Asklepios: Ancient Hero of Medical Caring James E. Bailey, MD, MPH

Western culture's demands of integrity, sacrifice, and com­passion from its physician healers have roots in the mythic traditions of ancient Greece. By understanding these tra­ditions, modern physicians can better understand their patients' expectations and the high expectations physi­cians often have for themselves. The mythic figure Askl­epios was the focus of Greek and Roman medical tradition from approximately 1500 BC to 500 AD. As a physician-hero, Asklepios exemplified the ideal physician and the pitfalls he or she may face. With the progressive deification of Asklepios and the spread of his worship first in Greece and then in the Roman empire, Asklepios became gener­ally recognized as the god of healing and served as an object of supplication, particularly for the poor and disre­garded. Asklepian traditions for medical service provide historical insight into the role of modern physicians and their obligations to care for the underserved.

From the University of Washington, Seattle, Washington. For the current author address, see end of text.

Ann Intern Med. 1996;124:257-263.

I swear by Apollo Physician, Asklepios, Hygiea, Pana­cea and all the gods and goddesses, making them my witnesses. . . . Into whatever houses I may enter, I will come for the benefit of the sick.

Hippocratic Oath, circa 400 BC

Western society has long expected physicians to be caring and dedicated to patient welfare

and has even viewed compassion as integral to phy­sician competency. Expectation of physician caring predates Christianity. The ancient Greek origins of Western traditions for medical caring are rooted in the myths of the physician-god Asklepios. The Askl­epian tradition, largely forgotten by modern physi­cians, provides some of Western culture's earliest guidelines for physician behavior. Prominent ancient physicians, including Galen, considered themselves followers of Asklepios (1-3), and Plato called even Hippocrates "the Asklepiad" (4). Although physi­cian roles and status have changed substantially in the last 3000 years, the public's demand for integ­rity, sacrifice, and compassion from its physician healers has remained relatively constant. Under­standing the ancient Greek origins of our traditions for medical caring can help us to understand the basis for our own aspirations as physicians and the expectations of our patients.

Health care reform and economic pressures have revived ancient debates over the obligations of phy­

sicians and society to provide health care to the medically disadvantaged. Decisions on provision of care to the underserved are value laden and should be informed by careful examination of personal and societal values. The Asklepian myth illustrates an ancient understanding of physicians' duties for pro­viding care to the underserved, which historians have previously underemphasized. Because Western medical ethics originate largely from ancient Greece, it is appropriate to examine these early traditions in order to better understand our own values regarding medical philanthropy.

The Homeric Asklepios

Although Mycenaean inscriptions dated as early as 1500 BC suggest the worship of Asklepios (5), Homer first related the myth of Asklepios (circa 900 BC). Homer does not consider Asklepios a god. As Roman commentator Theodoretus (circa 393 to 457 AD) points out (6), Homer only refers to Asklepios as "the blameless physician" (7). Only Asklepios's sons, Machaon and Podalirius, appear in the Iliad or Odyssey, in which they are presented as craftsmen skilled in the art of healing like their father. They serve as physicians with the Argive soldiers arrayed against the Trojans. Although Machaon and Poda­lirius are depicted as heroes, they are unlike all other heroes of the Homeric epic in that they are not recognized for their prowess in war or leader­ship capability but for their skill as physicians (8, 9). The wise leader Nestor recommends that great measures be taken to save Machaon when he is endangered in battle, saying "a leech [a physician] is of the worth of many other men" (10).

All other Greek heroes of this period were chief­tains and aristocrats; why did Homer elevate Askl­epios and his sons to the status of heroes? In Ho­meric times, physicians were of inferior standing and were considered craftsmen, not noblemen. In the Odyssey (11), physicians are placed in a class with other itinerant laborers, and, in the Homeric epic, Asklepios is not even recognized as the son of the god Apollo. The Edelsteins (12) point out that Asklepios is never depicted as a traditional Greek hero. Throughout Greek literature he performs no heroic feats other than healing. Unlike traditional

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Greek heroes who gain their livelihood through conquest, Asklepios has to work for a living. This makes Asklepios a very unusual type of hero, found nowhere else in Greek mythology.

