Central Medical Journal of Obstetrics and Gynecology
Perspective *Corresponding author John L Yovich, PIVET Medical Centre, Perth, Western Australia 6007, Australia; Curtin University, Perth, Western Australia 6845, Australia; Cairns Fertility Centre, Cairns, The History of Endometriosis Queensland 4870, Australia, Email: [email protected]. au Submitted: 22 April 2020 Preceding Sampson Accepted: 08 May 2020 John L Yovich* Published: 09 May 2020 PIVET Medical Centre, Perth, Curtin University, Australia ISSN: 2333-6439 Copyright Abstract © 2020 Yovich JL Until recently historical reports concerning endometriosis begin with the 1860 publication by OPEN ACCESS the pathologist Rokitansky when he described “benign sarcoma” describing three phenotypes in the uterus among some of the females of his many thousands of autopsies performed in Vienna. Keywords The defning of adenomyosis, then endometriosis improved with ensuing pathologists providing • Endometriosis better descriptions brought about by the addition of improved microscopy for histological • Adenomyosis examinations introduced by Rudolf Virchow, Hans Chiari and Friederich von Recklinghausen, as • Hysteria well as advanced tissue specimen preparation, especially using the microtome with diamond • Suffocation of the womb cutting blades, used by William Welch, Robert Myer and Thomas Cullen at the Johns Hopkins • Strangulation of the womb Hospital in Baltimore, USA. So too did John Sampson continue with those advanced pathology • Demonic possession methods when he moved from the former location to Albany in New York. Of all those revered • History of endometriosis professors, only Cullen and Sampson were physicians, actually highly capable surgeons with a • Witchcraft strong interest in gynecology, and who focused their pathology reports on trying to explain the patient’s symptomatology and correlate their live operative fndings. Two recent authors have started the process of deciphering the past enabling one to track the disorder of endometriosis back to Egyptian times (1855 BC), thereafter to Hippocrates and his histerikos-hysterike pnix disorders and the idea of “suffocation/ strangulation of the womb”. However, the association of severe abdomino-pelvic pain with menses appears to have taken centuries to clearly emerge. The preferred idea espoused by Plato, Pliny the Elder, Soranus, Celsus and a procession of physician philosophers through to both the early and late Middle Ages as well as the Renaissance, was that the symptoms which today we attribute to endometriosis were due to “suffocation/ strangulation of the womb”. This diagnosis prevailed within Christian, Jewish and Muslim/ Zoroastrian/ Persian societies and was widely considered to be “due to remaining barren for too long after puberty”. All the authorities noted that the symptoms, often described as “hysterical” and sometimes as “demonic possession” would disappear permanently after the woman “fulflled her marital duties” and bore children. The nineteenth century was possibly a worse era for women with endometriosis with the popularisation of psycho-neurogenic ideas espoused by prominent physicians like Thomas Sydenham and practiced by “off-track” psychiatrists such as Sigmund Freud. It was Sampson who unraveled the complex pathogenesis of endometriosis and led to the improved outlook for women today.
INTRODUCTION alternative pathogenetic mechanisms. Nonetheless, with an appreciation of Sampson’s earlier studies on myomata and the Our current knowledge about endometriosis is derived venous drainage mechanism of the uterus [4,5], he was able to from the work of John Sampson and his detailed publications show that foreign material could escape from the uterine cavity covering two important theories/ mechanisms concerning its and appear in the uterine veins [6]. This led him to publish his pathogenesis. John Sampson defined the term “endometriosis” important first mechanism/ theory under the title of ‘Metastatic in 1925 [1], and most gynecologists are familiar with his or embolic endometriosis due to the menstrual dissemination of implantation theory (being secondary to a mechanism involving endometrial tissue into the venous circulation’ in 1927 [7]. This retrograde spill from the fallopian tubes) which he proposed in was an earlier publication in 1927 from that reporting on the 1927 [2], and fully described in a lecture he presented to the implantation theory. American College of Obstetricians and Gynecologists in 1940. PERSONAL PERSPECTIVE This lecture was in response to an invitation to explain the Having graduated in medicine as an MD 50 years ago (1970), implantation theory and was published in the college journal and specializing in Obstetrics and Gynaecology 6 years later, following its presentation [3]. However, this mechanism cannot thereafter Subspecialty practice (Certification in Reproductive explain all forms of endometriosis hence many have proposed Endocrinology and Infertility; 1990) involving advanced
