232 MEN AND Booxs: Ascuia'ius, GOD OF MEDICINE

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T HE story of the god of medicine begins in the sixth century B.C. when Asclepius* was a minor deity serving the needs of the itinerant Greek physicians. Civilized life in the ancient world sought health and freedom from disease which Asclepius, through his temple priests and physicians, offered to mankind. Because of this, his power and appeal increased until in the third century A.D. he was designated Zeus Asclepius and his cult was the predominant religion in the ancient world. The blasphemy of the Christian leaders, the disfavour of paganism manifested by Christian emperors, and the chaos of the fourth, fifth and sixth centuries resulted in the fall and extinction of the Asclepian cult. In spite of this, Asclepius survived and today remains among us as a pagan god symbolizing the Platonic idea of health and healing. The Oath of Hippocrates is solemnified by swearing to him, his father and his two daughters. A single snake curling about a staff was the ancient mark of the god and is today symbolic of medicine and of various major medical societiest (Fig. 1). Exceptional students at many universities belong to Asclepian societies which are dedicated to pure academic advancement. Hippocrates, who according to some ancient writers was a 19th descendant
From the Department of Medicine, University of Toronto, and The Toronto East General Hospital.

Fig. 1.-Variants of the staff of Asciepius used in medical symbolism. The first is the symbol of The Canadian Medical Association, the second of the College of General Practice of Canada, the third of the American Medical Association, and the fourth of the British Medical Association.

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4

*Asclepius is also spelt Aesculapius (Latin), ATKX7J7rLOS (Greek), Asciepins, and Askiepios. There are many versions of the derivation of the word. One refers to his curing Asides of oplithalmia and another is based upon the ancient word for mildness, while Leake suggests that there is some relation to the herb of life, mistletoe.
tThe snake has been worshipped by many cultures around the globe. The annual shedding of its skin symbolized new life or rejuvenation, and through its ability to assume the shape of a living circle it was regarded as the symbol of eternity. In early Greek medicine the snake reputedly had great knowledge of medicinal herbs and also had a healing lick. The association with Asciepius was a practical one: It not only symbolized the healing power but also kept the temples free of rats and mice. Today this could be interpreted as a supplemental role for the goddess Hygieia, as the removal of rodents decreased the spread of disease at the temple sites. The harmless Elaph longissima has been identified as the temple serpent, and its distribution in Europe today follows approximately the boundaries of the Roman Empire and its Asciepian temples. The caduceus Is formed by two snakes twisting about a single staff and was erroneously introduced as a medical symbol. Its first association with a physician was in 1545 when Sir William Butts, physician to Henry VIII, adopted it into his crest. In 1856 the United States Public Health Department used It on the uniform of hospital stewards and in 1902 the Medical Corps of the United States Army adopted the caduceus as the symbol for non-combatant forces in the field. Because of this error most of the laity and many members of the medical profession equate it with the medical symbol. The first recorded caduceus appears on Babylonian cylinders (3000 B.C.) in which the snake was the symbol of supreme sexual prowess and fertility; in order to illustrate the bisexual nature of the snake two heads were added to a single body (Fig. 6). Later the caduceus was adopted as the symbol of Hermes or Mercury-the god of heralds. commerce, rogues, cattle rustlers, dreams and magic. This symbol is still used by financial Institutions and indeed it is displayed by the service stations of a large oil company.

of Asclepius, was a devotee of the god of medicine, and reverence for the father of clinical medicine indirectly venerates Aselepius. The new mace of office of the American College of Physicians will 'be carved from a slab of timber from a 2500-year-old plane tree at the Asclepian sanctuary at Cos (Fig. 2). At the Ninety-Fourth Annual Meeting of The Canadian Medical Association, Dr. Wilder Penfield presented the Association with a gavel fashioned from a branch of one of these plane trees, beneath which it is said Hippocrates taught his students in the fifth century B.C. On an earlier occasion, in 1954, the late Dr. T. Clarence Routley presented a similar gavel to the College of General Practice of Canada at their founding meeting.

Fig. 2.-The plane tree of Hippocrates.

