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Metrodora, Physician (Practiced around 200-400 CE)

July 22, 2019

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History of Medicine
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Metrodora, Physician
Graphic credit: Alzinous;
https://commons.wikimedia.org/w/index.php?curid=45495859

Metrodora, who was a Greek physician sometime around 200-400 CE, was the author of the oldest medical book known to be written by a woman, On the Diseases and Cures of Women. The book was referenced frequently by other medical writers during the ancient Greek and Roman times, and was used in Medieval Europe as well. Metrodora is known to be the first female medical writer and was influenced by the works of Hippocrates, a major Greek physician (460-370 BC).Her medical treatise covers many areas of medicine, including gynecology, but not obstetrics. It was widely referenced by other medical writers in ancient Greece and Rome, and was also translated and published in Medieval Europe. Nothing is known of Metrodora's identity beyond her name. However, several women physicians are known to have existed in the ancient Greco-Roman world, and she is generally regarded as the first female medical writer.

Metrodora's book, On the Diseases and Cures of Women survives in two volumes, containing 63 chapters. Metrodora's approach was heavily influenced by the work of Hippocrates and the Hippocratic Corpus, as were most physicians of her era, for example, she shared Hippocrates' theories concerning hysteria. Metrodora was decisive about controversial topics involving symptomology and etiology; inflammation of the uterus is one example. She made her own unique contributions to advancing medical understanding of theory and etiology. Although female physicians were active in gynecology and obstetrics in ancient Greece and Rome, it was rare that women physicians practiced in other areas of medicine. Childbirth and obstetrics in antiquity were viewed as acceptable areas of medical practice for women who were able to gain medical training as physicians, in large part because of the ancient tradition of midwifery and its association with women trained by other women. Metrodora writes on many areas of medicine in On the Diseases and Cures of Women, including all aspects of gynecology, but obstetrics is not dealt with in the volumes that are extant. Surgery was not typically practiced in ancient Greece or Rome, and is also not covered in her treatise. This is in contrast with the writing of another female physician, Aspasia the Physician, who covered gynecologic surgery including abortion. Aspasia's work was also often referenced by other physician writers, including Aetius and Soranus. Metrodora did not deal with obstetrics, the traditional domain of midwifery, instead focusing on pathology, the same approach being used by male physicians influenced by Hippocrates. She differed from many other male medical writers of her era in analyzing and referring to the writings of Hippocrates directly, rather than using the proliferation of secondary sources in the intervening centuries as the substance of her work.

The first Latin translations of On the Diseases and Cures of Women appeared between the 3rd and 5th centuries. The oldest known manuscript of Metrodora's work is located in Florence, Italy. Metrodora's work was referenced by other physician writers, and also republished in extracts. The scholarly texts of ancient Greece and Rome were part of the foundation of Western research during the Middle Ages in Europe. Metrodora's work was circulated during this period as well. Her bibliographic references include “a Berenice called Cleopatra“ or “mono marciglia“, which caused some Medieval publishers to incorrectly attribute her work to the famous Cleopatra VII of Egypt, and it was under the name of “Cleopatra“ that On the Diseases and Cures of Women was published by Caspar Wolf in 1566, and then by Israel Spach in 1597. Metrodora was evidently greatly experienced with clinical practice. Her works reference examinations done both digitally (that is, by hand alone) and using a speculum, and show a detailed familiarity with physiology. She made contributions by formulating classifications of vaginal discharges, and proposed theories on etiology such as the possibility of rectal parasitic infections causing vaginal discharges. Her contributions in these areas appear to have been her original research and theory. There are also many medicine compounds provided in her treatise that have not been found elsewhere. Her work also appears to include the first known alphabetized medical encyclopedia, using alphabetic headings for ease of reference, although it exists in an incomplete manuscript that ends with epsilon.

In ancient Egypt, midwifery was a recognized female occupation, as attested by the Ebers Papyrus which dates from 1900 to 1550 BCE. Five columns of this papyrus deal with obstetrics and gynecology, especially concerning the acceleration of parturition (the action or process of giving birth to offspring) and the birth prognosis of the newborn. The Westcar papyrus, dated to 1700 BCE, includes instructions for calculating the expected date of confinement and describes different styles of birth chairs. Bas reliefs in the royal birth rooms at Luxor and other temples also attest to the heavy presence of midwifery in this culture.