The Edelsteins (12) introduce the concept that perhaps Asklepios, as an archetypal physician for the Greeks, was first a representative and hero of the common people, not the aristocrats. Whenever Asklepios is mentioned, his honorific is as "a great joy to men, a soother of cruel pangs" (13) or as a "gentle craftsman" brought to "heal mortal men of painful maladies" (14). In the earliest literature, Asklepios is described primarily as a healer, helper, and hero of the common people.

The Hesiodic Myth

The oldest written version of the myth of Askl­epios was told by Hesiod (15) in approximately 700 BC. Only fragments remain, but they are corrobo­rated by the tale recorded by the mythographer Apollodorus around 50 AD (16). Apollodorus's myth is thought to most accurately reflect the story of Asklepios's birth and death in ancient Greek times (17, 18):

Asclepius was . . . a son of Coronis, daughter of Phl-egyas in Thessaly. And they say that Apollo loved her and at once consorted with her, but that she, in ac­cordance with her father's judgement, chose Ischys and married him. . . . Apollo cursed the raven that brought the tidings and made him black instead of white, as he had been before; but Coronis he killed. As she was burning, he snatched the babe from the pyre and brought it to Chiron, the Centaur, by whom he was brought up and taught the arts of healing and hunting. And having become a surgeon, and carried the art to a great pitch, he not only prevented some from dying, but even raised up the dead; for he received from Athena the blood that flowed from the veins of the Gorgon, and while he used the blood that flowed from her left side for the bane of mankind, he used the blood that flowed from her right side for salvation, and by that means he raised the dead. I found some who are reported to have been raised by him: Capaneus and Lycurgus . . . Hippolytus . . . Tyndareus . . . Hy-menaeus . . . and Glaucus, son of Minos. . . . But Zeus, fearing that men might acquire the healing art from him and so come to the rescue of each other, smote him with a thunderbolt.

The broad strokes of the myth are clear. Askl­epios was the son of a god, as were Achilles and Hercules. Like them, Asklepios shares an aspect of his father's godlike character; Apollo is the god of healing as well as the sender of plagues. Coronis, Asklepios's mother, is killed by her lover Apollo because of Apollo's jealousy. Asklepios is then born by cesarean section, more properly called Apollo­nian delivery, out of the womb of his dying mother, thereby symbolizing by his very life the ability of the physician to bring life out of death. Asklepios re­

fines the art of medicine to the degree that he can raise the dead. Zeus then killed Asklepios because he restored the dead to life.

As the Edelsteins (19) point out, Zeus resents Asklepios in the same way in which he resents Prometheus, the Greek demigod Zeus eternally punished for bringing fire to mankind. The actions of Asklepios and Prometheus helped mortals and elevated the human race, making them the equals of gods and ultimately threatening the gods' power. Asklepios is destroyed precisely because of his benev­olence to mankind. To the Asklepiads, the physician followers of Asklepios, "his boldness, his Promethean endeavor was in line with their own ideals; his suffer­ing, in their eyes could only be merit and distinction" (20). What made the Asklepios of Hesiod heroic and gave his physician followers honor was that Asklepios stood up for mankind, even risking death to alleviate the suffering of others.

However, Asklepios's fault was not raising the dead in general but restoring the lives of those Zeus had condemned (21, 22). As Jonsen (23) points out in his essay "Asklepios as Intensivist," Asklepios was killed because he "was extending his compe­tence into a forbidden field—life-saving service to one whose life was forfeit to the gods." That the gods permitted Asklepios to raise the dead is sug­gested in the Hesiodic-Apollodorian myth by Athe­na's act of giving him the Gorgon's blood, the means by which Asklepios restores the dead to life. Ovid's version of the myth (24), written between 43 BC and 18 AD, makes this explicit: " . . . to thee shall it be counted right to restore the spirits of the departed. But having dared this once in scorn of the gods, from power to give life a second time thou shalt be stayed by thy grandsire's lightning." Ovid (25) suggests that Asklepios's error was to act "against the will of Dis," directly at odds with the purposes of the gods.