Cite this article: John L Yovich (2020) The History of Endometriosis Preceding Sampson. Med J Obstet Gynecol 8(1): 1131. Yovich JL (2020)
Central laparoscopic surgery and Infertility management 30 years ago, and advanced their o n uni ue contributions, each reflecting I have been perplexed that Sampson’s work was not clearly the limitations as well as the advances prevailing within their presented. Younger trainees may still not be aware that John personal eras. Sampson’s work explains why normal menstruation is a controlled process, mainly on the basis of the unique vascular arrangement CARL VON ROKITANSKY, THE PATHOLOGIST of the uterus, particularly that pertaining to the venous drainage AROUND WHOM ENDOMETRIOSIS PIVOTS, 1860 [4]. Furthermore, the mechanism by which leiomyomata can The historical background for the pathogenesis of cause menorrhagia is also based on disturbances of the venous endometriosis is usually cited as commencing ith Carl von drainage mechanism described by Sampson more than a century Ro itans y (1 0 1 7 ) ho, at the second Medical School ago [8]. It is Sampson’s work which explains why myomata in the in ienna provided the first descriptions of the t o entities periphery of the uterus can cause abnormal uterine bleeding and which later received their current titles - endometriosis and disturb fertility, contrary to current teaching that only intracavity adenomyosis - in 1860. At that time Rokitansky was still and submucus fibroids are clinically relevant. My group has continuing the tradition of bare-hand, naked-eye examinations as also attempted to redress current teachings with respect to established by the acknowledged Founder of modern pathological endometriosis and adenomyosis [9], including that condition anatomy iovanni attista Morgagni (1 1771). hese ere no n as deeply invasive endometriosis (D ) and specifically macroscopic morbid pathology descriptions. By a state mandate that of deeply invasive endometriosis involving the rectum of 1753, under Emperor Francis I Stefan ruling with the popular (DIER) [10] from John Sampson’s perspective. By understanding Habsburg mpress Maria heresa, autopsies had to be carried these processes, I believe we can reduce the burden of surgical out on all patients dying at the eneral ienna Hospital, enabling treatments for young women and manage their endometriosis/ Rokitansky to conduct more than thirty thousand, possibly adenomyosis conditions by applying long-term hormonal si ty thousand post mortems. He published his Handboo of suppression therapy [11]. Pathological Anatomy in three volumes across the years 1844- SAMPSON’S POSITION IN THE EVOLUTION OF 1846; a major treatise of macropathology. Following an academic UNDERSTANDING ENDOMETRIOSIS visit to Paris in 1842, Rokitansky did introduce microscopy into his department, but he found it of limited value in the 1850’s John Albertson Sampson (1873-1946), was born in Troy, New before adequate tissue preparation and staining techniques or and graduated MD at Johns Hop ins niversity in 1 99. developed in ienna. He did add microscopic histology into his After completing his internship, he undertook a residency in 1860 “benign sarcoma” descriptions with three phenotypes gynecology under Dr Ho ard elly until 190 , follo ing hich noted containing endometrial stroma and glands: he moved to Albany in New York establishing a private practice. i. Sarcoma adenoids uterinum, with invasion of the n addition, he as attached to the lbany Medical College here, myometrium in 1911 he was appointed Professor of Gynecology. In 1927 he as also appointed ynecologist in Chief at the lbany Medical ii. Cystosarcoma adenoids uterinum, the cystic variety, Hospital thereafter spending his remaining career on the shared including a polypus variant campus ith the university college. t Johns Hop ins during the iii. Ein ovarial-cystosarcom, describing endometriosis within 4 years of his gynecological residency, Sampson had exposure to the ovary the lectures and advice of homas Cullen ho as the Director of Gynecological Pathology from 1893. Sampson was also in the key These descriptions implied new diseases, but the reality is position to discuss elly s operative specimens ith Cullen, ho they are the first “modern” descriptions of conditions affecting the was not only a pathologist, but an accomplished gynecological female “uterus” (“deep pelvic structures”), for at least 200 years surgeon. Sampson published 18 articles, including book reviews, prior [12]. At this stage the “sarcoma” entities were embraced on surgical and gynecological subjects by the time he left Johns as variants of the same process (categorized benign), and were Hop ins at the end of 190 . hese ere mostly as sole author, seen to be distinct from both fibroids (benign), and carcinoma none ith Cullen as co author. t lbany, Sampson remained a (malignant). It would await Sampson to clarify this terminology bachelor