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Endometriosis: ancient disease, ancient treatments

2012; Elsevier BV; Volume: 98; Issue: 6 Linguagem: Inglês

10.1016/j.fertnstert.2012.08.001

1556-5653

Camran Nezhat, Farr Nezhat, Ceana Nezhat,

Uterine Myomas and Treatments

Ever since Vincent Knapp published his 1999 article "How old is Endometriosis?" (1Knapp V.J. How old is endometriosis? Late 17th- and 18th-century European descriptions of the disease.Fertil Steril. 1999; 72: 10-14Abstract Full Text PDF PubMed Scopus (54) Google Scholar), there seems to have been renewed interest in identifying just when endometriosis was discovered as a distinct disease entity.While the history of endometriosis subsequent to its 1860 microscopic unveiling by Karl von Rokitansky has been well-studied, its story leading up to that moment has remained largely unknown. The time seemed ripe to cast light on this chasm of history and give voice to the inaudible narratives of illness that have been lost in the margins of centuries. Inexact as the study of history may be, nevertheless clinical observations from the past may offer unique perspectives that would otherwise have been entirely overlooked.Moreover, in surveying the historical development of scientific medicine, it is evident that nearly all of our current understandings of complex disease-states have resulted from the synthesis of centuries of observations. Even medical theories that ultimately proved to be exquisite fallacies have actually served as essential counterpoints throughout the ages, refining knowledge by producing the searing clarity that only unanticipated failures can yield; the sort of shock medicine sometimes needs to achieve transformative change. Viewed in this light, to exclude the formative years leading up to the microscopic discovery of endometriosis is to deprive our discipline of an invaluable reservoir of knowledge that may reveal essential new insights about a disorder that continues to reign as one of gynecology's most perplexing diseases.Solving the mystery of hysteriaWas Freud Wrong Yet Again?With these ideas in mind, we applied a broader set of criteria in searching historical records for the earliest possible signs of endometriosis, taking care to include historical descriptions of clinical and macroscopic findings that corresponded to contemporary understandings. Historical perspectives on pelvic pain in women have also informed our analyses.By applying this broader set of criteria we were able to uncover substantial, if not irrefutable, evidence that hysteria, the now discredited mystery disorder presumed for centuries to be psychological in origin, was most likely endometriosis in the majority of cases (Fig. 1). If so, then this would constitute one of the most colossal mass misdiagnoses in human history, one that over the centuries has subjected women to murder, madhouses, and lives of unremitting physical, social, and psychological pain. The number of lives that may have been affected by such centuries-long misdiagnoses is staggering to consider, likely involving figures in the multiple millions.MethodologiesA broadly defined subject such as pelvic pain is naturally bound to yield results mired in inescapable ambiguity, especially because conditions like appendicitis, nonendometriotic ovarian cysts, infections, and leiomyomas can produce similar gynecologic symptoms (2Giudice L. Managing symptomatic endometriosis.Sex Reprod Menopause. 2011; 9: S31-S33Google Scholar). However, after filtering all histories through the lens of modern understandings, we feel confident that the following analyses include only those patterns of illness that share significant correspondence to current clinical interpretations of endometriosis.For our research methodology, we pursued several strategies, including traditional searches of the PubMed/Medline databases. Additionally, archival research was performed at several locations including the National Library of Medicine in Bethesda, Maryland; the Lane and Green libraries at Stanford University in California; and the medical history library of the University of California at San Francisco.In some cases, it was necessary to translate primary sources that were available only in Latin. For this specialized task, we consulted with the Cambridge-educated Latin and Greek scholar, J. R. T. Holland of Quintus Latin Translation Service, whose expertise in translating medical texts from premodern eras proved especially crucial for demystifying several contested areas of the history of endometriosis.Newly digitized medical literature made available by Google Books also proved to be a surprisingly useful new source. To achieve an interdisciplinary perspective, we also referenced a wide range of material from outside of