ADandmaysurprisepresentdayAsclepianpuristsAccessionnumber12572intheGuildhallMuseumLondonisanoculistsstamponwhichareinscribedmanycaduceiThisartefactwasexcavatedin1931from15feetbelowstreetleve ID: 938678
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MEMAWDiOOCCSTheearliestmedicaluseofthecaduceusGeraldD.Hart,m.d.,f.r.c.p.[c],f.r.n.s.,f.a.c.p.,TorontoThecaduceusisasymbolknowntomankindforoverfourthousandyears.ItsearliestformatwasBabylo-nianandwasastaffsurmountedbytwoserpentheadsrepresentingthesupremesexualpowersoftheserpent1(Fig.1).Overthecenturiesvariousartistshavesimplifiedorembellisheditsform(Figs.2a,2b).Thepresentdaycaduceusconsistsoftwoserpentssymmetricallyentwinedaroundastafftotheheadofwhichisaffixedapairofwingswithsometimesapineconeorsimilarobjectontop.TotheGreeksandRomans,aswellastoustoday,itrepresentstherodorwandofHermesorMercuryandconnotesthatgod'spatronageofpeace,trade,commerceandcommunication.Medicalhistorianshavequestionedtheworthinessofthecaduceusasalogoforthemedicalprofession.2Itsacceptanceassuchinmanypartsoftheworld,especiallyintheUnitedStates,resultedfromanomissiononthepartoftheUnitedStatesMarineServicein1856.Atthattimeasymbolwasrequiredfornon-combatantmedicalpersonnelinthefield.ThecaduceuswasselectedforthisrolewhiletheSurgeon-General'screstof1818designedforthispurposeandshowingthestaffofAsklepioswasignored.Thecaduceusservedwellandin1857wasadoptedbytheU.S.Armyastheinsigniaforhospitalstewards.In1871itbecamethesym¬bolfortheUnitedStatesPublicHealthServiceandin1902itbecamethebadgeoftheUnitedStatesArmyMedicalCorps.3Asaresultofsuchofficialusemanydevelopingmedicalorganizationsincorporatedtheca¬duceusintotheircrestsandhenceitbecameanemblemofmedicine.TheRoyalCollegeofPhysiciansofDepartmentofMedicine,UniversityofTorontoReprintrequeststo:Dr.G.D.Hart,Director,DepartmentofHaematology,TorontoEastGeneralHospital,825CoxwellAve.,Toronto13,Ontario.Londonprobablyhadanindirectin¬fluenceinpopularizingthecaduceusasamedicalsymbol.JohnCaius,PresidentoftheCollegein1556,pre¬sentedtothecollegea"caduceus"tobecarriedbythePresidentasanensignofhonourbywhichhewouldbedistinguishedfromotherFellowsonallimportantoccasionssuchastheholdingofComitiaandthedeliveryoflectures.Thiscaduceusisasilverrodorsceptre26inchesinlengthand17ouncesinweight,bearingatitsheadFIG.1.TheearliesttypeofcaduceusasfoundonBabyloniancylinderseals.Thisshowstheheadsofamaleandfemaleserpentattachedtoasinglebody.ThissexualsymbolwasheldinthehandofthemothergoddessIshtar.thearmsofthecollege,supportedbyfourserpentsplacedatthecorners.Dr.Caius,thedesignerofthe"cadu¬ceus",statedthatthesilverrodin¬dicatedthatthePresidentshouldrulewithgentlenessandclemency,unlikethoseofoldentime,whoruledwitharodofiron.Theserpents,thesymbolsofprudence,teachthenecessityofrulingprudently,whilethearmsofthecollege,placedonthesummit,indicatethatgentlenessandprudencearethemeansbywhichtheCollegeissustained(Fig.3).Areplicaofthisoriginal"caduceus"waspresentedin1954totheAmericanCollegeofPhy¬siciansbythelateLordBrainandisusedonsimilaroccasionsbythePresidentoftheAmericanCollegeofPhysicians.4Inspiteofthisbackground,manyauthorscannotacceptthecaduceusasasubstituteforthetruemedicalsym¬bol,namely,thestaffofAsklepios(asingleserpententwinedaboutastaff).ThisreportdescribesmedicalusageofthecaduceusinthethirdcenturyFIG.2a.A3rdcenturyRomancoin,contemporarytotheoculist'sstamp,showingthesimplified"mirrorimage3"caduceus.Fig.2b.An18thcenturycommercialtradetokenshowinganembellishedcaduceussimilartothatusedbytoday'smedicalsocieties.C.M.A.JOURNAL/DECEMBER9,1972/VOL.1071107 