and worked tirelessly, completing many unique studies to what is understood today. Although Rokitansky’s descriptions and achieved a total publication profile of articles, each have been challenged, particularly by Robert Scully 1921-2012 being extensively detailed in its descriptions and abundantly rofessor of athology at Harvard Medical School, ho as illustrated, mainly with his unique radiomicrographs for he was dissatisfied ith the “polypus” inclusion, there is wide acceptance also a pioneer in this application of the new technology involving that these descriptions by Rokitansky should be accepted as two rays 11 . Sampson s final publication as in 19 , the year of of the three essential criteria, recently put forward by Benagiano his death following a motor vehicle accident, although, at age 73 and rosens 1 , are satisfied, albeit belatedly 1 ,15 . years, he was still working until that event. THOSE WHO INFLUENCE ROKITANSKY In drawing attention to Sampson’s two theories/ mechanisms Rokitansky’s publication of 1860 constitutes an important and his numerous articles, this infers he had a central position in event but was not a spontaneous epiphany. One needs to consider clarifying the evolving understanding of the conditions embraced the interactive influences of a number of bio scientific thin ers under the term “endometriosis”. I personally believe this to be of the early nineteenth century including poet-scientist Johann the correct view, but researchers will need to investigate a Wolfgang von Goethe (1749-1832), who objectively and precisely progressive line up of historical figures ho preceded Sampson
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Central sketched plants and animals and coined the term ‘morphology’. the several professors ho had observed M llerian disorders or it as he ho influenced the brothers le ander (1759 although it was Rokitansky who provided the full description. 1 59), and ilhelm (17 7 1 5), von Humboldt ho separated Conversely ith his reporting in 1 0 of “benign sarcomas” the rts from Science and introduced deductive scientific thin ing (later to become no n as adenomyosis by Cullen in publications based upon research. So, too did von oethe directly influence of 1908, 1914 and 1920 [16-19], and endometriosis by Sampson the young ‘disciple Johannes eter M ller (1 01 1 5 ), ho in 19 5 1 these conditions ere seen to be diseases of M llerian as called to the Chair in natomy and hysiology in erlin in excess. Given the subsequent disputes about pathogenesis, this 1833, having already published work on the embryology of view could be considered appropriately perceptive. “his” M llerian ducts, follo ed by his monumental Handboo of Human hysiology in 1 0. long ith le ander von Humboldt HISTORICAL BACKTRAIL they, in turn, influenced Charles Robert Dar in (1 09 1 ), and promoted natural scientific thin ing throughout the universities The historical back-trail for endometriosis (and its variant, of Germany, including Vienna. adenomyosis) reveals that it did not emerge anew in the middle of the nineteenth century, but descriptions in various latin HISTORICAL NOTE CONCERNING THE POLITICAL tomes 200 years earlier indicate the condition was not rare in GERMAN PERSPECTIVE post-pubertal women and the descriptions do not at that stage, claim the findings as novel 1 . he historical trail actually The region of Germania, comprising many tribes with a goes back much further with seminal reports best described similar language structure, was a border region under the Roman by the Nezhat brothers, all Iranian-born gynecologists. In their Empire and thereafter the Germanic Territories were embraced comprehensive historical contribution [20] they made the ithin he Holy Roman mpire hich began hen ope eo perspicacious observation that “to exclude the formative years cro ned the ran ish ing Charlemagne as the first Carolingian leading up to the microscopic discovery of endometriosis is to Emperor in 800 AD. Regarding itself as independent from the deprive our discipline of an invaluable reservoir of knowledge that atican and unofficially no n as the Holy Roman mpire of the may reveal essential new insights about a disorder that continues German Nation, it persisted until 1806 when it was dissolved to reign as one of gynecology’s most perplexing diseases.” For the by Napoleon. Following the Napoleonic Wars, resolutions at the modern vidence ased Medicine purist, the follo ing ideas may Congress of ienna in 1 15 created the mpire of ustria and not be universally accepted [15], but I, for one, like the story, the erman Confederation ruled under the ustrian presidency. which includes the idea that hysteria (ungovernable emotional hereafter the ingdom of ermany as established in 1 71, excess), the now discredited disorder that the eminent Sigmund arising from the Duchy of Prussia uniting with other Germanic Freud (1856-1939), studied in large numbers of young women states. This union