly unusual or unique. Indeed, since similar types of instruments and expertise were present at Rimini, Marcianopolis and Pompeii, we have no reason to conclude that Allianoi was exceptional in this respect. If anything, both the Rimini and Marcianopolis instrumentaria indicate a range of medical skills on the part of their owners that could be said to supersede those available at Allianoi – at least thus far. The uniqueness of Allianoi lies not in the medical expertise its finds represent, but rather the portrait it provides of a medical system of sorts – a medically based marketplace in which patients, physicians, suppliers and perhaps also manufacturers of instruments and medicines came together to form the medical economy of a town. The presence of the natural thermal springs as well as its proximity to the famous Pergamene Asklepeion made it ideally situated to develop a type of medical industry. As such, it seems reasonable to suggest that patients and physicians would similarly have been drawn to the town either in search of treatment or to take advantage of the professional opportunities. But while Allianoi may well be exceptional in this sense – and it is certainly exceptional as an archaeological site – there is at present no reason to believe that the medical expertise that third-century patients found there could not also be found elsewhere in the Empire. 220 Conclusion Individually, the medical sites of Rimini, Allianoi, Rhodiapolis and Marcianopolis have much to offer to the field of Graeco-Roman medicine, particularly as it pertains to the civilian sphere of the Empire during the Imperial period. Considered together, the sum of the information from each site is, in some ways, greater than the whole. By situating these sites within the broader context of the field, (i.e., comparing them to evidence from previously known sites) a picture of civilian medicine in the Imperial period emerges with greater clarity. Civilian and Military Medicine In compiling and considering the evidence for the various ways in which military and civilian medicine, and particularly practitioners, interacted and intersected with each other, we now have a greater understanding of the nature of the relationship between the two. While the martial and civic environments – and the professional organizational structure of the medici who worked within them – were quite different from one another, in the course of this study’s investigation of the available evidence it becomes clear that the physicians themselves, as well as their knowledge, moved relatively easily between these two spheres. Furthermore, the medical implements recovered from Rimini, Allianoi and Marcianopolis, considered together with other known instrument typologies from sepulchral contexts as well as Pompeii and Herculaneum, indicate that the same types of medical procedures and expertise employed for the benefit of soldiers was also available in civilian, urban environments, suggesting that in terms of actual practices and available technologies the two medical paradigms were not markedly different from one another. 221 Those military medici who went on to establish civilian practices upon their discharge from the army brought with them into the civilian world medical skills they acquired during their service. Such skills would have included a knowledge of human anatomy and surgical techniques that were difficult to come by in civilian environments. Likewise, civilian physicians could enlist in the army and become military doctors - evidently obliged for shorter periods of time than their combatant counterpoints. Military physicians who treated the civilian inhabitants of their castra or towns, as well as civilian physicians who maintained their civilian status yet were employed by the military, seem to have been viable scenarios. Thus there were myriad ways in which Roman medical practitioners – and their knowledge – could move between the martial and civic spheres of Roman society, learning and/or imparting new knowledge and skills in the process. The instrumentaria recovered from Marcianopolis and the Domus del Chirurgo in Rimini indicate that their owners were familiar with surgical procedures employed to address the types of injuries sustained in conflict conditions. Given the nature of their instruments, as well as the proximity of their respective cities to conflict zones, it seems likely that they would have treated soldiers as well as civilians. In the case of the Marcianopolis physician, it is impossible to know where he came by his various types of expertise. However, in addition to his expertise addressing bone and other types of traumatic injuries, the specula and other gynecological instruments identified in the collection indicate he included women among his patients. In the case of the Rimini physician, his strong martial connections are made clear by more than just his considerable and expertly assembled instrumentarium. The three weapons recovered from his domus, characteristic of those used by the Roman army in the third century, as well as the votive hand of Iuppiter Dolichenus discovered at the site are compelling indications that Eutyches had close ties with the Roman army and likely spent at least part of his professional life in its service. 