I am writing this essay on Soranus (Fig. 1) as a tribute to that great physician of the Greco-Roman Era. I feel it is worth remembering the first perinatologist in the post International Year Of The Child. I have used Owesi Temkins' Soranus' Gynecology as primary reference, for nothing can surpass his scholarly work. This essay is also for those who may be wondering: "Who is this Soranus anyway?"
THE TIME AND SETTING
In order to appreciate the greatness of Soranus's sensibility and deep scientific insight, it is essential to perceive the scientific and cultural aura of his time. Soranus was born in Ephesus, a city in Asia Minor, the gateway to the "Fertile Crescent." The era, the first and second centuries A.D., can rightly be called a "Twilight Zone;" the period in human history interposed between the tumultuous time of Christ and Caesar, and the Dark Ages; a period of relative peace and prosperity in the vastness of the Mediterranean lands.[2,3]
While very little is known about Soranus himself or the circumstances of his life, we do know that he practiced medicine in Rome during the rule of Trajan (98-117 A.D.) and Hadrian (117-138 A.D.). That a Greek born in Ephesus should be trained in Alexandria only to settle in Rome to work is no accident of history, since tradition had already established this path for all young aspiring Greeks.
Ever since its founding, almost up to the Fourth century A. D., Alexandria, the magical town on the Mediterranean, remained the most prestigious place for all scientific learning.[3-5] It was "enough to commend a physician's skills if he can say that he learned medicine in Alexandria." Not unlike the present era, specialists were the order of the day.
It is, therefore, very likely that Soranus developed special skills in the art of the diseases of women and children in addition to his diverse interest in surgery, to which his works testify. Having learned his trade, as a matter of course, Soranus went to Rome to practice.
In Rome, however, physicians were looked upon as a different breed of creature. For one thing, most of them were Greeks. Tradition forbade that Romans themselves practice medicine. Just like other artistic talents, such as that for music, dance, poetry, magic, etc, medicine was considered a profession "worthy only for slaves, freedmen, or foreigners" who were, of course, Greeks!
This prejudice against the men of medicine in the early Roman period seems to have had its origin in the pre-Christian era. Greek prisoners of war brought into Rome after the fall of Corinth (146 B.C.) were mostly physicians who were later freed by Caesar. The state of medical arts was a mixture of quackery and high sounding names. Even drug peddlers abounded.[5-7] Although the Roman aristocracy snubbed the physicians, the latter, at times, were used for gainful employment. The migrating Greek physician, with his countless number of snakes kept in private houses in persuance of the Aesculapian cult, was hired by Royal ladies (Claudius's wife, Messalina, for instance) to carry out fraudulent practices for political reasons. In the streets of Rome, booths were installed in which a freedman-physician prescribed and compounded. Even the Romans themselves had a god for every existing disease and every known physiological function. Thus Soranus, although a foreigner to Rome, was quickly accepted into what was already an established cult of medical practice. Despite an ambivalent attitude of the Romans towards Greek doctors, great men of Greek heritage also had their heyday before Soranus. Discorides, the originator of Materia Medica, was in the service of Nero (54-68 A.D.); Rufus (37-68 A.D.) of Ephesus, a surgeon and anatomist, who first described the optic chiasma and oviduct of sheep, was Soranus's contemporary .[5-9]
As Temkin says, it is impossible to understand Soranus's work without looking at the complexion of the "Schools of Medicine" in Roman antiquity. From the first century B.C. through the second century A.D., various medico-philosophical doctrines and arguments consolidated into different branches, forming at least three major schools of medicine: Dogmatic, Empiric and Methodist.[4-8]
The Dogmatic school, probably the earliest to evolve, emphasized the study of anatomy and believed in Plato and Aristotle. The Empiricists relied upon philosophical arguments to solve problems and were known as medical "skeptikoi" who offered opinions.
The Methodists relied on the Hippocratic doctrines for their medical philosophy and practice and insisted that diseases are to be judged only by symptoms and not by causes. Soranus belonged to the Methodist school and, in this context, his writings are of great significance: the scope of his knowledge and the thoroughness in his approach to illness extended far beyond the basic doctrines of the school of which he was an unquestioned champion.
Although the Methodist school was a product of Greek philosophy and thought, it found considerable popularity in Rome. Since the Methodists did away with the causes and numerous arguments relating to the origin of diseases, their approach to human illness became simplistic. The shortcomings, however, were obvious with this approach. Galen, a "foe of the Methodists," was born at about the time of Soranus's death. Although he disliked all Methodists, Soranus was a notable exception. Galen held Soranus in the highest esteem.
Discovery of Soranus Over 20 books have been ascribed to Soranus but only a few have come to us in their original form, the most important being Gynecology. Others, extant in Greek, On bandages, On fracture, Surgery, in part, and Life of Hippocrates were also probably written by Soranus. Caelius Aurelianus (5-6 century A.D.) translated from the Greek original of Soranus's On acute and chronic disease. It appears that Soranus's interest was wide in many fields of medicine and he also wrote on embryology and the soul, exerting considerable influence on theologians of his time and future philosphers. For about 15 centuries following Soranus, his views and practices survived through translations into German, Latin, French, and possibly Arabic. Several abbreviations and additions were carried out by translators and compilers throughout the latter part of antiquity and the middle ages.