excluded Austria with its capital, Vienna, and in the late nineteenth / early twentieth century, was most likely hich continued under the ustro Hungarian compromise of an endometriosis-triggered disorder. The Nehzat group raked 1867 until 1918, when its numerous member nations sought through ford s odleian ibrary and discovered 1 th century their respective independent status at the Treaty of Versailles in manuscripts depicting imagery of a young woman doubled over 1919. he treaty specifically forbad any union bet een ustria in pain suffering “strangulation of the womb” a condition which and Germany. can trace its derivation to the hysterikos-hysterike pnix disorders RETURNING TO THE INFLUENCES FOR described by Hippocrates ( 0 70 C), and other reco Roman ROKITANSKY authorities, which in turn was derived from the ancient Egyptians ith similar documentation from 1 55 C. f further interest it is Considered together, the aforementioned ‘revolutionary apparent that such women actually suffered infertility, and that is minds who embraced science, arts and philosophical ideas, why the uterus was “upset”. This infertility was usually sheeted influenced emergent embryologists such as Johannes riederich to the woman as representing her failure to be a good wife in her Mec el (17 1 1 ), disciple of Jean aptiste amarc (17 marriage and unsuited to motherhood. In the circumstance of 1 9) also Casper riederich olff (17 179 ), embryology achieving a normal pregnancy, the attending doctors invariably founder and believer in epigenesis and arl rnst von aer noted that her pelvic pain and associated symptoms became (1792-1876), founding father of embryology and critic of resolved and she ould no be classified as a “normal, good Charles Dar in. ogether they ushered in a period of scientific oman”. rom the time of Hippocrates, physicians have urged enlightenment. These are only a few of the medical scientists and women suffering from dysmenorrhoea to “marry and conceive thin ers ho directly influenced Ro itans y s education. as quickly as possible”. Even Plato, who was not a physician, he Second ienna Medical School as established by e pressed his opinion ( 75 C), that omen ith menses Baron von Turkheim (1749-1824), who centered all teaching related pain were suffering from “suffocation of the womb”, and research around Rokitansky’s autopsy table leading to due to remaining barren for too long after puberty. The Nehzat one of the most fruitful epochs in Viennese medicine. In 1838 historical document indicates that many of history’s revered Ro itans y described partial M llerian agenesis, an anomaly writers added to the subject – including the Roman scholar Pliny which carried his eponym but would become known as the the Elder (23-79 AD), and the Greek scholar Soranus of Ephesus Mayer Ro itans y ster Hauser Syndrome paying homage to (98-138 AD), who is known to have conducted autopsies. Soranus historical contributors. rofessor Mayer of onn (17 7 1 5), proposed inflammation as a cause of “suffocation of the omb”. Germany had reported a case of vaginal agenesis in 1829, hence he ersian physician Hunayn bn sha al ‘ badi ( 09 7 D), the Rokitansky Syndrome gradually acquired the names of endorsed the Hippocratic Corpus. he Roman encyclopedist
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Central
ulus Cornelius Celsus ( 5 C 50 D), rote De Medicina, the Inquisition in some Italian and Spanish jurisdictions. With respect only surviving book of a series of encyclopedia. De Medicina itself to his dissections on the female reproductive system, Vesalius is divided into eight boo s, boo pertaining to specific diseases. corrected Galen’s descriptions of the 2-chambered uterus, but Celsus described the recurrent nature of attac s of uterine appears to have had few female, especially pregnant, cadavers pain, sometimes ith associated “hysterical fitting”. he ree available for dissection. Possibly he was not very interested as physician Dioscorides (40-90 AD), who wrote the 5-volume De it as his follo er in 1551 to the rofessorial Chair of Surgery Materia Medica, which became the basis for medical teaching and Anatomy in Padua, Gabrielle Fallopius (1523-1562), over the next 15 centuries, wrote about intermittent menses- who described the Fallopian tubes. Despite their enormous related pelvic pain, sometimes with collapse, from “strangulation contributions to human anatomy however, neither Vesalius of the uterus”. Greco-Roman Galen (126-210 AD), of Pergammon, nor Fallopius made any relevant advanced contributions to the now Bergamma in Turkey, became physician to several Roman subject of “suffocation/ strangulation” of the uterus. In fact, the mperors. He developed uni ue anatomical dra ings said to be one case, in Spain, where Vesalius was to undertake an autopsy derived from his well-known animal dissections (as autopsies on a woman following a seizure due to suffocation/ strangulation ere banned in Rome at the time). Ho