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February 3, 1999

Aesculapius: A Modern Tale

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JAMA. 1999;281(5):476-477. doi:10.1001/jama.281.5.476-JMS0203-4-1

It is in and through symbols that man, consciously or unconsciously, lives, works, and has his being.—Thomas Carlyle, Sartor Resartus, 1836

Modern medicine lately has been the focus of much criticism. Both patients and physicians are quick to highlight the problems and pitfalls of the current medical system and foresee hard times in the profession's future. Although people in the United States have access to more technologically advanced health care than ever before, they are more distrustful of doctors and the powers of what may be broadly called the "medical system." Medical science seems to be fulfilling the prophecies of science fiction, in which doctors are portrayed as either heroes or villains.

To decipher the controversies surrounding medicine today, it is helpful to reexamine the discipline's origins in ancient Greece. After all, it is from ancient Greece that we derive our earliest and most enduring icons and ideals of medicine. Knowing the origins of the traditions of caring can deepen our personal understanding of the basis for our aspirations as physicians, the expectations of our patients, and the difficulties we encounter in our efforts to achieve these goals.

The Ancient Greeks

Study of ancient medical lore reveals that the controversies and contradictions facing modern medicine span the history of the profession. The language and mythology of the ancient Greeks reveal their recognition of the dual roles medicine plays as mediator of both mortality and cures. Apollo was both the god of physic and sender of disease. Pharmakos is the Greek word for both remedy and poison.

The image of the physician in the Western world originates with the Greek god of health and father of medicine, Asklepios, whom we also know by his more familiar Roman name, Aesculapius. According to earliest known writings, dated around 1500 BC, Aesculapius was the son of Apollo and his mortal mistress Coronis. Apollo killed Coronis in a fit of jealous rage after she was unfaithful to him. As her body was placed on the funeral pyre, he discovered that she was pregnant. He was stricken with remorse. He delivered their unborn child, Aesculapius, from her womb and gave him to Chiron, the centaur, to raise and to train in the art of healing.1 Aesculapius became the symbol of the healer in ancient Greek society and, later, throughout the Roman Empire. For centuries physicians were referred to as followers of Aesculapius.2 Hippocrates referred to himself as such and appealed to Aesculapius in the first line of the Hippocratic oath.2 Galen, the most influential physician of the Middle Ages, considered himself a devout follower of Aesculapius after he was healed at an Aesculapian temple. He held his medical practice in the ruins of this temple and was assisted in cures by the appearance of Aesculapius in his dreams.1,3 The famous Arabian physician, Avicenna, published his medical texts in 1544 with an image of Aesculapius on the frontispiece. The Aesculapian staff remains the artistic symbol of medicine today.

"Portrait of Asklepios or Aesculapius" by Carlo Gregori, Italian, 1719-1759, copper engraving, circa 1750. Photo credit: From the Collection of W. Bruce Fye.

"Portrait of Asklepios or Aesculapius" by Carlo Gregori, Italian, 1719-1759, copper engraving, circa 1750. Photo credit: From the Collection of W. Bruce Fye.

The Intensivist

Aesculapius was known by all accounts as a kind and gentle healer, relieving men of their pain and suffering.2 Eventually, his skill as a physician became so great that he was not only able to keep all his patients from dying, but he was also able to raise the dead. Zeus, king of the gods, was so angered by the audacity of a mere mortal performing such miracles that he killed Aesculapius with a thunderbolt. The contradiction here is self-evident. Zeus resented Aesculapius for the very reason that he was venerated on earth. He healed mortals and elevated the human race. He had discovered how to make men potential rivals to the gods and ultimately threatened their power.1,3

Is this so different from today, when physicians are accused of "playing god" by defying the natural boundaries of life and death? Critics often blame the explosive advances in scientific knowledge for transforming the traditional art of healing and palliation into an unnatural extension of life. Volumes have been written about the industrialization of medicine and the consequences of what has been considered technology-driven medicine. Yet, as one can see in the tales of Aesculapius, the "intensivist" character of the physician, who expands the art of healing ultimately to defy death, has existed for centuries, long before modern miracles such as cloning, gene therapy, organ transplantation, and artificial reproductive technologies.