Midwifery in Greco-Roman antiquity covered a wide range of women, including old women who continued folk medical traditions in the villages of the Roman Empire, trained midwives who garnered their knowledge from a variety of sources, and highly trained women who were considered physicians. However, there were certain characteristics desired in a “good“ midwife, as described by the physician Soranus of Ephesus in the 2nd century. He states in his work, Gynecology, that “a suitable person will be literate, with her wits about her, possessed of a good memory, loving work, respectable and generally not unduly handicapped as regards her senses [i.e., sight, smell, hearing], sound of limb, robust, and, according to some people, endowed with long slim fingers and short nails at her fingertips.“ Soranus also recommends that the midwife be of sympathetic disposition (although she need not have borne a child herself) and that she keep her hands soft for the comfort of both mother and child. Pliny, another physician from this time, valued nobility and a quiet and inconspicuous disposition in a midwife. There appears to have been three “grades“ of midwives present: The first was technically proficient; the second may have read some of the texts on obstetrics and gynecology; but the third was highly trained and reasonably considered a medical specialist with a concentration in midwifery.

Midwives were known by many different titles in antiquity, ranging from iatrine (Gr. nurse), maia (Gr., midwife), obstetrix (Lat., obstetrician), and medica (Lat., doctor). It appears as though midwifery was treated differently in the Eastern end of the Mediterranean basin as opposed to the West. In the East, some women advanced beyond the profession of midwife (maia) to that of gynecologist (iatros gynaikeios, translated as women's doctor), for which formal training was required. Also, there were some gynecological tracts circulating in the medical and educated circles of the East that were written by women with Greek names, although these women were few in number. Based on these facts, it would appear that midwifery in the East was a respectable profession in which respectable women could earn their livelihoods and enough esteem to publish works read and cited by male physicians. In fact, a number of Roman legal provisions strongly suggest that midwives enjoyed status and remuneration comparable to that of male doctors. One example of such a midwife is Salpe of Lemnos, who wrote on women's diseases and was mentioned several times in the works of Pliny. However, in the Roman West, information about practicing midwives comes mainly from funerary epitaphs. Two hypotheses are suggested by looking at a small sample of these epitaphs. The first is the midwifery was not a profession to which freeborn women of families that had enjoyed free status of several generations were attracted; therefore, it seems that most midwives were of servile origin. Second, since most of these funeral epitaphs describe the women as freed, it can be proposed that midwives were generally valued enough, and earned enough income, to be able to gain their freedom. It is not known from these epitaphs how certain slave women were selected for training as midwives. Slave girls may have been apprenticed, and it is most likely that mothers taught their daughters.

The actual duties of the midwife in antiquity consisted mainly of assisting in the birthing process, although they may also have helped with other medical problems relating to women when needed. Often, the midwife would call for the assistance of a physician when a more difficult birth was anticipated. In many cases the midwife brought along two or three assistants. In antiquity, it was believed by both midwives and physicians that a normal delivery was made easier when a woman sat upright. Therefore, during parturition, midwives brought a stool to the home where the delivery was to take place. In the seat of the birthstool was a crescent-shaped hole through which the baby would be delivered. The birthstool or chair often had armrests for the mother to grasp during the delivery. Most birthstools or chairs had backs which the patient could press against, but Soranus suggests that in some cases the chairs were backless and an assistant would stand behind the mother to support her. The midwife sat facing the mother, encouraging and supporting her through the birth, perhaps offering instruction on breathing and pushing, sometimes massaging her vaginal opening, and supporting her perineum during the delivery of the baby. The assistants may have helped by pushing downwards on the top of the mother's abdomen.