A.D.andmaysurprisepresent-dayAsclepianpurists.Accessionnumber12,572intheGuildhallMuseum,London,isanoculist'sstamponwhichareinscribedmanycaducei.Thisartefactwasex-cavatedin1931from15feetbelowstreetlevelat129-130UpperThamesStreetintheCityofLondon.ThefindattractedtheattentionofthepopularpressanditwasdescribedintheDailyTelegraphofJuly31,1931.ThestampreceivednoticeintheAn-tiquariesJournalof1932whenthecaduceiwerenotdetectedbutweredescribedasacuriousdesignlikeacross.5TheartefactsurvivedthebombingandburningoftheGuild-hallinWorldWarIIand,moreamazing,itsurvivedthemuseum's20yearsoftemporaryquartersintheRoyalExchange!Itisatpresentdisplayedinthenewtemporarymu-seuminBarbican,CityofLondon.Oculists'stampsareofgreatinter-esttomedicalhistorians.Approxi-ilhiFIG.3-Topdetailoftheserpentson"thecaduceus"orthebadgeofdistinctionforthePresidentoftheRoyalCollegeofPhysicians,London(1556).(PhotographkindlysuppliedbytheCollege).FIG.4Oculist'sstampshowinginscriptionsontheedgeandcaduceiscratchedontothetopsurface.(PhotographsuppliedbyGuildhallMuseum,London).mately200areknowntoex
istandtheyhavebeenfoundmostlyinCelticareas,namelyGaul,GermanyandBritain.EyediseaseswerecommonintheRomanworldandmanyeffectiveremediesweredeveloped.Forcon-venience,medicamentsweredis-pensedinasolidstate.Theingredi-entsofvariouspreparationswerehardenedwithgumsorsomeotherviscidsubstanceandweremadeintosolidstickswhichbeforedryingwerecircumscribedwiththenameofthemedicalpractitioner,thenameofthespecialmedicineormedicalformulaandthediseaseforwhichthemedi-cinewastobeused.6Thisancientlabellingconformstopresent-daydis-pensingpractice.Foruse,piecesofthestickwerebrokenoffandmixedinamortarwithoil,honey,butteroregguntilanointmentofsatisfactorycon-sistencewasformed.Themethodofinscribingoculists'stickswassimplifiedbytheuseofspecialoculists'stampsmadefromsteatiteorgreenishschist.Thesestampsaresquareoroblongblockswithaninscriptiononeachofthefouredges.Theinscriptionsareinsmallcapitalletters,cutintagliate(likelet-tersonamodernseal)andconse-quentlyreadingonthestoneitselffromrighttoleftsothattheymakeanimpressionwhenstampedwhichreadsfromlefttoright.Fig.4showstheinscriptionontwoedgesofthecaduceusstamp.Whenprintedout(thestampstillworks)theinscriptionsareasfollows:(a)CSILVITETRICIEVODESADASPRITUDINES-"CaiusSil-viusTetricus'sscentedointmentforgranulations".(b)CSILVITETRICIPENI-CILLADIMPETLIPPITUDIN-"CaiusSilviusTetricus'ssalveforanattackofinflammation".(i.e.on-setofblepharitis).(c)CSILV(ITET)RICIDIAMI(SUS)ADD(IATH)ESEDCI-CAT-"CaiusSilviusTetricus'ssalvefordiseasesandsores(orscars)oftheeyes".(d)CSILVITETRICIBI-PROSOPUNADIM...-"CaiusSilviusTetricus'sapplicationforin-flammationoftheeyes".Thisstampindicatesthediseaseswhichwereprevalentatthattime.Side(c)istheonlyonegivingacluetothetypeofmedicineused;"DIAMI"(SUS)isthecollyriumdiamysuswhichcontainedmisyasitsprincipalingredient.Thissubstancewasamet-allicvitriolicusedbytheancientsasa*TenuatelN.F~N.F.)Indicatedforshorttermuseinthemedicalmanagementofobesity.AnorextcCOMPOSITIONTenuateTablets:Eachlightbluetabletcontains25mg.ofdiethylpropionhydrochlorideN.F.,asympathomimeticagent.TenuateDospan:Eachcapsule-shapedwhitetabletcontains75mg.ofdiethylpropionhydrochlorideN.F.,asympathomimeticagentcombinedwithaspecialhydro-philicmatrix.ACTIONThesoleclinicaluseofdiethylpropionhydrochlorideisreductionofappetite.Thisanorexicactionhasbeendem-onstratedinlaboratoryanimalsandinnumerousclinicalstudies.INDICATIONANDCLINICALUSEOverweight.Diethylpropionhydrochlorideisindicatedasanaidtocontroloverweight,particularlywhereitcom-plicatesthetreatmentorprognosisofcardiovasculardisease,diabetes,orpregnancy.