medicine, drawing from the disciplines of psychology, literature, art history, and medical anthropology. Given the allegorical nature of many these alternative sources, they were not evaluated in the same manner as the medical literature intended to represent empirical experiences. Rather, their utility lies in their unique ability to convey otherwise nearly imperceptible cultural undertones, the prisms through which illnesses are invariably experienced and conceptualized.With thousands of conceivable sources from which to choose, this brief survey should in no way be considered an exhaustive study. Nevertheless, we believe it fills a gap in the literature by providing a multidisciplinary historical analysis of endometriosis as it may have been conceptualized before its 1860 microscopic discovery by Rokitansky. We first presented the preliminary results of this research in March 2011, at the World Endometriosis Symposium held in Atlanta, Georgia.The Search BeginsHistorical representations of pelvic pain: Oxford's Bodleian Library MS Ashmole 399We began our analysis by focusing first on the broadest category under consideration: historical representations of pelvic pain in women. As it turned out, this subject proved rather elusive, one curiously and consistently neglected in the archives of history. Detailed accounts of menstrual pain in particular were rarely if ever chronicled. Yet the hundreds of medicants for gynecologic ailments listed in the various Materia Medicas throughout the ages provide in themselves a strikingly different account, articulating by proxy stories of illness that belie those found in mainstream medical literature.It was by tracing these nearly imperceptible leads that we eventually stumbled upon a late 13th-century medical manuscript, referred to as MS Ashmole 399 (folios 33–34) in which images of a woman apparently doubled over in pain can be found (3MacKinney L.C. Bober H. A thirteenth-century medical case history in miniatures.Speculum. 1960; 35: 251-259Crossref PubMed Scopus (5) Google Scholar) (Fig. 2). Although there are no texts to accompany the original drawings, experts believe the imagery represents a woman suffering from what was usually called at the time "strangulation or suffocation of the womb." The linguistic lineages of these terms are still contested, but many scholars believe their roots can be traced to the hysterikos-hysterike pnix family of disorders, loosely defined disease frameworks formulated by Hippocratic and other Greco-Roman authorities throughout Classical and Late Antiquity, and the original source of the word hysteria (4King H. Hippocrates' woman: reading the female body in ancient Greece. Routledge, London1998Google Scholar, 5Dixon L.S. Perilous chastity: women and illness in pre-Enlightenment art and medicine. Cornell University Press, Ithaca, NY1995Google Scholar, 6Carroll J.L. Stewart A.G. Saints, sinners, and sisters: gender and northern art in medieval and early modern Europe. Ashgate, Aldershot, UK2003Google Scholar, 7Gilman S.L. King H. Porter R. Rousseau G.S. Showalter E. Hysteria beyond Freud. California University Press, Berkeley1993Google Scholar).Figure 2Experts on medieval medicine describe this late 13th-century image from a medical textbook as one depicting a case of uterine suffocation, a disease profile with many similarities to endometriosis.(Reproduced with permission of Oxford University, Bodleian Library, MS Ashmole 399, f. 33–34.)View Large Image Figure ViewerDownload Hi-res image Download (PPT)Classical and late antiquityThe Animalistic WombAlthough strangulation or suffocation of the womb took on many contradictory meanings throughout history, their earliest antecedents may have stemmed from concepts first posited by the ancient Egyptians as long ago as 1855 BC. However, they were later popularized by the Hippocratic texts, Plato, and other Greco-Roman sources of Classical Antiquity (8Griffith FL. The Petrie papyri: hieratic papyri from Kahun and Gurob, principally of the Middle Kingdom. 2 vols. London: Bernard Quaritch, 1897–1898.Google Scholar) (Fig. 3). The basic concept underlying these disorders rested on the premise that the uterus was not actually a regular organ, but rather one more analogous to a live animal, hungry for motherhood.Figure 3In the Hippocratic Corpus several gynecological symptoms are mentioned, which bear striking similarity to those of endometriosis, including uterine ulcers, adhesions, and infertility.