Finally, the midwife received the infant, placed it in pieces of cloth, cut the umbilical cord, and cleansed the baby. The child was sprinkled with “fine and powdery salt, or natron or aphronitre“ to soak up the birth residue, rinsed, and then powdered and rinsed again. Next, the midwives cleared away any and all mucus present from the nose, mouth, ears, or anus. Midwives were encouraged by Soranus to put olive oil in the baby's eyes to cleanse away any birth residue, and to place a piece of wool soaked in olive oil over the umbilical cord. After the delivery, the midwife made the initial call on whether or not an infant was healthy and fit to rear. She inspected the newborn for congenital deformities and testing its cry to hear whether or not it was robust and hearty. Ultimately, midwives made a determination about the chances for an infant's survival and likely recommended that a newborn with any severe deformities be exposed.

A 2nd-century terracotta relief from the Ostian tomb of Scribonia Attice, wife of physician-surgeon M. Ulpius Amerimnus, details a childbirth scene. Scribonia was a midwife and the relief shows her in the midst of a delivery.Graphic credit: by wellcomeimages.org; Wellcome Collection gallery (2018-03-23): https://wellcomecollection.org/works/f54q45ya CC-BY-4.0, CC BY 4.0, https://commons.wikimedia.org/w/index.php?curid=36319212

The services of a midwife were not inexpensive; this fact that suggests poorer women who could not afford the services of a professional midwife often had to make do with female relatives. Many wealthier families had their own midwives. However, the vast majority of women in the Greco-Roman world very likely received their maternity care from hired midwives. They may have been highly trained or possessed only a rudimentary knowledge of obstetrics. Also, many families had a choice of whether or not they wanted to employ a midwife who practiced the traditional folk medicine or the newer methods of professional parturition. Like a lot of other factors in antiquity, quality gynecological care often depended heavily on the socioeconomic status of the patient. From the 18th century on, a conflict between surgeons and midwives arose, as medical men began to assert that their modern scientific techniques were better for mothers and infants than the folk medicine practiced by midwives. As doctors and medical associations pushed for a legal monopoly on obstetrical care, midwifery became outlawed or heavily regulated throughout the United States and Canada. In Northern Europe and Russia, the situation was a little easier - in Imperial Russia at the Duchy of Estonia, Professor Christian Friedrich Deutsch established a midwifery school for women at the University of Dorpat in 1811, which existed until World War I. It was the predecessor for the Tartu Health Care College. Training lasted for 7 months and in the end a certificate for practice was issued to the female students. Despite accusations that midwives were “incompetent and ignorant“, some argued that poorly trained surgeons were far more of a danger to pregnant women. The argument that surgeons were more dangerous than midwives lasted until the study of bacteriology became popular in the early 1900s. Women began to feel safer in the setting of the hospitals with the amount of aid and the ease of birth that they experienced with doctors. “Physicians trained in the new century found a great contrast between their hospital and obstetrics practice in women's homes where they could not maintain sterile conditions or have trained help.“ German social scientists Gunnar Heinsohn and Otto Steiger theorize that midwifery became a target of persecution and repression by public authorities because midwives possessed highly specialized knowledge and skills regarding not only assisting birth, but also contraception and abortion.

By the late 20th century, midwives were recognized as highly trained and specialized professionals in obstetrics. However, at the beginning of the 21st century, the medical perception of pregnancy and childbirth as potentially pathological and dangerous still dominates Western culture. Midwives who work in hospital settings also have been influenced by this view, although by and large they are trained to view birth as a normal and healthy process. While midwives play a much larger role in the care of pregnant mothers in Europe than in America, the medicalized model of birth still has influence in those countries, even though the World Health Organization recommends a natural, normal and humanized birth. The midwifery model of pregnancy and childbirth as a normal and healthy process plays a much larger role in Sweden and the Netherlands than the rest of Europe, however. Swedish midwives stand out, since they administer 80 percent of prenatal care and more than 80 percent of family planning services in Sweden. Midwives in Sweden attend all normal births in public hospitals and Swedish women tend to have fewer interventions in hospitals than American women. The Dutch infant mortality rate in 1992 was the tenth-lowest rate in the world, at 6.3 deaths per thousand births, while the United States ranked twenty-second. Midwives in the Netherlands and Sweden owe a great deal of their success to supportive government policies. Source: Wikipedia

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