ever, his description of of the uterus, she awoke during her autopsy. Although not clearly s ollen and inflamed uterine ligaments in omen ith uterine substantiated, Vesalius was pursued by the Inquisition and it was pain, implies that he was familiar with the utero-sacral ligaments, during his escape he met an early accidental death. a common site for endometriosis; albeit Galen is known to have The research undertaken by the Nehzat brothers indicates dissected Barbary macaque monkeys, a species of primate which that prominent medical authorities of the 1 th Century accepted is known to develop endometriosis, especially those which have the diagnosis of suffocation/ strangulation of the womb in no offspring. Galen also connected psychological disturbances of explaining women’s unique illnesses but one, French barber- women to this disorder of pelvic pain from uterine suffocation/ surgeon Ambroise Paré (1509-1590), clearly related the strangulation. disturbances to menstruation and described “swollen uterus” female physician from the early Middle ages rota or and “distensions on the uterine ligaments” as features of the Trotula of Salerno (1050-1097), wrote 3 books, comprising condition. nfortunately, ho ever, the process of enlightenment 200 manuscripts, on the conditions and treatments of women, arising from the Renaissance was slow to dismiss the primitive collectively no n as the rotula. She as the first riter to thin ing of the Middle ges hich categori ed many omen ith attempt to correct misogynistic views about “the secrets of the symptoms of uterine suffocation/ strangulation as having women”, and described many of the mysterious actions, which demonic possession or being immersed in witchcraft. Such earlier writers described as hysteria and anti-matrimonial women were often blamed as causing unexplained community behaviour, as foundered in the disorder of uterine suffocation/ ailments including delivering the plague. Even the esteemed strangulation being clearly a menstrual-related disturbance. illiam Harvey (157 1 57), rote that female hysteria as brought on by “unhealthy menstrual discharge” related to “being n the late Middle ages and early Renaissance period, lemish too long un edded”. rom a scientific perspective Harvey did anatomist and physician Andreas Vesalius (1514-1564), is make one small positive contribution in demonstrating that he regarded as the founder of modern human anatomy as he was could reproduce the woman’s hysterical symptoms by distending allowed to conduct autopsies on human corpses, thanks to the her uterus (during treatment for cervical ulceration). Protestant Reformation movement. Vesalius became Professor of Surgery and natomy at the niversity of adua ( t avia), in 15 7. Ho ever, despite the terrible conse uences for omen he rotestant Reformation movement as started by Martin ith uterine suffocation/ strangulation in the Middle ges, the uther (1 15 ), ho published his treatise comprising 95 ne t period, one of scientific and artistic enlightenment as theses from ithin the Holy Roman mpire (of Germany), and characterised by the evolution of neuroscience. This period led to hich as condemnatory of the Roman apacy. uther as a shift in focus away from the uterus as the cause for female hysteria particularly annoyed about the practice of “indulgences” which but considered it more likely an expression of the increasingly enabled wealthy sinners to be absolved by payment directly to popular psychological-neurologenic theory. Despite embodying the ope. uther s treatise led to ope eo issuing a apal ull some of the best attributes of the scientific enlightenment in 1520 termed Exsurge Domine which required the “heretic period, revered physician Thomas Sydenham (1624-1689) priest” to retract his 95 theses. uther famously refused and described that female hysteria was a “disease of civilization, more was excommunicated by the Roman Vatican the following year common in leisured ladies with lives characterized by idleness thereafter setting about the creation of his ne rotestant Church. and overindulgence”; hence he thought it was caused by “frayed his entailed re ecting Roman Catholic vie s about the Soul hich nerves”. For the next 200 years, many prominent physicians was the foundation for Vatican’s view against autopsies. Apart including Sigmund Freud (who was mentioned at the start of this from a requirement for respectful handling, autopsies are not section) identified hysterical behavior including nymphomania banned in the rotestant vie . Hence, esalius did not encounter and neuroses as having an entirely psycho-neurogenic basis, opposition to his dissections performed in Switzerland and other totally removed from any pelvic connection. Reformist countries enabling him to publish his groundbreaking The beginnings of modern thinking regarding endometriosis work “De Humani Corporis Fabrica Libri Septem” (On the fabric of and adenomyosis can be ascribed to German physician the human body) in 15 . Ho ever, it appears the atican as Daniel Shrön (Shroen; 1690), who described ulcers/ deposits not so tolerant and Vesalius appears to have been pursued by the scattered throughout the visceral and peritoneal surfaces of