An essential part of the Hesiodic myth that other interpreters have overlooked is that the persons for whom Asklepios knowingly risked death were con­demned criminals such as Capaneus, Lycurgus, and Hippolytus (26). Asklepios is killed for extending his compassion to the condemned and raising from the dead the most infamous of men. Even a cursory reading of the Greek tragedies shows that those cursed by the gods were outcast by society. No one dared assist these outcasts for fear of incurring the wrath of the gods. The ancient Greeks considered Asklepios as the foremost physician because he alone dared to care for the outcast, to succor any­one suffering, regardless of the consequences. This suggests that the obligation of the physician to assist the suffering, regardless of the sufferer's station and the personal risk the physician might incur, is inte-

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gral to the ancient Greek understanding of physi­cian duty.

The Pindarian Myth

Contrast the stories of Hesiod and Apollodorus with the more modern version related by the poet Pindar (circa 520 to 442 BC) (27):

Cheiron . . . reared Asclepius, that gentle craftsman who drove pain from the limbs that he healed—that hero who gave aid in all manner of maladies. . . . Apollo... bare the babe away, and gave it to the Magnesian Centaur to teach it how to heal mortal men of painful maladies.

And those whosoever came suffering from the sores of nature, or with their limbs wounded either by gray bronze or by far-hurled stone, or with bodies wasting away with summer's heat or winter's cold, he loosed and delivered divers of them from divers pains, tend­ing some of them with kindly incantations, giving to others a soothing potion, or, haply, swathing their limbs with simples, or restoring others by the knife. But alas! even the lore of leechcraft is enthralled by the love of gain; even he was seduced, by a splendid fee of gold displayed upon the palm, to bring back from death one who was already its lawful prey. There­fore the son of Cronus with his hands hurled his shaft through both of them, and swiftly reft the breath from out their breasts, for they were stricken with sudden doom by the gleaming thunderbolt.

Pindar's myth is best known and most frequently cited as a warning to physicians to avoid putting fee collection above the duty to serve a patient's best interests. Yet, Pindar's version alters essential ele­ments of the myth. In the beginning of the passage (which is not shown), Apollo has his lover Coronis killed, not because of jealousy but because she con­sents to marry the mortal Ischys without her father's permission. Furthermore, Asklepios transgresses di­vine decree not for compassion but for greed. These major departures from the earliest texts are attrib­uted to Pindar's association with the cult of the Delphic Apollo (28). Pindar reinterprets the myth in light of a new understanding of the Olympian gods, in which Apollo is given a central position in the hierarchy of the gods as a consistent harbinger of justice. As the divine guardian of law and order, he loses his rash and jealous Homeric character. This emerging world view could not attribute petty jeal­ousies to the gods nor suggest that a faultless Askl­epios was killed because the gods wished to protect their power.

Many commentators find Pindar's interpretation of the Asklepios myth troubling because of its treat­ment of his death. Roman commentator Tertullia-nus (29) criticizes Pindar's depiction of Asklepios for this reason. In Plato's Republic (30), Socrates questions Pindar's version of the myth for its deg­radation of Asklepios in the same way in which Pindar sought to avoid degrading Apollo:

And yet in disregard of our principles the tragedians and Pindar affirm that Asclepius, though he was the son of Apollo, was bribed by gold to heal a man already at the point of death, and that for this cause he was struck by the lightning. But we . . . refuse to believe both statements . . . if he was the son of a god he was not avaricious . . . and if he was greedy of gain he was not the son of a god.

The quandary related by Socrates developed as a result of a changing understanding of the gods in post-Homeric Greece. The sanctified gods could not bear the same relation to a divine Asklepios as had previously been recorded. Within this world view it would be inconsistent for Asklepios to restore to life those condemned by the gods, just as it would be inconsistent for Apollo to kill Coronis in a jeal­ous lover's rage.