(SeeWarning.)CONTRAINDICATIONSDiethylpropionhydrochlorideshouldnotbegivenconcur-rentlywithmonoamineoxidaseinhibitors,norshoulditbegiventopatientshypersensitivetodiethylpropionhydro-chlorideortoemotionallyunstableindividualswhoareknowntobesusceptibletodrugabuse.WARNINGAlthoughdiethylpropionhydrochlorideisgenerallysaferthantheamphetamines,itshouldbeusedwithgreatcautioninseverehypertensionandseverecardiovasculardisease.Althoughratandhumanreproductivestudieshavenotindicatedadverseeffects,thisdrug,likeallmedications,shouldnotbeusedduringthefirsttrimesterofpregnancyunless,intheopinionoftheprescribingphysician,thepotentialbenefitsoutweighthepotentialrisks.ADVERSEREACTIONSRarelysevereenoughtorequirediscontinuationoftherapy,unpleasantsymptomswithdiethylpropionhy-drochloridehavebeenreportedtooccurinrelativelylowincidence.Asischaracteristicofsympathomimeticagents,itmayoccasionallycauseCNSeffectssuchasinsomnia,ner-vousness,dizziness,anxiety,andjitteriness.Incontrast,CNSdepressionhasbeenreported.Inafewepilepticsanincreaseinconvulsiveepisodeshasbeenreported.Sympathomimeticcardiovasculareffectsreportedincludeonessuchastachycardia,precordialpain,arrhythmia,palpitation,andincreasedbloodpressure.OnepublishedreportdescribedT-wavechangesintheECGofahealthyyoungmaleafteringestionofdiethylpropionhydro-chloride;thiswasanisolatedexperience,whichhasnotbeenreportedbyothers.Allergicphenomenareportedincludesuchconditionsasrash,urticaria,ecchymosis,anderythema.Gastrointestinaleffectssuchasdiarrhea,constipation,nausea,vomiting,andabdominaldiscomforthavebeenreported.Specificreportsonthehematopoieticsystemincludetwoeachofbonemarrowdepression,agranulocytosis,andleukopenia.Avarietyofmiscellaneousadversereactionshavebeenreportedbyphysicians.Theseincludecomplaintssuchasdrymouth,headache,dyspnea,menstrualupset
,hairloss,musclepain,decreasedlibido,dysuria,andpolyuria.DOSAGEANDADMINISTRATIONTenuate(diethylpropionhydrochloride):One25mg.tabletthreetimesdaily,onehourbeforemeals,andinmideveningifdesiredtoovercomenighthunger.TenuateDospan(diethylpropionhydrochloride,continuousrelease):One75mg.tabletdaily,swallowedwhole,inmidmorning.Experiencewithdiethylpropionhydrochlorideinchildrenunder12yearsofagehasnotbeensufficienttorecommenduseinthisagegroup.DOSAGEFORMSTablets25mg.:bottlesof100and1000DospanTablets75mg.:bottlesof30and250RegisteredTrademarks:Tenuate,DospanInitialPrintingNovember,1970TenuteMN.F.)T=ohelcqnTTHEWM.S.MERRELLCOMPANYDivisionofRichardson-Merrell(Canada)Ltd.MEM^ERWeston,Ontario_PMC2-169_1108C.M.A.JOURNAL/DECEMBER9,1972/VOL.107 