The rediscovery of Soranus, establishing his towering place in medical history, was attempted for the first time in 1830-31 in Paris by Reinhold Dietz. Later, Rose and Ilberg, philologists, undertook the massive task of reconstruction of Soranus' Gynecology. Johannes Ilberg spent 19 years attempting to reedit the 1882 edition of Rose and finally completed the Greek original of Soranus in 1927. Thus, 19 centuries later, after nearly 100 years of work by various scholars, the original Gynecology in Greek by Soranus found its way back into Greek. Owesei Tempkin translated Ilberg's work into English in 1956.1
The Gynecology is in four major parts: Books 1 through 4. "Things Normal" are dealt with in Books 1 and 2, and "Things Abnormal" in Books 3 and 4. It is in Book 1 that we find an extraordinary chapter "on the care of the newborn," probably the first chapter ever devoted entirely to the care of newborn infants; and many chapters in Book 4 deal with the care of abnormal pregnancy.
I have paraphrased below topics of interest to neonatologists from Gynecology without attempting to provide any interpretation of the original writings in the light of present day knowledge.
In Book 1, Soranus stressed that an ideal midwife must have good memory, be qualified and free from superstitions. In an age when magic and cults were the order of the day and part of medicine, this suggestion is noteworthy. An extensive discussion follows regarding anatomy of the female reproductive organs (Fig. 2), physiology, or the "nature of the fetus,"(Fig. 3) and the care of the mother in pregnancy. He recognizes pica, and carefully describes signs of imminent labor and delivery.
He notes that fetal nourishment takes place via the blood vessels in the umbilical cord. The chapter on "care of the mother and baby" at delivery testifies to the meticulousness of Soranus's observation and practice. Both psychological and physical comforts of the mother are stressed. The details are comprehensive and specific, providing good reasons for each recommendation.
Soranus states that some of the newborns survive at seven months of gestation. This is the only reference he makes to prematurity. He suggests that the navel cord be cut in the middle after ligating in two places to prevent bleeding from the mother and baby. His recommendation to cleanse and resuscitate the newborn were revolutionary for his time and are routine practice today. He rejects splashing cold water, (as was the practice of barbarians) or wine on the infant, but recommends lukewarm water to cleanse the infant since, according to him, "cold on account of its strong and needless condensings action, the like which the child has not experienced, harms all." He felt that the delivery room air was enough to stimulate the infant to cry.
Soranus was the first in Western medical science to recommend cleaning the eyes with olive oil, "to wash off the thickest moisture in them, and if not done the infant becomes dim sighted." Is this a reference to neonatal gonococcal ophthalmia? Gonorrhea disease was prevalent in epidemic proportions in Europe throughout the recorded history of that time.
A long discourse follows about feeding and other problems of the baby, breast feeding, testing the milk, weaning from the breast milk, problems of nursing, excess of crying, constipation, teething, assessment of growth and development, tonsillitis, thrush, skin lesions, diarrhea in infants, and wheezing and coughing. He is probably one of the first to describe clinical signs of rickets in Roman children.
The most outstanding aspect of Soranus's contribution to medicine is that he was far ahead of his own time in his approach to human illness. He was a thorough clinician, a writer with a keen sense of observation. The text of Gynecology is divided into chapters which are similar to modern textbooks of Perinatal Medicine. For each suggestion he makes, he provides lengthy and convincing reasoning. This rationale is far superior to anything comparable in his time. Until the Renaissance, very little was changed from what he wrote and, perhaps due to his influence, millions of pregnant women and infants were saved from the savage quackery that was prevalent throughout the Dark Ages.
And so, that is who Soranus was, and that is what he did.
Fig. 1. Soranus of Ephesus (98-138 A.D.): (From Gordon, B. L. reproduced with permission from Davis Corp., Philadelphia).
Fig. 2. Anatomy of Uterus: As found in Muscio manuscript (900 A.D.). Drawing with English terms in Tempkin: Reproduced with permission from Johns Hopkins University Press, Baltimore.
Fig. 3. Position of the Fetus: From Muscio manuscript. Reproduced with permission from Johns Hopkins University Press, Baltimore.
1. Tempkin O.: In Soranus' Gynecology. Baltimore: The John Hopkins Press, 1956, p. p. 1-174.
2. Breasted J. H.: Ancient Times, A History of Early World 2nd ed. Boston: Ginn Co., 1935, p.p. 619-740.
3. Durant W., Durant E.: The Story of Civilization III, Caesar and Christ. New York: Simon and Schuster, 1972, p.p. 295-505.
4. Castaglioni, A.: A History of Medicine. New York: Alfred-Knoff, 1941, p.p. 149-751.
5. Garrison F. H.: An Introduction To The History of Medicine. Philadelphia: W. B. Saunders Corp., 1929, p.p. 111-112.
6. Gordon B. L.: Medicine Throughout Antiquity. Philadelphia: F. A. Davis Co., 1949, p. p. 645-660.
7. Scarborough J.: Roman Medicine. New York: Cornell University Press, 1969, p. p. 39-159.
8. Robinson V.: The Story of Medicine. New York: Tudor Publishing Co., 1931, p.p. 112-425.
9. Ackernecht E. H.: A Short History of Medicine. New York: Ronald Press Co., 1968, p. p. 72-86.