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Central the abdomen and pelvis probably the first proper description FRIEDERICH VON RECKLINGHAUSEN of endometriosis 1 , 0 . Ho ever, a contemporary, Dutch Friedrich Daniel von Recklinghausen (1833-1910), had anatomist Frederik Ruysch (1638-1731), later provided even been the first assistant of the famed Rudolf ircho ho, in more detailed descriptions of widespread peritoneal lesions, Berlin, introduced advanced microscopic descriptions to all which he suggested was most likely a consequence of menstrual the organ pathologies of the body. With advancing methods of blood forced bac oods follo ing obstruction to normal flo , preparation of thin tissue slices, Von Recklinghausen became an idea that Sampson was reluctant to entertain until 1927 the ac no ledge “ ather of Modern athology”. He described . Ruysch lin ed these findings to the oman s history of the microscopic appearances of adenomyomata in a brief report cyclical abdomino-pelvic pain. The next stage in clarifying the in 1 9 and an e tensive treatise in 1 9 . He then established a pathology underlying these symptoms was developed by the Chair in Strasbourg (the city of lsace orraine on the rench French pathologists who took the art of autopsy investigations German border), at the time, following the Franco-Prussian War, to an advanced level, particularly heralding the application of a erman City (1 71 191 ), but no adays rench, apart from a histology pioneered by Marie ran ois avier ichat (1771 short period as German again, under Nazi occupation 1940-1944. 1802). It was the French group, including Armand Trousseau ollo ing his mentor, ircho s demotion of the inflammatory (1801-1867), and Alfred Velpeau (1795-1867), who changed theory proposed by Ro itans y for his 1 0 findings, von the thinking from suffocation/ strangulation of the uterus to a Reklinghausen developed his ideas that the adenomyomata were new set of terms – catamenial hematoceles, pelvic sanguinous derived from embryological rests of the resorbed olffian Duct. tumours and sanguinous cysts. This enabled advanced clinicians He published these ideas in short articles in 1 9 and 1 95 to dismiss the “hysteria” label and deal with their female patients in which he referred to Rokitansky and his theories, preferring from a clear pathological entity. Even Rokitansky admits his ideas his own. Reklinghausen described microscopic pseudoglomeruli hich led to the first clear depictions of uterine adenomyosis, that resembled the glomeruli of the kidneys and which thus emerged after his important visit to the French pathologists in formed the basis for his olffian rest theory. on Re linghausen 1 , follo ing hich he added the histological findings into also included the recently described “salpingitis isthmica nodosa” his autopsy evaluations. So too, did Sampson apply terms such as a form of his “adenomyomata” and similarly, he felt, was as “heterotopic endometrial tissue” until firming his definition of derived from olffian rests. t as Hans Chiari (1 51 191 ), endometriosis in 1925 [1]. assistant of Rokitansky, who described, among other important RUDOLF VIRCHOW pathologies) the condition of “salpingitis isthmica nodosa” in After Rokitansky’s important publication of 1860, 1887. As von Reklinghausen had a formidable reputation in the evolution towards Sampson considers other German histopathology, Chiari, ho believed his eponymous condition pathologists, each stepping up on the foundations laid by their had an inflammation basis (li e Ro itans y s adenomyomata), predecessor [21]. Although not directly interested in pelvic allo ed the olffian cell rest hypothesis to prevail. Ho ever, it disorders of the female, Virchow is an important pillar in the as the first gynecological pathologist in orth merica, homas evolution of histopathology. Rudolf ud ig Carl ircho (1 1 Cullen, ho demonstrated that neither the inflammation nor 190 ), studied in the niversity of erlin here he pro ected the olffian theory as correct, but these lesions ere clearly the ne ideas of cell biology and cell theory. Microscopy as derived from the M llerian tract. his became a concept to hich an essential tool enabling him to extend on the unique cellular von Reklinghausen conceded in 1903 after 2 of his own students, theories of his mentor Johannes M ller (1 01 1 5 ), previously namely illiam Henry elch (1 50 19 ), and Robert Meyer mentioned with Rokitansky, and his assistant Theodor Schwann (1864-1937), showed him the indisputable evidence which (1810-1882), who had published his foundational Microscopical Cullen had revealed in his e uisitely mounted, and clearly Researches into the Accordance in the Structure and Growth