222 Rimini and Marcianopolis are, of course, extremely rare as archaeological sites today. However, we cannot infer from their paucity in present times that they represent correspondingly rare scenarios in antiquity. On the contrary, inasmuch as both towns can be considered examples of others similarly situated throughout the Empire, I believe that the physicians of Marcianopolis and Rimini are instead illustrative of a broader dynamic that existed between the military and civilian medical communities. As medical practitioners moved between the civic and martial environments, their knowledge and skills would likewise transfer from one context to the other. Given the flexibility medical practitioners seemed to have vis-à-vis treating both civilians and soldiers simultaneously – a circumstance that would have been facilitated by a town or fort’s proximity to a conflict zone – we can now see multiple points at which military and civilian medicine intersected. Though the medical structure implemented by the state for the care of its soldiers had no counterpart in the civilian world, insofar as the medical practitioners themselves – and their knowledge – is concerned, the evidence presented in this study indicates that the boundary between these two components of Roman society was relatively permeable and that the relationship between martial and civic medicine was more emmeshed than the disparities between the two environments might suggest. Organizing Influences on Civic Medicine The lack of a state-organized medical structure in the Empire’s civic sphere notwithstanding, there were nevertheless certain state actions (e.g., laws granting tax immunities and benefits to physicians) that influenced the organization of the profession. The resulting competition for the role of the public physician, with its commensurate benefits, engendered a professional 223 hierarchy, with the archiatri occupying the uppermost tier. The increasing importance of professional collegia from the second century onwards coincided with the implementation of the second-century Antonine law restricting the number of public physicians a city could have at one time. As such, membership in – or exclusion from – a city’s medical collegium could have played a significant role in the social and professional lives of its medici and was likely a determining factor in the professional and social success (or lack thereof) of at least some of the Empire’s physicians. However, the available evidence indicates that such influences fell short of establishing professional standards of competence when it came to actual medical practices. To date, we have no evidence that demonstrated clinical ability was a prerequisite for inclusion in medical collegia. Evidently, one could take advantage of the social and professional benefits that membership in a collegium medicorum conferred without actually being an effective practitioner. For controls of medical competence (such as they were), we may look to a different type of societal force: that of the medical marketplace. Though the nature of the Roman economy as a whole is still very much a topic of study by subject experts, there is no evidence to suggest that the individual economy of civilian medicine functioned as anything other than a free market. As such, while hardly foolproof, it is reasonable to hypothesize that at least some degree of “quality control” of physicians may have arisen as a result of patient choice. It seems likely that, at least in some cases, a medicus who earned a reputation for administering demonstrably effective treatments would have found himself with an increasing number of patients who were willing and able to pay him handsomely for his services. In this way, a rudimentary form of medical meritocracy may have evolved, at least in some instances. Of course, this could be undermined by the social constructs of the time, which, if Galen is to be believed, allowed an incompetent medicus to achieve success with the 224 upper classes if he made up for his lack of practical skill with a convincing combination of showmanship and sycophancy. 651 Yet, even given the numerous and complex social variables that may have come into play within the landscape of civic medicine, it is hard to imagine that a demonstrably gifted and competent medicus would not have acquired at least some direct benefit resulting from an application of his skills. Those practitioners who earned (or otherwise cultivated) a good reputation may have benefitted from this in the forms of repeat patients, new patients and perhaps even patronage. Allianoi’s Medical Economy When it comes to understanding what an individual, multi-faceted medical economy may have actually looked like, the case study of Allianoi provides us with at least a partial view. Though the existing evidence may tell us little of the competence or success (financial or otherwise) of individual doctors