Asklepios as a Physician-God

Resolution of the conflicts between the old myths surrounding Asklepios and the emerging under­standing of the sanctified gods came through the progressive deification of Asklepios from approxi­mately 500 BC to 100 AD. The earliest clear refer­ral to Asklepios as a god in Hellenistic Greece comes from an Athenian inscription of 420 BC (31). The Hymns attributed to Hesiod, which were writ­ten at the end of the fifth century BC to promote the cults of Delphi, attest to the worship of Askl­epios (32). The myth that emerges from the Delphic cult is purified, and all traces of violence and jeal­ousy are eradicated. The first complete rendering of the divine myth does not appear until 140 AD. This myth comes by way of Pausanias (33), a Roman, who relates the tale he heard on his visit to Epi-dauros, where the most famous of the temples to Asklepios had arisen:

[Phlegyas] was accompanied by his daughter, who all along had kept hidden from her father that she was with child by Apollo. In the country of the Epidaurians she bore a son and exposed him on the mountain. . . . As the child lay exposed he was given milk by one of the goats that pastured about the mountain, and was guarded by the watch-dog of the herd. . . . The herds­man . . . finding the child, desired to take him up. As he drew near, he saw lightning that flashed from the child, and, thinking that it was something divine, as in fact it was, he turned away. Presently it was reported over every land and sea that Asclepius was discovering everything he wished to heal the sick, and that he was raising dead men to life.

Most Roman sources agree with the outlines of the story above and report that Asklepios was res­urrected after his death on earth to live on as an immortal, ever-present in the Asklepian temples, or Asklepeions. The only healing Roman sources con­sistently attribute to the god Asklepios during his life on earth was that of Askles, a tyrant of Epidau-

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ros. Although writers dispute the etymology of the name Asklepios, several suggest that the god's name is derived from his "epios" (Greek for gentleness, kindness, calmness) with the tyrant Askles (34). Thus, Asklepios's name attests to his characteristic kindness to all those suffering. Writers agree that mildness and kindness were Asklepios's essential attributes and those of the ideal physician (35, 36).

In the later Greek and early Roman literature, Asklepios increasingly appears to represent an ab­stract personification of the ideal physician. His wife and children are made to personify abstract medical concepts: His wife, Epione, personifies "epios"; Machaon is the representative of surgery and Poda-lirius, the representative of internal medicine; Hy-giea gave Asklepios dual roles as the giver and preserver of health; and Panacea represented the "soothing simples" or remedies by which the god Asklepios brought the suffering comfort.

The Rise of the Asklepeions

Scholars agree that the worship of Asklepios be­gan in the rural provinces of Greece among the common people. The Edelsteins (37) attribute the rapid ascendancy of Asklepios to his popularity among the poor and lower classes, who saw in Askl­epios a god particularly interested in their welfare. Alone among Greco-Roman gods, Asklepios is de­scribed as "looking after man" and as a lover of all people, regardless of station (38). As a physician-god, his primary interest was to help individuals. Asklepios was personally accessible to supplicants through divine revelation and healing, within and outside of his temples, as no previous god had been. It is of particular interest that in Greek and Roman mythology, a physician plays this role. This associa­tion placed the physician followers of Asklepios un­der strong obligation to serve all those suffering.

The general acceptance of Asklepios as a god in the Greek world is signified by his coming from the central sanctuary at Epidauros to Athens in 420 BC and the consecration of his temples there (31). His worship subsequently spread throughout Greece, much of Asia Minor, and even Carthage and Egypt, partly through Alexander the Great's staunch devo­tion to Asklepios. Furthermore, Asklepios was among the first foreign gods accepted in Rome. In response to an epidemic in Rome, the Romans consulted oracles of Apollo and were told to bring the god Asklepios from Epidauros to Rome, where a temple was founded around 291 BC (39, 40). From Rome, the worship of Asklepios spread with the expansion of the Roman empire throughout the Western world (41).

Descriptions of the remains of the Asklepeions

and the worship practices there are well detailed (42-44). Supplicants with illnesses unresponsive to traditional therapies would make pilgrimages to Asklepeions to entreat the assistance of the god. Priests there would turn away those deemed incur­able but would invite in all others to undergo "in­cubations," in which they would sleep in the temple and the god would visit and heal them in their dreams. Testimonials to the many cures are in­scribed in the walls of the temples.