Early mankind attempted to explain nature and to justify existing social systems and customs through reference to mythology and the gods. Perhaps the existence of a host of unanswered medical

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MEN AND BooKs: Asci.rius, GOD OF MEDICINE 233 Gods, from power to give life a second time thou shalt be stayed by thy grandsire's lightning. So, from a God shalt thou become but a lifeless corpse but from this corpse shalt thou again become a God and twice renew thy fates!"' Some interpretations which might be placed on this myth are as follows: Apollo was associated with the prophesies of the Delphic Oracle, and as the father of Asclepius there is a symbolic background to the prognostic power of the physician. The divine father and mortal mother support the mystical element of medical practice. Delivery by Cesarean section was believed by the ancients to be an indication of divinity or of outstanding personality. This is the first account of such surgery (Fig. 3).

problems and the mystical power of the art of medicine have resulted in our tacit preservation of this Greek god.
Tmi. ORIGIN OF ASCLEPIUS

Homer, Hesiod, Pindar, the Greek lyricists and much mythology have invested Asclepius' origin with a colourful array of fact and fancy from which unffied conclusions cannot be drawn. Some feel that Asclepius was always a god, while others argue that he was a hero-physician who was later deified. In the Iliad (circa 850 to 1200 B.C.) Asclepius is a king, but Homer uses this as a literary device to maintain the dignity of the epic and the heroic role of its participants. Asclepius' two sons, Machaon and Podalarius, are poetic princes who in reality are the best physicians in the Greek army at Troy. Machaon is the surgeon who treats Menelaus' wound, and Podalarius is the physician who treats Ajax's madness. Ovid's "Metamorphosis" offers to physicians the most unified account of the Asclepian myth. The following is an extract from the Miller translation as it appears in Edelstein's "Asclepius", Volume 1: "In all Thessaly there was no fairer maid than Coronis of Larissa, and the raven told Apollo that he had seen Coronis lying beside the youth of Thessaly. When that charge was heard, his heart became hot with swelling anger, he seized his accustomed arms, strung his bent bow from the horns, and transfixed with unerring shaft the bosom which had been so often pressed to his own. The smitten maid groaned in agony, and she drew out the arrow, her white limbs were drenched with her red blood. 'Twas right, Oh Phoebus,' she said, 'that I should suffer thus from you, but first I should have borne my child. But now two of us shall die in one.' While she spoke her life ebbed out with her streaming blood, and soon her body, its life all spent, lay cold in death. "The lover, alas! too late repents his cruel act: he hates himself because he listened to the tale and was so quick to break out in wrath. He hates the bird by which he has been compelled to know the offence that brought his grief. He fondles the fallen girl, and too late tries to bring help and to conquer fate; but his healing arts are exercised in vain. When his efforts were of no avail and he saw the pyre made ready with the funeral fires which were to consume her limbs, he pours fragrant incense on her unconscious breast and gives her the last embrace. But that his own son should perish in the same funeral fires he cannot brook. He snatched the unborn child from his mother's womb and from the devouring flames, and bore him for safekeeping to the cave of the two formed Chiron. "Meantime the Centaur was rejoicing in his fosterchild of heavenly stock, glad at the honour which the task brought with it. His daughter not satisfied to have learned her father's art, but she sang prophesy. She looked upon the child and cried: 'Oh child, health bring to the whole world, speed thy growth. Often shall mortal bodies owe their lives to thee, and to thee shall it be counted right to restore the spirits of the departed. But having did this once in scorn of the

Fig. 3.-The purported Cesarean delivery of Asciepius. From an old wood cut by A. Benedetti in 1495.

That Asclepius should be entrusted to the centaur Chiron would be most acceptable to Ovid's readers. Chiron was the inventor of herbal medicine and the friend and patron of heroes; his home on Mount Pelion in Thessaly was rich in medicinal plants, which suggests that Asclepius was destined to be a physician rather than a surgeon. Asclepius' healing power increased and eventually he was able to raise the dead. Hades, the god of the underworld, complained to Zeus that Asclepius was depopulating his domain, and the healer was punished by a bolt of lightning for his interference with natural laws of mankind and the universe. After death he was deified by Zeus and made god of medicine.
Asciiuius AND EARLY MEDICAL PRACTICE

The early Greek physicians were craftsmen who toured the countryside soliciting business from those able to pay and treating the poor without charge. They carried instruments, medicines and a staff. The last helped them over the rugged terrain and is still depicted in the staff of Asclepius. Physicians, like tinkers, acrobats and poets, needed a hero and a protector. The poets had chosen Homer and they distinguished themselves with the appellation Homerids, or sons of Homer. Around the sixth century B.C., physicians became Ascle-