who worked in the spa-town, it does provide us with an intriguing glimpse into what seems to have been an entire medical economy made up of at least two interconnected and mutually reliant markets. The first was comprised of the physicians who supplied their services and the patients who came to the town seeking treatments. The second was founded upon the supply of medical instruments and medicines to the doctors and (in the case of medicines, at least) patients who demanded them. The presence of the thermal baths, in addition to the ubiquitous distribution of medically related objects throughout the town and the presence of the two enormous pithoi that once contained large quantities of medicinal substances all seem to indicate that at least part – probably a significant part – of the town’s economy was founded upon medicine for much of the Imperial period. 651 See n. 430. 225 Behind the tableau of the robust medical market presented by Allianoi, we can perceive the presence of the vast trade networks of the Empire that allowed goods to be brought to Allianoi from as far away as Africa, India or the Middle East. 652 Likewise, whether the complex medical instruments identified in Allianoi were produced locally or were imported from elsewhere, their presence in the spa-town represents a sophisticated manufacturing industry that was able to marshal the necessary resources (i.e., the raw materials and the highly skilled metalsmiths to work them) in order to produce such objects. The fact that such sophisticated instruments, as well as medicines containing ingredients from far-flung regions of the Empire and beyond, have been identified at sites throughout the Empire in a variety of contexts (e.g., civilian, martial, and burial) implies that the procurement, manufacture and/or distribution of such products comprised a medical economy that extended beyond the confines of an individual site or town. A future study that investigates a broader view of the medical economy of the Imperial period and its place within the Empire’s economy as a whole would be well-worth undertaking. For now, the view that Allianoi presents to us is that of a medical system of sorts in which doctors, patients, merchants, and craftsman comprised and were participants in the medical market of this particular town. Medical Libraries as Training Centers? The ways in which physicians were able to acquire medical education and practical experience were varied. Apprenticeship would have been one possibility, while enlisting in the army’s medical corps was another avenue available to those seeking to develop practical medical experience, particularly with regard to human anatomy and surgical expertise. Neither of these 652 As represented by the frankincense that was a primary ingredient of errhinon ioudaikon, the medicinal substance that was stored in one of the pithoi identified in the south locus. See page 161 of this study. 226 precludes a third educational possibility: medical libraries that functioned as centers of medical training. A medicus living in the Imperial period could have availed himself of one, two or all three of these educational opportunities during the course of his career, depending on his interests and circumstances. This study’s analysis of the material from Rhodiapolis in the context of other known medical libraries demonstrates that medical libraries were not restricted to major cities such as Rome, Athens, Pergamon and Alexandria. In addition to the medical centers of learning that existed in other cities such as Smyrna, Ephesus and Tarsus, the epigraphic evidence associated with the medical library at Rhodiapolis indicates that a similar institution also existed on Rhodes. If smaller cities such as these had medical libraries, it is reasonable to infer that at least some other similarly sized cities may have had such institutions as well. This suggests two new possibilities: 1) greater number of medical libraries may have existed than those for which we have concrete evidence, and 2) such libraries may have also functioned as training centers where physicians and aspiring physicians could have had access to more clinical types of training (e.g., medical demonstrations). While Galen’s training suggests that the Library of Alexandria may have been considered the gold standard for medical education in the Graeco-Roman world, access to collections of medical texts – and the knowledge contained within them – was not restricted to those who had the means to travel to Egypt. Those who wished to pursue or further their medical training may well have been able to do so closer to home. Certainly in the case of medici from the Lycia et Pamphylia region of the Empire, Rhodiapolis may well have been an attractive alternative to the more famous, yet more far-flung and costly, alternatives. Furthermore, it is possible, perhaps even likely, that other forms of medical training were available at such medical centers of 227 learning beyond just the study of texts. The anatomical demonstrations that we know were performed for the benefit of students in Alexandria