Asklepios as a Man-God

Asklepios remained very different from all the other Olympian gods. He was typically referred to as a "daimon" (Greek for spirit) who would come to supplicants in their dreams rather than a "theos" (Greek for god). He was clearly understood as a man-god, that is, as a god who once walked the earth. He died the death of a mortal before ascend­ing to the heavens, from which he could still visit mankind in response to their prayers. In Roman times Asklepios became the "most powerful antag­onist in the spiritual struggle . . . between paganism and Christianity" (45). Christian apologists, justify­ing their religion, suggested that their belief that Jesus died the death of a mortal was no stranger than Roman beliefs about the god Asklepios, who had suffered the same fate (46). Justin (47), a lead­ing Christian apologist of the second century, wrote "and when we say also that . . . Jesus Christ . . . was crucified and died, and rose again, and ascended into heaven, we propound nothing new and different from what you believe regarding . . . Asclepius, who though he was a great physician, was struck by a thunderbolt, and so ascended to heaven."

As the Edelsteins (48) point out, it is little won­der that Asklepios presented formidable competi­tion to the emerging worship of Jesus Christ in the Roman Empire. Jesus is emphasized in the early gospels as a physician, healer, and savior, with a particular interest in the poor and destitute. Askl­epios and Christ are similarly described as blame­less. Church fathers found little to criticize in the life of Asklepios on earth. As he is described during this period, Asklepios is likened to the god of the New Testament (49); he was viewed as provident, and he forgave any offense because of his devotion to mankind (50). Individual Greeks and Romans often believed in the god Asklepios because of the powerful cures demonstrated at his temples. Even Galen (circa 129 to 210 AD) became a devoted follower of Asklepios because he was healed at the god's temple and was assisted in cures through Asklepios's appearance in his dreams (3, 51).

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Physician Followers of Asklepios

Although ancient Greek physicians held low sta­tus in society as itinerant craftsmen, they gained prestige through their association with Asklepios. Most modern commentators agree that " . . . Ascl-epius, before becoming a healing god, was the pa­tron saint of the medical men . . . " (52). By the latter half of the 6th century BC, physicians (Greek, "iatros") were increasingly referred to as Asklepiads (Greek followers or sons of Asklepios). Authors suggest that this title originally referred to one fam­ily of physicians whose descendants were called Asklepiads and into which outsiders were later ad­mitted by adoption (53, 54). However, by the fifth century BC, the title Asklepiad is most commonly used generically to refer to all physicians (55, 56). The title of Asklepiad is particularly given to phy­sicians of note, as is witnessed by Plato's referral to Hippocrates as "the Asklepiad" (57) and Aristotle's referral to him as "the leader of the Asklepiads" (58). On the other hand, priests in the temples of Asklepios were almost always referred to as priests or sacristans (59).

The risk for death faced by the mythical Askl­epios was a real risk confronted by physicians in their daily practice, as Greek historical accounts confirm. The most famous portrayal is Thucydides' account of the plague of Athens around 430 BC (60):

They had not been many days in Attica before the plague first broke out among the Athenians. . . . There was no record of the disease being so virulent any­where else or causing so many deaths as it did in Athens. At the beginning the doctors were quite inca­pable of treating the disease because of their igno­rance of the right methods. In fact mortality among the doctors was the highest of all, since they came in contact more frequently with the sick.

Thucydides suggests that the physicians' craft was not highly esteemed because of its frequent ineffec­tiveness and was undesirable because it exposed the physician to dangerous communicable diseases. Fur­thermore, he implies an expectation that physicians would not avoid such exposure because avoidance would be inconsistent with the practice of their art. The practice of medicine was understood to entail responsibility to care for the sick, even if this work placed the physician in danger. The passage does not ascribe to the physician altruistic motives for providing care to Athens' plague-ridden people but simply portrays an expectation that physicians prac­tice their art.

The Duties of the Asklepian Physician

Once Asklepios was generally recognized as the god of medicine, physicians who considered them­

selves followers of Asklepios had a clear obligation to treat the rich and the poor alike. The god Askl­epios was noted for his devotion to healing the poor (61, 62), regardless of the size of their offering (59). The donations of the rich were used to subsidize care for the poor in the Asklepeions. Cost shifting is evidenced by the many temple inscriptions record­ing cures of those able to afford traveling from out of town (63). The Hippocratic Precepts explicitly encouraged similar cost shifting (64).