The very birth of Aesculapius from the womb of his dying mother, in what many consider the earliest documented cesarean delivery, symbolizes the ability of the physician to seize life from death. The snake wrapped around the Aesculapian staff may also have had more than merely symbolic value. Snakes tied to a stick may have been a way of inoculating patients with nonlethal doses of snake venom—a primitive hypodermic injection device.4 Aesculapius is often depicted as a surgeon, holding a surgical knife or even performing surgery. These early images demonstrate the existence of surgical and other invasive life-saving procedures long before the development of modern science and technology. The implication is that the enmity engendered by modern physicians represents an inherent duality of human nature, rather than a natural reaction to technology gone awry.

The Divine

To blame modern society for elevating physicians to god-like status, as critics do when they assert that traditional religion has been replaced by the worship of science, is simply inaccurate. Aesculapius was venerated for his healing abilities. Over the centuries his status evolved from mortal to divine. He was vested with the unique ability to rise from the dead. Eventually, he became the most worshipped god in Greece. He was one of the first foreign gods accepted in Rome, and numerous Aesculapian temples persisted for centuries throughout the Roman Empire. The status of Aesculapius in pagan religion was considered parallel to that of Jesus Christ in Christianity, as the central deity around which the religion persisted.1,2 Thus, we can see that the near-religious reverence that some hold for physicians is not just a phenomenon of modern society but parallels attitudes that date back as far as 3000 years.

As humans, we want to defy mortality. In the face of death, we seek miraculous cures and unlimited hope. At the same time, we fear and resent the mortal who can achieve these goals. Such abilities may challenge our innate belief in the sanctity of the human soul, imagined to be beyond the control of man. The mythical status of Aesculapius, as demigod, represents the inherent contradictory expectations that we have of physicians. Throughout time, men have shared the common fantasy of the physician capable of healing all illness and defeating death. Thus, we created Aesculapius, a figure who was born out of death, who learned through perfecting his healing craft to bring others back from the dead, and who was finally resurrected from death himself.5 Yet, in being killed, Aesculapius fails as a god. Ultimately, he cannot save himself from death. His status as a half-mortal, who possesses emotion and dwells on earth, rather than on Olympus, represents his failure. At the same time, he fails as a mortal, by using his craft to save those already condemned to death. This tale demonstrates that from the earliest known times, the physician has been caught in the contradictory expectation to be both human and divine. Consequently, he can never fully be either.

The Tale Retold

Contemporary discussions often question the focus of medicine, arguing that traditional medicine has emphasized the maintenance of life at the expense of quality and comfort. The historical trajectory of medicine is often divided into 3 eras: the prescientific, in which medicine could not significantly save or extend life, but only provide some comfort and palliation; "technology-driven medicine," in which science has been used myopically to cure disease; and, more recently, public outcry for a "return to humanism." In this current phase, we are trying to synthesize the pluralistic demands of modern Western society into one coherent system of care. This pluralistic approach is evidenced by the recent attention to alternative medicine, spirituality, ethics, prevention, mental health, and holistic health. However, an examination of the history of medicine shows us that none of this is new.

Critics of modern medicine should not blame the technological revolution or loss of humanism for our current state of dissatisfaction with physicians. Rather, they should blame our timeless inability to reconcile conflicting desires and beliefs within ourselves about our own mortality. Our current veneration and concomitant distrust of the medical profession are sentiments that have been present throughout time, and probably will continue. The modern physician perpetuates the tradition of Aesculapius and, in doing so, bears the same social burden of both veneration and hostility. Rather than trying futilely to eliminate these contradictions, it seems our efforts as physicians would be better spent continuing to emulate the example of Aesculapius, carefully negotiating the contradictions of the powers and limits that we will face in the process.

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