and the similarly instructive medical demonstrations and/or competitions that took place in Ephesus and Pergamon may well have been replicated in other cities. Furthermore, the arrangement of the small rooms on either side of the courtyard in the medical complex at Rhodiapolis, and the medical instruments recovered from at least one of them, suggests that these were places of medical treatment, training, or both. If this is true in Rhodiapolis, then might it not have been true at other medical libraries in the Empire? I believe that this may have been the case. If so, this would change our understanding of the various ways in which physicians could have acquired their professional knowledge and skills. If the medical libraries of smaller cities also functioned as loci of clinical training, we may add this to the options available to physicians wishing to access – or expand – their medical education. While the evidence from Rhodiapolis suggests that this is a distinct possibility, further investigation is needed. An exhaustive study of the textual and archaeological evidence for medical libraries in the Graeco-Roman period has the potential to shed further light on the question of medical libraries as training centers. Such a study would be a useful contribution to the field and our understanding of how physicians in the Imperial period could have acquired their medical education. Extant Archaeological Sites of Civic Medicine as Representative Examples Though the number of non-sepulchral sites that can be definitively associated with civilian medical practices is extremely limited, the contribution of the sites considered in this study are proportionally substantial, particularly when it comes to our understanding of the types of medical expertise available in the civic sphere. These contributions are particularly helpful when 228 it comes to deducing the types of medical specializations and expertise physicians in civilian environments possessed. The picture that emerges is that similar types of procedures and expertise were represented in various sites throughout the Empire. Though the Rimini surgeon’s instrumentarium is exceptional in its size and quality, many of the instruments associated with various types of bone surgery from this particular collection have counterparts in Marcianopolis, Allianoi, Pompeii/Herculaneum and some burial contexts (e.g., Bingen). 653 Other types of surgical interventions and specialties represented in the collections of Rimini, Allianoi and Marcianopolis that have comparanda in Pompeii, Herculaneum and sepulchral contexts include ophthalmological procedures, lithotomies, uvulectomies, hemorrhoidectomies, tonsillectomies and dental procedures. The various types of extant specula from antiquity represent medical procedures related to obstetrics/gynecology, the treatment of hemorrhoids, fistulas and even the remediation of traumatic wounds. Though these devices are quite rare as archaeological finds in our present time, they were certainly less so in antiquity. While their complex design would have made them costly to acquire and therefore out of reach for some practitioners, their presence in a variety of geographically disparate sites, including Pompeii/Herculaneum and Marcianopolis, indicates they were used in civilian environments throughout the Empire. 654 Like the Roman Empire itself, civic medicine in the Imperial era was not a homogenous paradigm. Variations across regions and cultures meant that approaches to the treatment of disease and injury would have been similarly varied; it seems likely that knowledge of some medicinal substances, surgical techniques and instruments may have remained localized in a 653 For analyses of the bone surgery instruments from the Bingen collection as well as several other contexts, see Jackson 2005. 654 Places in which various forms of specula/dilators have been found include Italy, Bulgaria, Romania, and the Netherlands. See Jackson 1991, Table 1. 229 single region, town or even with a single practitioner. Regardless, the addition of the medical evidence from the sites under consideration in this study to that which is known from Pompeii, Herculaneum and burial contexts allows for the conclusion that these sites, though rare in present times as examples of medicine as it was practiced in the civilian sphere, were not particularly unique in their own time. As such, I propose that the medical practices and practitioners associated with them can reasonably be considered representative of similar urban contents through the Empire in the first five centuries of the Common Era. Given how rare medically related sites from the period are in general, the addition of Rimini, Allianoi, Rhodiapolis and Marcianopolis to the compendium of evidence upon which the study of Graeco-Roman medicine is founded significantly expands the potential of the field. We may still only be able to render the landscape of Roman civic medicine in the Imperial period with broad strokes, but I am convinced that the investigation of the evidence from these four sites considered in this study renders a more complete and clearer image than that which has been presented in the past. The fact that new discoveries, studies, and avenues of inquiry in the future may illuminate that view even more is something to which I look forward. 