stimulantandescharotic;itisbe-lievedtohavecontainedferrousandcoppersulfate.TheuniquenesstomedicalhistoryoftheGuildhallstamprelatestothecaduceiinscribedonthetopandbot-tomsurfaces.Onthetopsurfacearefourlightlyscratchedcaduceijoinedatthecentretoformacross(Fig.5a).Thebottomsurfaceshowstwocom-pletedandtwopartialcaducei(Fig.5b).Thesecaduceiareofthe"reverse3type"frequentlyusedinancienttimes(Fig.2).ThecontrastbetweenthemandtheprofessionalletteringontheedgeoftheinscriptionsuggeststhatCaiusSilviuswasaseconomical-lymindedastoday'sphysician.Hedidnotwishtopayforunnecessaryprofessionalletteringwhenhehimselforsomelessskilledpersoncouldscratchthecaduceishown.TheGuildhalloculist'sstampistheearli-estidentifiedarcheologicalevidenceforanassociationbetweenthecadu-ceusandMedicine.Whywasthecaduceususedonthisstamp?Wasitusedonotheroculists'stamps?Thefirstquestioncanbeansweredherebutthesecondques-tionrequiresapilgrimagetothemu-seumsofEurope.FIG.5a-Sketchesofcaduceiontopsurfaceofstamp(actualsize).(ByH.P.A.Chapman,GuildhallMuseum).1(FIG.5b-Sketchesofcaduceionbottomofstamp(actualsize).(ByH.P.A.Chapman).AmedievalalchemistorastudentofthehistoryofchemistrywouldsuggestthatthecaduceuswasusedbecausethevariouspreparationsofCaiusSilviusTetricuscontainedquicksilverormercury.Thiselementhadbeensymbolizedbythecaduceusformanycenturies.Suchanexplana-tionwoulddelightourmoreseniormedicalcolleagueswhorememberprescribingyellowoxideofmercuryeyeointments.Unfortunatelythereisnoevidencethatthecaduceuswasusedasachemicalsymbolinthethirdcentury.AnalternativeexplanationhasnolinkwithHermes(Mercury)ortheothergodsoccasionallyassociatedwiththecaduceus.Hermeshadsomemedicalrolesinthathedidassistinconductingthedeadtotheunder-worldandalsoreceivedsomecreditforrelievingplaguesandepidemicsinAsiaMinor.TheseexploitsdonotseemapropostoLondiniumofthethirdcentury.Inancienthistorythecaduceusbe-ganasaphallicsymbolandendedasarodsymbolicofMercury.Atthemid-pointofitshistory,Homer(circa900B.C.)describedtheGreekcaduceusasbeingmadefromgoldandposses-singtheabilitytocharmtheeyesofmen.7ItisprobablyinthisrolethatthethirdcenturyLondonoculistusedthecaduceusonhismedicationstamp.Ifotheroculiststampsdonotcontainacaduceus,thenitislikelythatTetricuswasafanofHomer'sandaddedalittleextramagicandfaithtohispreparations.ItisironicalthatHomershouldsupplytheexplanationfortheearliestmedicaluseofthecaduceus-hisIliadgivestheearliestreferencetoAsklepios.8ThisassociationshouldallowsomedegreeofrespectabilitytothecaduceusamongmoderndayAsclepiads.Itsrole,ofcourse,shouldberestrictedtotheoculists'fieldandthestaffofAsklepiosshouldremainasthetruetraditionallogofortheprofession.Theauthoracknowledgestheencour-agementandassistanceofMr.H.P.A.Chapman,GuildhallMuseum,London.Mr.ChapmankindlymadethesketchesshowninFigs.5aand5bandtheCorpora-tionofLondonsuppliedthephotographshowninFig.4.TheauthorwishestothankDr.CharlesNewman,HarveianLibrarianoftheRoy-alCollegeofPhysicians,London,forinformationonthecaduceusoftheCol-legeandtheCollegeforsupplyingthephotographinFig.3.References1.FROTHINGHAMAL:BabylonianoriginofHermes,theSnake-God,andofthecadu-ceus.AmJArchaeol20:2ndseries,19162.KELLYAD:Medicine'slogo.CanMedAssocJ100:1064,19693.MCCULLOCHCCJR:CoatofArmsofMedicalCorps.MilitSurg41:137,19174.NEWMANC:TranscriptfromoldportraitcatalogueofRoyalCollegeofPhysicians.Personalcommunication5.DUNNINGCD:RomanfindsinLon-don.AntiqJ12:437,19326.BARNESH:OnRomanmedicineandRo-manmedicalinscriptionsfoundinBritain.ProcRSocMed7:71,19137.BELLEWG:Caduceus,inTheCoatofArms,volIV,1957,p3118.EDELSTEINE,EDELSTEINL:Askiepios.Baltimore,JohnsHopkinsPress,19451110C.M.A.JOURNAL/DECEMBER9,1972/VOL.1