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piads or sons of Asciepius. This family symbolism represents the earliest attempt by practising physicians to band together in a group for mutual protection and advancement. In the fifth century B.C. the hero of the physicians became the god of physicians because doctors needed a god to support and bless their difficult tasks. Eventually Asciepius became the consultant of the day and his temple the hospital. From this evolved the practice of temple medicine in which the accompanying pomp and awe it invoked would often speed recovery of difficult illnesses, especially if these were psychological in origin. Even today a visit to a specialist or a large clinic may have, per se, a therapeutic effect. Temple medicine adopted all the standard methods of treatment, and the sojourn in the dream room was often preceded by a lengthy delay in the temple surroundings. Here the sick received massage, hydrotherapy, exercise and a healthful diet. They were given unguents and poultices, and were subjected to hygienic measures. They derived hope from the votive offerings of cured patients which abounded in the temple halls and grounds. This modern general therapy preceded the sleep in the Abaton or incubation and dream room of the temple, where, during hypnotic somnolence, the god appeared to the patient and performed surgery or other treatment and made recommendations to be followed or interpreted 'by the temple physicians. During these rounds Asdepius was often 'accompanied by his daughters Hygieia (health) and Panacea (cureall), and his treatments were sometimes carried out by a sacred temple snake or dog licking the diseased part. No direct fee was charged, but the wealthy gave according to their status and response to treatment, while the poor were treated free; this represented the first venture in organized medical care for the needy.
AsCLEPIAN RELIGION

a cock or lamb was frequently offered, but in the Asclepian cult prayer was the most important part of the ritual. Like other gods, Asclepius had festivals which attracted visitors from afar to the major centres. The usual parades, prayers and sacrifices were supplemented by games and drama enacted in the amphitheatres which adjoined many of the temples. There exists a record from Ephesus in Asia Minor which describes in the second century a medical contest as a unique addition to the usual religious ritual of the god. This was indeed a significant illustration of the scientific approach of the Asclepiads to medical advancement and is suggestive of today's Royal 'College 'Medal and other notable prizes for scientific advancement. The plaque from Ephesus records that P. Vedius Rufinus won the prize essay, P. Aelius Menander won the prize in surgery, and P. Aelius won the prize for inventing new instruments. Though the last name is missing from this inscription, one is tempted to speculate that it was the same man who won the prize in surgery. Perhaps his invention was the prototype of a modern retractor or a clamp.
Tini INFLUENCE OF AsGLEPIus

The worship of any god in the ancient world was accompanied by 'ancillary rites, sacrifices, hymns, processions and festivals. From these the cult of Asclepius evolved with devotions given to preserve health (prophylaxis) and to treat disease. Physicians prayed daily either at temples or in their 'homes, while the prayers of regular devotees were supplemented by festivals. The sick prayed at home or at temples, and often relatives or friends would also pray for assistance. The temples had buildings to 'house the sick in which treatment was carried out. The Abaton was the most sacred of these, and 'here the sick slept at the foot of a large ornate statue of Asclepius. The god would not treat illness caused by luxury and folly, and the dream visits occurred only after suitable 'hypnotic conditioning. Dying and obstetrical patients were also excluded. A sacrifice of

In 292 B.C. an uncontrolled epidemic was raging in Rome and envoys were sent to obtain help from Asclepius at Epidaurus. The god caine to the city in the form of a snake and after controlling the pestilence established a sanctuary on an island in the Tiber.* Other centres of healing were established thoughout Greece, in the Aegean islands, in Italy, Asia Minor, Carthage, Egypt, 'Cyrene, Spain, and Phoenicia. The Roman legions even took the god to Britain and although no sanctuaries have been found, there are four known dedications, and a symbol similar to the staff of Asclepius appears on part of the temple of Sul Minerva at Bath (Fig. 4). The sanctuary at Epidaurus in Greece was founded in the sixth century B.C. and endured until 355 A.D.; archeological studies have allowed the reconstruction of that famous site which was favoured by both Alexander the Great and the Emperor Hadrian. At the zenith of the god's influence there were an estimated 800 temples. Study of all the sites is far from complete and much valuable information still awaits the skilled digger. Perhaps some day our medical associations and pharmaceutical 'houses may encourage further study in this valuable aspect of medicine.
*The island was shaped in the form of a boat and may still be seen today. W4th' the ascendancy of Christianity, St. Bartholomew took over the sanctuary and continued to care for the sick. It was here that the ailing London monk, Rahere, was treated for malaria and in thanks for his recovery fulfilled a vow to build in London a hospital to St. Bartholomew. St. Barts is today a major scientific and teaching Institution and is the only hospital In the city of London (the area bounded by the original Roman and medieval "walls).