(Page of text in "Aphorismi" with an illuminated small "M," Record UI. 1014450-55, In: Hunayn ibn-Ishaq al-'Ibadi, Oxford, 13th century, l. 19v, Isagoge and other medical texts, Census 78. Reproduced courtesy of the U.S. National Library of Medicine.)View Large Image Figure ViewerDownload Hi-res image Download (PPT)Though a metaphorical rather than literal analogy may have been intended, the idea of the animalistic womb eventually began informing everyday practices. From this pretext emerged one of ancient medicine's most enduring dogmas, the idea that if a woman did not fulfill the socially proscribed roles of marriage and motherhood her uterus would be deprived of its intended purpose. From this presumed unnatural state, it was believed that the uterus would begin to wander about—the famous wandering womb—and thus contribute to the onset of all manner of illness (5Dixon L.S. Perilous chastity: women and illness in pre-Enlightenment art and medicine. Cornell University Press, Ithaca, NY1995Google Scholar, 7Gilman S.L. King H. Porter R. Rousseau G.S. Showalter E. Hysteria beyond Freud. California University Press, Berkeley1993Google Scholar, 9Demand N.H. Birth, death, and motherhood in classical Greece. Johns Hopkins University Press, Baltimore1994Google Scholar, 10Hanson A.E. Conception, gestation, and origin of female nature in the Corpus Hippocraticum.Helios. 1992; 19: 31-71Google Scholar, 11Dean-Jones L. The politics of pleasure: female sexual appetite in the Hippocratic corpus.Helios. 1992; 19: 72-91Google Scholar, 12Pinault J.R. The medical case for virginity in the early second century C.E.: Soranus of Ephesus, Gynecology I.32.Helios. 1992; 19: 123-139Google Scholar, 13King H. Bound to bleed: Artemis and Greek women.in: McClure L. Sexuality and gender in the classical world: readings and sources. Blackwell, Oxford2002: 77-97Crossref Scopus (6) Google Scholar, 14Archer L.J. Fischler S. Wyke M. Women in ancient societies: an illusion of the night. Macmillan, Basingstoke, UK1994Google Scholar). The notion of a wandering womb naturally strikes a modern audience as an anatomic impossibility. Yet it suggests a causal connection with pregnancy that is nearly identical to a modern assumption about endometriosis: the idea that pregnancy can temporarily suppress symptoms.The Hippocratic CorpusThese theories inform many of the medical practices described in the Hippocratic corpus, a compilation of works written by various authors throughout the 5th through 4th centuries BC. The translations of these Hippocratic texts have been the subject of academic debate for centuries. However, after consulting numerous sources, we identified several relatively unambiguous disease profiles that allude to the wandering womb and other symptoms suggestive of endometriosis. The correlations become particularly evident when we learn that the Hippocratics viewed the following four factors as highly predictive of gynecologic disease: [1] menstrual dysfunction is a cause of disease, [2] pregnancy is a possible cure, and [3–4] pain and infertility as potential outcomes if the woman is left untreated (7Gilman S.L. King H. Porter R. Rousseau G.S. Showalter E. Hysteria beyond Freud. California University Press, Berkeley1993Google Scholar). Nearly 2500 years have passed since these observations were made, yet remarkably they correspond nearly seamlessly to the set of symptoms identified today as emblems of endometriosis. It is unfathomable that such uncanny correlations could remain suspended in a timeless stasis for so long. But what is even more incomprehensible is how such a uniquely patterned symptom profile could exist for ages without others realizing it was the hallmark of a distinct disease.It was most likely the endless upheavals of medieval times that left such crucial Hippocratic insights buried in the debris of history. This is the most plausible explanation because, as we will see, these four core assumptions would inform essentially all Greco-Roman ideas of why gynecological disorders arise up until about the fifth century AD, the period many mark as the beginning of the European Middle Ages.The Hippocratic texts provide many examples of how these four core concepts not only influenced ancient diagnostics and prognostics but also closely paralleled modern views. For example, in a near conceptual equivalent to the 20th-century notion of endometriosis as a "career woman's disease," the Hippocratics suggested that delaying motherhood could trigger disorders of the uterus, with painful menstruation cited as one such outcome.Women who suffered from dysmenorrhea were therefore urged to marry and conceive as quickly as possible (15Soranus. Soranus' gynecology. Owsei T, trans. Baltimore: Johns Hopkins Univeristy Press, 1991.Google Scholar).Other dire consequences were predicted for those who failed to partake in the pregnancy prescription. One Hippocratic author warned that "if they have never been pregnant, the deranged state of menstruation is more common and more dangerous than when they have borne children" (a paraphrase by the translator) and that she will be "release[d] from this disease, when she is pregnant" (4King H. Hippocrates' woman: reading the female body in ancient Greece. Routledge, London1998Google Scholar, 7Gilman S.L. King H. Porter R. Rousseau G.S. Showalter E. Hysteria beyond Freud. California University Press, Berkeley1993Google Scholar).Childlessness in older, married women (i.e., cases of presumed infertility) was recognized as another predisposing factor for gynecologic disorders (4King H. Hippocrates' woman: reading the female body in ancient Greece. Routledge, London1998Google Scholar). Drawing from the same pregnancy-as-therapy orthodoxy, another group believed to be particularly susceptible to gynecologic disorders were presumably fertile women who nevertheless remained childless; young widows and virgins who had already menstruated but remained unmarried typified this category of susceptible females (4King H. Hippocrates' woman: reading the female body in ancient Greece. Routledge, London1998Google Scholar, 16Coxe J.R. The writings of Hippocrates and Galen, epitomised from the original Latin. Lindsay and Blakiston, Philadelphia1846Google Scholar).Detailed reports of menstrual disordersDetailed accounts of other menstruation-related disorders were reported in a chapter titled "Aphorisms," in which the Hippocratic author describes menorrhagia as a potential cause for pathology (16Coxe J.R. The writings of Hippocrates and Galen, epitomised from the original Latin. Lindsay and Blakiston, Philadelphia1846Google Scholar) and proclaims: "When the menses are excessive, diseases take place" (17Hippocates. Aphorisms, Section V. Adams F, trans. Available from: http://classics.mit.edu/Hippocrates/aphorisms.5.v.html.Google Scholar). It was also observed that in some women their "floodings," an archaic term for menstruation, were followed by "grumulous clots . . . accompanied with pain, inflammation of the uterus, [and] hysteric paroxysms." Additionally, in the Hippocratic chapter titled "Diseases of Young Girls" (translated less accurately today as "Virgins"), the authors observed that "the menses sometimes suddenly appear abundantly at the end of three months, in clots of black blood, resembling flesh; sometimes ulcers of the uterus ensue, requiring much attention" (16Coxe J.R. The writings of Hippocrates and Galen, epitomised from the original Latin. Lindsay and Blakiston, Philadelphia1846Google Scholar). The Hippocratic author goes on to report: "When in a diseased state, the menses are of a bilious character; they have a black and shining appearance . . . and are accompanied with an erratic fever, chills, nausea, and heartburn." Allusions to perhaps bowel or lung endometriosis are also evident in the observation that "sometimes the menses are vicariously discharged by vomiting or stool; more commonly is the case with virgins than with married women…"Uterine adhesions and ulcersIn the chapter "On the Nature of Women," we learn that the Hippocratics were also familiar with uterine adhesions. As the translator of these texts explained, they advised that "in case of adhesions between the uterus and other parts, indurations, suppuration of the womb, and ulcers, sometimes arise, or discharges which prove fatal if not attended to; fomentations of urine are among the measures recommended. The usual effect of this state is said to be sterility" (16Coxe J.R. The writings of Hippocrates and Galen, epitomised from the original Latin. Lindsay and Blakiston, Philadelphia1846Google Scholar). Some of these translations are still the subject of heated academic debates, particularly the term "hysteric paroxysms." Yet based on the textual evidence in its entirety, it is at least reasonable to surmise that these Hippocratic physicians may have been encountering endometriosis.Medical therapiesThe types of therapeutic options available were generally ingestible concoctions, fumigants, or suppositories that contained such substances as the urine of men or bulls, tar water, chaste tree (Vitex agnuscastus), pomegranates, cantharides, or castor oil (Figure 4, Figure 5, Figure 6). In analyzing the histories of these individual substances, we came across some surprising results. The medicinal usage of cantharides, for example, has an especially colorful history; although it is actually derived from dried beetles, throughout history it came to be known as the infamous aphrodisiac "Spanish fly."Figure 4Allegorical image of fumigation, as depicted in John Collier's painting "Priestess of Delphi," 1893.(Reproduced with permission of the Art Gallery of South Australia, Adelaide.)View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 5Lytta vesicatoria, known in modern times as the aphrodisiac Spanish fly, was one of many pharmaceuticals prescribed in the Hippocratic Corpus for treating menstrual disorders and infertility.