230 Figures 231 1. 1 Locations of Rimini, Allianoi, Rhodiapolis and Marcianopolis (produced by and courtesy of Megan Sauter). 232 1. 2 Domus del Chirurgo, located in the northeast section of the archaeological complex in Piazza Ferarri, Rimini (modified from the Soprintendenza Archeologia, belle arti e paesaggio per la città metropolitana di Bologna e le province di Modena, Reggio Emilia e Ferrara, http://www.archeobo.arti.beniculturali.it/rimini/domus_chirurgo/domus_chirurgo.htm). 233 1. 3 Identified rooms/structures in the Domus del Chirurgo (modified from the Soprintendenza Archeologia, belle arti e paesaggio per la città metropolitana di Bologna e le province di Modena, Reggio Emilia e Ferrara, http://www.archeobo.arti.beniculturali.it/rimini/domus_chirurgo/domus_chirurgo.htm). 234 1. 4 Orpheus Mosaic (after Fontemaggi and Piolanti 2016, 86). 1. 5 Reconstruction of the medica taberna and patient’s cubiculum in the Domus del Chirurgo. Museo della Città, Rimini (courtesy of the Museo della Città, Rimini). 235 1. 6 3D map of ancient Ariminum. The Domus del Chirurgo is circled in red (modified from Arimini Caput Viarum, http://www.riminiromana.it/). 236 1. 7 Site plan of Allianoi (modified from Baykan 2012a, 194). 237 1. 8 Close-up of the the north locus depicting the “yard-type structure and the medical instrument distribution (modified from Baykan 2012a, 207). 238 1. 9 View of the bath complex of Allianoi, prior to its flooding in 2011. View to the west (after Eurasianet, https://eurasianet.org/turkey-roman-ruins-lost-amid-economic-development). 1. 10 View of the bath complex of Allianoi, prior to its flooding in 2011. View to the northeast (after Eurasianet, https://eurasianet.org/turkey-roman-ruins-lost-amid-economic-development). 239 1. 11 City plan of Rhodiapolis (after Çevik et al. 2010, 57, fig. 2). 240 1. 12 Theater of Rhodiapolis with the Opramoas monument beyond the skene (backdrop of the stage). View to the southeast (author). 241 1. 13 Medical complex of Rhodiapolis (modified from Çevik 2010, 57, fig. 2). 242 1. 14 Interior of the Temple of Asklepios and Hygieia with the dedicatory inscription by Heraclitus (Inv. 557). View to the west (author). 1. 15 Inscription commemorating the works of Heraclitus (TAM II 910) in front of the remains of a section of the triple portico. View to south/southeast (author). 243 1. 16 Network of Roman roads in the Balkans in the first – fifth centuries C.E. (after Evangelidis et al. 2015, 265, fig. 1). 1. 17 Heinrich Hartl’s 1898 survey map (after Kalinka 1906, 360, fig. 160). 244 2. 1 Second-century C.E. tomb relief of Asclepiades, archiatros of Odessos. Note the images of military weapons along the bottom of the relief. Varna Regional Museum of History. IGBulg. I 2 150. Photo by V. Yotov (modified from Aparaschivei 2012c, 76, fig. 7). 245 2. 2 Portion of the Diocles’ Spoon from the Domus del Chirurgo, which was used to extract barbed projectile points. Museo della Città, Rimini (courtesy of Ministero per i Beni e le Attività Culturali - Soprintendenza Archeologia, Belle Arti e Paesaggio per le Province di Ravenna, Forlì-Cesena e Rimini). 2. 3 Image of the votive hand representative of the cult of Iuppiter Dolichenus from the Domus del Chirurgo (ca. 12cm x 4cm). Museo della Città, Rimini (after Jackson 2009b, 92). 246 2. 4 The votum pro salute monument dedicated to Iuppiter Dolichenus by T. Flavius Galata Eutyches for his freedman Amarantus. Museo della Città, Rimini (after Cenerini 2000, 68). 2. 5 Third-century iron weapon points recovered from the Domus del Chirurgo. Such weapons were characteristic of the Roman military in this period. From left to right: A. pilum (javelin), B. spear C. lance. Museo della Città, Rimini (modified from Ortalli 2009, 28). 247 3. 1 Foot of Hermarchus statue recovered from the Domus del Chirurgo. Museo della Città, Rimini (after Ortalli 2009, 28). 3. 2 Third-century C.E. statue of Hermarchus (copied from a third-century B.C.E. Greek original) recovered from the Roman bath complex in Sarteano, Italy. Museo Archeologico Nazionale di Firenze (modified from Biondini et al. 2017, 14). 248 3. 3 Set of five ophthalmic needles and their container (far left) which were recovered from the river Saône in Montebellet, France. The center needle is an inventively designed retractable needle, which measures 13.5cm. Musée Greuze, Tournus, France (after Bliquez 2015, 400, fig. 30). 3. 4 Interior view of the retractable ophthalmic needle. Musée Greuze, Tournus, France (from Bliquez 2015, 401, fig. 31). 249 3. 5 Drawing of finely calibrated, copper-alloy plunger forceps. The rod-like plunger handle compresses the jaws of the forceps as it is depressed. The plunger could then be locked in place, freeing the user from the necessity of holding it closed or having to engage a sliding lock-ring. Ashmolean Museum, Oxford (after Jackson 2014, 133, fig. 18.6). 