Slavery was prevalent in ancient Greece and Rome. There can be little doubt that slaves did not have equal access to medical care in these societies. However, as Asklepios rose in stature, even slaves had recourse to his temples and could expect a measure of assistance. Writing at the end of the first century AD, Suetonius (65) reports:

When certain men were exposing their sick and worn out slaves on the Island of Aesculapius [the Tiber Island in Rome] because of the trouble of treating them, Claudius decreed that all such slaves were free, and that if they recovered, they should not return to the control of their master; but if anyone preferred to kill such a slave rather than to expose him he should be liable to the charge of murder.

Similar manumissions of slaves were associated with temples of Asklepios in the Roman Empire in Orchomenos, Thespiai, Stiris, Elateia, Amphissa, and Naupaktos (66), implying that Asklepios, alone among the gods, viewed people as equals and that Asklepios and his followers had a special interest in seeing that all people were treated equally.

The Asklepian tradition in the age of the divine Asklepios is clear in its commitment to equal ser­vice to all people, and it demands this commitment of its physician followers. An inscription at the Athenian temple to Asklepios on the Acropolis reads "These are the duties of a physician . . . he would be like God savior equally of slaves, of pau­pers, of rich men, of princes, and to all a brother, such help he would give" (67).

Conclusion

Although the stories about Asklepios have largely been forgotten, they had far more influence on an­cient Greek and Roman societies' expectations of physicians than did the Hippocratic corpus. Askl­epian myth insists much more than does the Hip­pocratic literature on care for the poor and disre­garded, and as such it presents a different and more suitable ethic for modern medical practice. Askl­epian myth shows us that Greeks and Romans ex­pected physicians to practice their craft without pri­mary regard for the social status of their patients, personal risk, or financial gain. Asklepios, depicted

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in myth first as a physician-hero and then as a physician-god, represents the ideal physician to whom people in ancient Greece and Rome turned for healing and relief of suffering. Although some of the physicians who called themselves Asklepiads were certainly charlatans, at least some of the phy­sician followers of Asklepios aspired to emulate his selfless caring for all those suffering. Given that people are perhaps most equal in their capacity for suffering, is it not intriguing that a physician-god should be one of the only gods, in a strict caste society, to be egalitarian in his concern? Like the ancient Greeks and Romans, our patients are searching for the caring attributes of Asklepios in their providers. Perhaps by better understanding Asklepios we can help to restore the spirit of Askl­epios to the practice of medicine and thus satisfy both our patients and our deepest expectations for ourselves.

Acknowledgments: The author thanks Albert R. Jonsen, PhD, Robert Burns, MD, and Joel D. Howell, MD, PhD, for their review and helpful comments on the manuscript and Sharon S. Bailey, JD, Kathon Ann Kelly, and Pamela A. Swann for their expert editorial assistance.

Requests for Reprints: James E. Bailey, MD, MPH, The University of Tennessee, Memphis, Department of Medicine, 842 Jefferson Avenue, Room A607, Memphis, TN 38103.

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The truth is, an immense majority of all die as they are born—oblivious. A few, very few, suffer severely in the body, fewer still in the mind. Almost all of Shelley's description fits:

Mild is the slow necessity of death; The tranquil spirit fails beneath its grasp

Without a groan, almost without a fear, Resigned in peace to the necessity;

Calm as a voyager to some distant land, And full of wonder, full of hope as he.

No death need be physically painful. M. Maeterlinck has been most unfortunate to be able to say, speaking of doctors, "who has not at a bedside twenty times wished and not once dared to throw himself at their feet and implore mercy"; but this is the same type of hysterical statement as "all doctors consider it their first duty to protract as long as possible even the most excruciating convulsions of the most hopeless agony." There are no circumstances contradicting the practice of Thomas Fuller's good physician: "when he can keep life no longer in, he makes a fair and easy passage for it to go out." Nowadays, when the voice of Fate calls, the majority of men may repeat the last words of Socrates: "I owe a cock to Asclepius"—a debt of thankfulness, as was his, for a fair and easy passage.

Harvey Cushing, MD The Life of William Osier

Submitted by: B. Viswanathan, MD Gettysburg, PA 17325

Submissions from readers are welcomed. If the quotation is published, the sender's name will be acknowl­edged. Please include a complete citation, as done for any reference.—The Editors

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