(Reproduced courtesy of Christophe Franco, http://en.wikipedia.org/wiki/File:Lytta-vesicatoria.jpg.)View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 6Recent studies have begun to analyze the purported antiproliferative and antiaromatase properties of pomegranates, prescribed for fertility and menstrual disorders in both Hippocratic Medicine and ancient Chinese medicine.(Reproduced courtesy of Benjamin Trovato, http://en.wikipedia.org/wiki/File:PomegranateChina.jpg.)View Large Image Figure ViewerDownload Hi-res image Download (PPT)Pomegranates and chaste tree also were deployed for centuries as contraceptives and treatments for menstrual disorders. Known as shíliu in Chinese, the pomegranate has been traditionally viewed in China as a source and symbol of fertility (18Stover E.W. Mercure E.W. The pomegranate: a new look at the fruit of paradise.Hort Sci. 2007; 42: 1088-1092Google Scholar). Recent studies have even begun to analyze its purported antiproliferative and antiaromatase properties (19Adams L.S. Zhang Y. Seeram N.P. Heber D. Chen S. Pomegranate ellagitannin-derived compounds exhibit antiproliferative and antiaromatase activity in breast cancer cells in vitro.Cancer Prev Res (Phila). 2010; 3: 108-113Crossref PubMed Scopus (147) Google Scholar).In contrast, the pine resin-derived nostrum known as tar water was practically incompatible with life (21Bos G. Ibn al-Jazzar on women's diseases and their treatment.Med Hist. 1993; 37: 296-312Crossref PubMed Scopus (11) Google Scholar). The same foul substance Charles Dicken's character Pip was forced to ingest as punishment, tar water was considered by the Hippocratics as so effective (or so odious) that women of antiquity were warned they would be "barren forever" if they ingested it (20Langenheim J.H. Plant resins: chemistry, evolution, ecology, and ethnobotany. Timber, Portland, OR2003Google Scholar, 21Bos G. Ibn al-Jazzar on women's diseases and their treatment.Med Hist. 1993; 37: 296-312Crossref PubMed Scopus (11) Google Scholar). Fragments of this belief appear to have been handed down over time because today some veterinarian studies have shown pine extracts to exert modest anti-fertility effects in animal models (22Cogswell C. Kamstra L.D. Toxic extracts in ponderosa pine needles that produce abortion in mice.J Range Manag. 1980; 33: 46-48Crossref Google Scholar, 23Biely J. Kitts W.D. The anti-estrogenic activity of certain legumes and grasses.Can J Anim Sci. 1964; 44: 297-302Crossref Google Scholar).As for the use of urine for medicinal purposes, in modern gynecology we are no doubt familiar with the use of pregnant mare urine extracts as Premarin's main ingredient. What is less clear is whether the ancients would have been capable of extracting similar hormone-disrupting constituents from the urine of bulls or men. The literature provides few examples of well-designed, peer-reviewed studies in humans, but several animal studies do suggest that bull urine can exert antiestrogenic properties in mice (24Butz L. Hall S.R. Some characteristics of the androgenic fractions from bull urine.J Biol Chem. 1938; 126: 265-271Google Scholar).Other more inventive therapies were explored as well. One of the most unusual therapies was the practice of succession. Designed as a mechanical means for repositioning the uterus, a session of succussion involved tying the patient to a ladder, which would then be turned upside down and shaken up and down until the womb returned to its rightful place (25Shah S.M. Sultan A.H. Thakar R. The history and evolution of pessaries for pelvic organ prolapse.Int Urogynecol J Pelvic Floor Dysfunct. 2006; 17: 170-175Crossref PubMed Scopus (36) Google Scholar) (Fig. 7). In this case, visibly prolapsed uteri were most likely the intended target, making the practice infinitely more comprehensible from a modern standpoint.Figure 7Uterine suffocation, vaginal prolapse, and other gynecologic conditions were sometimes treated with succussion, the ancient Greek practice in which patients are bound to a ladder, turned upside down, and shaken vigorously, with the idea being that the uterus would be shaken back into its proper position.(Reproduced courtesy of BioMed Central Ltd and SpringerImages. Scoliosis 2009;4:6. Image from the illustrated comments of Apollonius of Kitium on the Hippocratic treatise On Articulations. Bibliotheca Medica Laurenziana, Florence.)View Large Image Figure ViewerDownload Hi-res image Download (PPT)Admittedly our analyses of ancient pharmacology are speculative at best, given the absence of high-quality evidence to support these theories. As Renckens argues so effectively in his article about alternative treatments in reproductive medicine, much of the existing evidence appears to be woefully inadequate (26Renckens C.N. Alternative treatments in reproductive medicine: much ado about nothing.Hum Reprod. 