250 3. 6 Plan of valetudinarium at Vetera I, a Roman legionary base on the Lower Rhine near Xanten, Germany. Cf. Fig. 1.8 (after Johnson 1983, 160, fig. 117). 3. 7 Plan of valetudinarium at Novae, a Roman legionary base on the Danube in northern Bulgaria. Cf. Fig. 1.8 (after Johnson 1983, 160, fig. 117). 251 3. 8 Plan of south locus depicting the indicated location of the two pithoi in quadrant EXI, circled in red (modified from Yaraş 2010, 98, plan 1). 3. 9 The two pithoi, in situ (after Yaraş 2010, 98, fig. 1). 252 4. 1 First-century C.E. relief from the tomb of L. Cornelius Atimetus in Ostia. Vatican, Galleria Lapidaria Inv. 9277 (after Krug 2008, 26, fig. 13) 4. 2 Second-century C.E. relief from the tomb of Verrius Euhelpistus in Ostia depicting the metalsmith at work in his workshop. Tomb #29 (courtesy of OstiaAntica.org https://www.ostia- antica.org/valkvisuals/html/tombe_29_3.htm). 253 4. 3 Second-century C.E. relief from the tomb of Verrius Euhelpistus in Ostia depicting a display of metal tool and blades. Tomb #29 (courtesy of OstiaAntica.org https://www.ostia- antica.org/valkvisuals/html/tombe_29_3.htm). 254 4. 4 Scalpel handles from Pompeii decorated with a bust of the demi-god Hercules. National Archaeological Museum of Naples, Inv. 77694 and 117667 (after Bliquez 1994, 119, fig. 20). 4. 5 A copper alloy, bifurcated blunt hook used in lithotomy procedures, modified from a double lancet. Museum of Classical Archaeology, Cambridge UK, Inv. 171 (after Jackson 2010, 396, fig. 2.5). 255 4. 6 Second-century C.E. tomb relief of Aelius Pius Curtianus depicting a physician’s basic instrument kit in a folding case (right) with a drawn reconstruction (left). National Archaeological Museum of Palestrina (after Krug 2008, 34, figs. 18 and 19). 4. 7 Reproductions of bronze cupping vessels (courtesy of the Claude Moore Health Sciences Library, University of Virginia). 256 4. 8 Basic physician's instrument collection from the Domus del Chirurgo in Rimini. Note the double scalpel with different blades at each end (far left). Museo della Città, Rimini. Photo by Ralph Jackson (after Jackson 2009b, 83, fig. 1). 4. 9 Two bronze trephines (drills) with the folding handle (bow) used to rotate them. Römisch- Germanisches Zentralmuseum, Mainz, Germany (after Parapia 2007, 15, fig. 2). 257 4. 10 Illustration of a trepanning procedure using a trepan drill and bow (courtesy of The Romans in Britain https://www.romanobritain.org/13_roman_medical/roman_surgery.php). 4. 11 Drawing of folding trepan drill bow depicting a stylized snake motif on the terminal. Museo della Città, Rimini (after Jackson 2009b, 77 fig. 26). 258 4. 12 The largest cluster of bone surgery instruments from the Domus del Chirurgo. The straight- jawed sequestrum forceps with decorated handles can be seen at the bottom center, while the folding trepan drill bow can be seen protruding from the cluster on the upper left. Museo della Città, Rimini (after Jackson 2009b, 84, plate 2). 4. 13 Ceramic medicine jars from the Domus del Chirurgo containing camedrium (left) and abrotonum (right). Museo della Città, Rimini (after Gazzaniga 2009, 98). 259 4. 14 Instruments from the Marcianopolis instrumentarium, including bronze trepans bow (center), modified, bifurcated lithotomy scope (bottom right), and a decorated ophthalmic needle handle (upper right). Varna Regional Museum (after Trakova 2016, 19). 4. 15 Instruments from the Marcianopolis instrumentarium, including caustic forceps (center), a traction hook (second from right) and a lithotomy knife handle (far right). Varna Regional Museum (after Trakova 2016, 18). 260 4. 16 Example of a trivalve vaginal speculum (courtesy of the Claude Moore Health Sciences Library, University of Virginia). 4. 17 Example of a bivalve speculum (courtesy of the Claude Moore Health Sciences Library, University of Virginia). 261 4. 18 Fragmented bronze “cupping vessel” (cf. Fig. 4.7). North locus, Allianoi. Bergama Museum (after Baykan 2012a, 157 no. 348). 4. 19 Blades of a bronze, double-sided serrated saw (serrula). North locus, Allianoi. Bergama Museum (after Baykan 2012a, 206, plate 20). 262 4. 20 Hemostatic forceps. North locus, Allianoi. Bergama Museum (after Baykan 2012a, 145 no. 297). 4. 21 Catheter fragments from Allianoi (after Baykan 2012a, 202, plates 10 and 11). 263 4. 22 Examples of two male catheters (top and middle) and a female catheter (bottom). Italy, first century C.E. British Museum Inv. 1968,0626.24 (courtesy of Mikael Häggström, MD). 4. 23 Pair of caustic forceps with intricately decorated handle. North locus, Allianoi. Bergama Museum (after Baykan 2012a, 205, plate 17). 264 Bibliography 265 Bibliography Adams, C. 1995. “Supplying the Roman Army: ‘Q. Petr.’ 245.” ZPE 109: 119-24. Adams, F. ed. and trans. 1847. The Seven Books of Paulus Aegineta. 3 vols. London: The Sydenham Society. Allbut, T. 1921. Greek Medicine in Rome. London: MacMillan and Co. Allison, P. 2013. People and Spaces in Roman Military Bases. Cambridge: Cambridge University Press. Alonso, M. 2018. 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Abstract (if available)