of superior, histological specimens. Animals and Plants in 1839. From this Virchow developed his THOMAS CULLEN revolutionary cell theory formulated as omnis cellula a cellula (all homas Stephen Cullen (1 195 ), graduated in Medicine cells from other cells) and his treatise entitled Cellularpathologie in oronto, Canada in 1 90, thereafter training as a ynecologist published in 1858). This idea gained immediate recognition and at the Johns Hop ins niversity 1 91, but also spending enabled Virchow to demote other theories of disease causation, 6-months working with Pathologist Johannes Orth (1847- including Rokitansky’s blastema theory which was based on 190 ), in ottingen, ermany before returning to Johns Hop ins the long-standing idea of haemato-humoral pathogenesis. Even in 1893. Ort was another protégé of Virchow and actually Rokitansky soon acknowledged that Virchow’s cellular origin of assumed his mentor s Chair in athology at erlin on ircho s disease was the better path, stating in 1855 that he “encouraged retirement. Ho ever, the senior surgical position Cullen had Virchow to further develop this natural scientific conception of e pected ith Ho ard elly as deferred hence he established, disease”. Rudolf Virchow is universally acknowledged as the at elly s invitation, a pathology laboratory, becoming the first “ ather of Modern athology” as ell as “ ounder of Social Gynecological Pathologist in North America whilst also practicing Medicine” and casually regarded as the “ ope of Medicine”. hese as a gynaecologist in private practice and assisting elly ith his terms reflect a varied, erudite and colourful political history gynaecological operations. Cullen eventually gained the position which is exciting to read about, and is one entirely missing from as Head of ynecology in 1919 after the retirement of elly the medical landscape of today.
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Central and had the title of rofessor of Clinical ynecology, a position is best described by Ronald att in Chapter of his History of he held until retirement in 1939. Between 1894 and 1909, Endometriosis [21], which is titled “From von Rokitansky to Cullen rote boo s on gynaecological diseases hich married von Re linghausen to Cullen” 5 . lthough Cullen visited histopathology with clinical symptoms and signs, one of which von Re linghausen in 1 9 to discuss their different findings as denomyoma of the terus 1 . Subse uently he published regarding adenomas of the uterus, it was not until 1903 after on the specific sub ect of adenomyosis of the rectovaginal septum presentations by his former students elch and Meyer, that von 17,1 as ell as an accumulated e perience of his findings of Re linghausen finally acceded that the pathogenesis as clearly extra-uterine adenomyosis, detailing 10 sites which he had Mullerian derived and the olffian hypothesis as discarded. personally documented 19 . Ho ever, the orst cases ere lthough von Re linghausen did not accept giving Cullen, hom those involving the recto-vaginal septum, numbering 19 in total, he saw as not having proper training as a Pathologist, face-to-face and hich led to its eponymous title “Cullen s Disease”. Cullen credit, he confided in colleagues the vie point that his autopsy also published on uterine haemorrhage and its treatment [22], specimens, “hand-cut with a razor and mounted in amyloid liver” classifying these into pregnancy-related and non-pregnancy ere different, (meaning inferior to), those of Cullen s fresh related. His description of discoloration of the s in about the surgical specimens. umbilicus , , became no n as Cullen s sign, particularly hen related to ectopic pregnancy, about hich Cullen rote o understand the man, Cullen, this is best revealed in his extensively. “Address in Gynaecology” [26], where he was invited to speak to the Canadian Medical ssociation in ondon, ntario. he first n the previous section described Cullen s successful or half of his presentation dealt ith Cancer here he presented to indicate that adenomyosis had its pathogenesis derived from details from many areas of the body; particularly that of breast M llerian origins, rather than from cellular rests of olffian cancer, skin cancer, cancer of the lip, cancer of the tongue, duct origin. his meant Cullen ta ing on the eminent figure of cancer of the stomach, cancer of the intestine, cancer of the Friederick von Reklinghausen, a giant in his time who, having rectum and gynecological cancers, particularly of the uterus, studied under Rudolf Virchow, progressed histopathology with the endometrium, the cervi and the ovaries. He made strong improved tissue preparations, their embedding and staining, observations about the need for surgery to be conducted in the along with the skillful process of cutting very thin tissue slices early course of those disease processes, and he was particularly and applying improved compound microscopy. Much of these critical of those