2002; 17: 528-533Crossref PubMed Scopus (22) Google Scholar). Even so, further investigations may be warranted. As reported in a recent editorial by endometriosis expert, Dr. Linda Giudice (2Giudice L. Managing symptomatic endometriosis.Sex Reprod Menopause. 2011; 9: S31-S33Google Scholar), preliminary studies suggest that: "Chinese herbal therapies have exhibited antiproliferative, antinociceptive, and prosedative properties, as well as anti-inflammatory actions, antioxidant characteristics, suppression of COX-2 and cytokines, and mechanisms involved in the cytokine response, such as inhibition of NF-KB" (19Adams L.S. Zhang Y. Seeram N.P. Heber D. Chen S. Pomegranate ellagitannin-derived compounds exhibit antiproliferative and antiaromatase activity in breast cancer cells in vitro.Cancer Prev Res (Phila). 2010; 3: 108-113Crossref PubMed Scopus (147) Google Scholar, 22Cogswell C. Kamstra L.D. Toxic extracts in ponderosa pine needles that produce abortion in mice.J Range Manag. 1980; 33: 46-48Crossref Google Scholar, 23Biely J. Kitts W.D. The anti-estrogenic activity of certain legumes and grasses.Can J Anim Sci. 1964; 44: 297-302Crossref Google Scholar, 24Butz L. Hall S.R. Some characteristics of the androgenic fractions from bull urine.J Biol Chem. 1938; 126: 265-271Google Scholar, 27Final report on the safety assessment of Ricinus communis (Castor) seed oil, hydrogenated castor oil, glyceryl ricinoleate, glyceryl ricinoleate SE, ricinoleic acid, potassium ricinoleate, sodium ricinoleate, zinc ricinoleate, cetyl ricinoleate, ethyl ricinoleate, glycol ricinoleate, isopropyl ricinoleate, methyl ricinoleate, and octyldodecyl ricinoleate.Int J Toxicol. 2007; 26: 31-77PubMed Google Scholar)."Extremest anguish"Although we do not usually think of the acclaimed philosopher Plato (375 bc) as being involved in medicine, this did not stop him from expressing his own opinions about gynecologic disorders. In fact, Plato was actually among the first to mention the extreme pain that women suffered as a result suffocation of the womb. He explained that the disorder is triggered when "the womb remains barren too long after puberty, is distressed and sorely disturbed, and, straying about the body and cutting off the passages of breath, it impedes respiration and brings the sufferer into the extremest anguish and provokes all manner of illness besides" (28Micklem N. The nature of hysteria. Routledge, London1996Crossref Google Scholar, 29Veith I. Hysteria: the history of a disease. University of Chicago Press, Chicago1965Google Scholar).By the time Roman scholar Pliny the Elder (23–79 ad) began reporting on suffocation of the womb, several new observations had been added to the diagnostic profile. Included among these was an account of the disorder's peculiar ability to reduce women to some sort of semiconscious state, lying "as if dead for seven days" (7Gilman S.L. King H. Porter R. Rousseau G.S. Showalter E. Hysteria beyond Freud. California University Press, Berkeley1993Google Scholar).SoranusInflammation of the uterusAbout a century later, Soranus (ca. 98–138 ad) reported similar findings, but offered critical new clinical insights when he explained that women were falling unconscious as a result of the disorder's characteristic violent uterine contractions, which Soranus observed could manifest in either chronic or acute forms (7Gilman S.L. King H. Porter R. Rousseau G.S. Showalter E. Hysteria beyond Freud. California University Press, Berkeley1993Google Scholar) (Fig. 8). To explain these symptoms, Soranus departed from tradition by becoming the first to suggest inflammation of the uterus as part of his radical new theory about the origins of suffocation of the womb.Figure 8Soranus of Ephesus (circa 98–138 ad) described many endometriosis-like symptoms, including menstrual disorders that led to infertility and cases of uterine suffocation that caused violent uterine contractions.(Reproduced courtesy of the U.S. National Library of Medicine; Portrait no. 6313-A.)View Large Image Figure ViewerDownload Hi-res image Download (PPT)More than just an essential new theoretical framework, Soranus's detailed macroscopic knowledge of these and other uterine pathologies supports the idea that human autopsies may have informed his views. Although Soranus admitted to having performed autopsies, they would have been considered highly unorthodox and somewhat risky for the times. Indeed, unassuming as this revelation may seem, Soranus's accurate anatomic descriptions of the uterus actually call into question other historical accounts that claim human dissections had been all but abandoned by that time.As for those susceptible to uterine disorders, Soranus report