Abstract The purpose of this study is to examine four archaeological sites involved in the practice of Graeco-Roman medicine in civilian, urban environments during the Imperial period (ca. first杅ifth centuries C.E.). Investigations of the four archaeological sites?one in Rimini, Italy (揇omus del Chirurgo?), two in Turkey (Allianoi and Rhodiapolis) and a fourth in Bulgaria (Marcianopolis)?have yielded information about medicine as it was practiced outside of military and temple environments. However, while each site has been the subject of site-specific publications and reports in varying detail, none of them has seriously been considered in the existing literature concerned with presenting a comprehensive view of Graeco-Roman medicine. By analyzing the material from these four sites in light of what we already know of the medical landscape of the Imperial era, this project attempts for the first time to bring these sites into their deserved place within the broader scholarly discourse and, in the process, fill in some of the lacunae in our knowledge.

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Creator Yeomans, Sarah Katherine (author)

Core Title Roman civic medicine: the archaeology of practices and practitioners in the Imperial age

School College of Letters, Arts and Sciences

Degree Doctor of Philosophy

Degree Program Art History

Degree Conferral Date 2021-08

Publication Date 07/21/2021

Defense Date 05/25/2021

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag Allianoi,ancient medical instruments,ancient medicine,ancient Roman medicine,archiatri,archiatros,Asclepius,Asklepios,Bingen,Casa del Chirurgo,Celsus,collegium medicorum,Diocles Spoon,Diosorides,Domus del Chirurgo,Galen,Graeco-Roman medical instruments,Graeco-Roman medicine,Greek doctor,Greek medical instruments,Greek medicine,Greek physician,Herculaneum,House of the Surgeon,instrumentaria,instrumentarium,Marcianopolis,Medici,medicus,OAI-PMH Harvest,Pompeii,public physician,Rhodiapolis,Rimini,Roman doctor,Roman medical instruments,Roman medicine,Roman military medicine,Roman physician,trepanation

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Language English

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Advisor Pollini, John (committee chair), Concannon, Cavan (committee member), Yasin, Ann Marie (committee member)

Creator Email skyeomans@gmail.com,syeomans@yahoo.com

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