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which stands on a serpent. The serpent is symbolic of both Asciepius and evil. This coin was minted shortly after the destruction by Constantine of the Asciepian temple at Aegea. No further coins depicting Asclepius appear until the Middle Ages. At this time the symbol of the snake and and staff reappears on plague tokens; even numismatically the god survived the dark ages. Edelstein has accumulated and translated 861 original Greek and Latin literary testimonies to the god Asclepius. These supply a ready source of reliable references attesting to his influence. Alexander the Great dedicated 'his breast plate and spear to the god. The dying words of Socrates (406 B.C.) were said to be "We owe a cock to Asclepius, and do not neglect it." Plato (427-348 B.C.) in the third book of "The Republic" revealed that Asclepius refused to treat those whose bodies were diseased throughout, thereby removing the handicapped and their offspring from the State (a philosophy of selective breeding and a system of therapeutics which is biased towards the therapist's success). Hippocrates makes many references to Asclepius, and one of these (T.568) supports the establishment of the sanctuary at Cos in pre-Hippocratic times. Celsus (first century A.D.) states, "Hence Asclepius, since he is celebrated and its most ancient founder and because he cultivated medicine with a little more exactness, was numbered among the Gods." Galen (129 to 100 A.D.) frequently refers to 'him in his writings: "the ancestral God Asclepius of whom I declare myself to be a servant since he saved me when I 'had the deadly condition of an abscess." In "De Anatomicis Administrationibus", Galen writes, "I was receiving instructions from Satyrus who was then spending 'his fourth year at Pergamum with Constunius Rufinus who was building for us the Temple of Zeus Asclepius." The equating of Asclepius with Zeus attests to the growth and influence of the Asclepian cult until in the second century the god of medicine was equated with the senior gods in the Greek Pantheon.
THE DECLINE OF AscLEPLus

The cult continued to thrive until the third century when Christianity became a major opposing religious force. The Christians condemned Asclepius more than any other pagan deity probably because in the early gospels Jesus was also a healer and a physician. Lactantius, the Christian writer and tutor of Constantine's son, the later emperor of Crispus, refers to Asclepius as the "arch demon". Tertullian, a Christian scholar from Carthage (circa 200 A.D.), calls him "a beast so dangerous to the world". Eusebius the Bishop of Caesarea and a Christian historian, describes him as "the one who draws men away from their true savi.our..

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A basic rancor is experienced even today when physicians are confronted by chiropractors or other professed healers with a different academic or philosophic background. Although 'both religions sought health and happiness, the Asciepian cult differed basically from Christianity in that it was selective. Asclepius would heal only those dedicated and pure in thought; and the dying and the pregnant were even excluded from his sanctuary. Jesus healed 'body and soul of good and bad and offered to all, even those about to die, eternal life. Both religions had a personal contact with their respective gods, but in Christianity this was more intimate and the people at that time sought and needed a personal friendly god. The serpent symbol of Asclepius served the Christian propaganda campaign well because for them the snake was the symbol of evil. The third most important Asclepian sanctuary at Pergamum was destroyed by an earthquake in the mid-third century and it was not rebuilt. This was a milestone in the decline of the Aselepius cult, symbolically hastened by nature, as Pergamum was a centre for teaching and pilgrimage. The adoption of Christianity as the official state religion by Constantine around 312 A.D. further weakened Asclepius and the damage increased when the Emperor ordered the destruction of the Asclepian temple at Aegea (331 A.D.). During the decline of popularity the intellectuals remained loyal to the cult. The Emperor Julian (355-363 A.D.) favoured return to the pagan religion and during his reign there was a temporary plateau in the downward course of the Asclepian cult. At Aegea he ordered the Christian priest to restore to the temple of Asclepius the pillars that were removed from it when Constantine had ordered the temple's destruction. This order was carried out so sluggishly, almost as if aided by nature, that it was not completed. This showed that in spite of the orders of an emperor called Apostate the cult could not regain its former glory. History does not record the fate of the other temples; some became early Christian hospitals while others were eroded by time, nature and 'Christianity.

The story of Asciepius spans three millennia, and a true evaluation of his contributions has not yet been reached. There is a hoard of literary references on this subject but they are seldom assessed by physicians. Our casual attitude towards our origin has allowed us to be symbolized in the minds of the public by a Babylonian phallic symbol, or at best the symbol of messengers, thieves and commerce. That this error should be fostered is a subtle tribute to the power of the U.S. Army who germinated it, but it also reflects our lack of historical interest. The numismatic material on the subject of Asclepius has been but superficially analyzed. Archeology will slowly supply more knowledge of our past. The Edelsteins were the first and probably the only authors to date who have realized the extent and religious significance of the Asclepian cult. The testimonies and dedications by every physician and philosopher of the classical period support their conclusions. The sources of information are so varied that every conclusion may be disputed. Even Sigerist, the greatest medical historian of this century, felt that the Asclepian cult followed rather than preceded Hippocrates at Cos. The fact remains that Asclepius has survived both the fall of the classical world and the rise of Christianity. He is still among us even if the humors have been replaced by hormones and the temples by hospitals.
REFERENCES 1. EDELSTEIN, E. AND EDELSTEIN, L.: Asciepius, Johns Hopkins Press, Baltimore, 1945. 2. GUIRAND, F., editor: Larousse encyclopedia of mythology, Prometheus Press, New York, 1959. 3. LAUGHLIN, V. C.: J. mt. Coil. Surg., 38: 82, 1962. 4. FROTHINGHAM, A. L., JR.: American Journal of Archaeology, 20: 175, 1916. 5. MARTI-IBANEE, F.: mt. Rec. Med., 173: 99, 1960. 6. TOOLE, H.: Surgery, 53: 387, 1963. 7. DURFEE, R. B.: ,T. mt. Coil. Sury., 38: 480, 1962. 8. SIGERIsT, H. B.: Bull. Inst. Hist. Med. John,s Hoph. Univ., 2: 190, 1934. 9. ABERNETHY, T. J.: Bull. Amer. Coil. Phys., 4: 229, 1963. 10. Editorial: J. A. M. A., 172: 245, 1960. 11. SCARTH, H. M.: Aquae solis, or Notices of Roman Bath, Simpkin, Marshall, & Co., London, 1864. 12. MARTI-IBANEE, F., editor: The epic of medicine, Clarkson N. Potter, Inc., New York, 1962. 13. POTTER, B. S.: Serpents in symbolism, art and medicine: the Babylonian caduceus and Aesculapius club, Privately printed, Santa Barbara, California: The Author, 1937. 14. LEAKE, C. D.: Arch. Intern. Med. (Chicago), 113: 496, 1964.

PAGES OUT OF THE PAST: FROM THE JOURNAL OF FIFTY YEARS AGO CASES FROM "THE SHAMBLES" his scapula chipped; a piece of shell made a gash over his right lower jaw, and fractured it, and besides these wounds As it has been my function to keep "Villa St. Pierre" full he had scratches elsewhere. He got to a base hospital in of cases, and to work there at night, I have not been able one day, but soon developed tetanus. He slowly recovered to follow up many cases closely. But some, I think, are and on December 7th was in good spirits, the first and worthy of mention. only time I saw him. The nurse outside his room was not Compound fractures; tetanus; recovery: Never were the able to say whether he had had antitetanic serum imhorrors of war brought so forcibly to me as when I chanced mediately, but he was injected later with it, and was kept to see a young British officer whom I knew and when I was under the influence of chlorotone, and was given hypoable to hear and read his story. As a cavalry officer he dermic injections of 2 per cent. carbolic. However, no was called upon to dismount and fight in the trenches. On attempt could be made up till that date to attend to the October 29th be was struck by an exploding shell. His arm properly.-The War, T. A. Malloch, Canad. Med. Ass. right arm was broken in several places, and pieces of the humerus protruded, his right shoulder was much torn and J., 5: 162, 1915.