surgeons who did not “dissect fully and excise advances were derived from Professor of Physiology, Jan widely”. A telling comment, with historical interest is his vangelista ur yn ( ur in e) (17 7 1 9), from the ustro statement: Hungarian region of ohemia (no C ech Republic). His name is attached to his discovery of large multi-dendritic neurons in the “When I started medicine a quarter of a century ago, asepsis cerebellum, pigmented neurons in the Substantia Nigra and the was slowly creeping into Ontario, and Lister’s carbolic spray fibres conducting electrical impulses from the atrio ventricular was still in vogue. We examined very little operative material node in the heart. Along with creating improvements in compound microscopically in those days. The time is rapidly drawing near microscopy, ur in e developed the first microtome to create when every surgeon, before he becomes a real surgeon, must have very thin histological specimens, an instrument probably not a thorough grounding in surgical pathology as he now has in the used by von Reklinghausen in Strassburg but rapidly adopted principles of bacteriology.” by his assistants such as illiam elch and Robert Myer hen he second half of Cullen s presentation focused on myomata they or ed in independent locations. hen Cullen returned to and adenomyomata of the uterus along ith that specific Johns Hop ins from his uropean so ourn in 1 9 , he or ed condition of “adenomyosis invading the rectovaginal septum” in the pathology laboratory of William Welch who had been an on hich he soon published specifically the follo ing year 17 . assistant under von Re linghausen. Cullen assisted the surgical He described the details of a 7 year old oman admitted to the procedures of Ho ard elly as ell as underta ing the pathology Johns Hop ins Hospital on June th, 191 she had previously evaluation of elly s specimens ith elch. hen Cullen read von had a supravaginal hysterectomy with bilateral salpingo- Reklinghausen’s monograph of uterine and tubal adenomyomas, oophorectomy, undertaken for pelvic pain in San Francisco but he had “an epiphany” and pulled out his own histology slides on similar cases undertaken in Baltimore during 1894 and 1895. her symptoms persisted along with irregular, almost continuous Cullen s histological specimens, confirmed by illiam elch bleeding from her remaining cervi . Cullen operated and and later by Robert Meyer sho ed clearly that the adenomatous reported: lesions ere derived from M llerian tissue and not derived, in “We are here dealing with an adenomyoma which has formed any ay, from olffian rests. his finding related to improved a cystic mass in the left broad ligament and which has become tissue specimen preparation using a modern American-made densely adherent to the rectum. We found the rectum densely microtome utilizing a diamond cutting blade, mounting his adherent to the bladder, and the left broad ligament was filled specimens in celloidin as well as utilizing the latest German- out by a rather cystic growth. Those assisting at the operation made microscopes which had been installed in the Pathology thought that we were dealing with a malignant growth which had laboratories at Johns Hop ins. Cullen as able to ta e thic spread into the broad ligament.” Cullen completed a conservative specimens of uterine tissue and cut ultrafine slices hich could operation for what is now termed deeply invasive endometriosis be examined sequentially, enabling a continuous tracking of involving the rectum (DIER), leaving a portion of the “now adenomyoma tissue from the periphery of the uterus back to the termed endometriosis/ adenomyosis” attached to the rectum. uterine cavity. his detail concerning Cullen s tissue preparation hen Cullen later e amined the e cised tissues he reported
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“on microscopic examination it was found that the wall hich specifically details Sampson s contribution to e plaining of the blood stained cyst was lined by one layer of cylindrical endometriosis in its 8 different clinical scenarios, 4 being epithelium, and that this rested on a definite stroma consisting common and 4 being uncommon [11]. The article also supports of cells having oval vesicular nuclei. The more solid portions of the recent publications which reveal that women have historically the groeth were made up of non-striated muscle fibres arranged been unfavourably depicted from Hippocratic, probably even in whorls, and of quantities of uterine glands embedded in their earlier Egyptian, times with the condition of “hysteria” caused characteristic stroma. In some places only two or three glands with by suffocation/ strangulation of the uterus. Sampson has placed the surrounding stroma were visible but at other points miniature all this on a firm diagnostic footing hich enables modern uterine cavities were found.” doctors to treat the condition of endometriosis in a rational and therapeutically valid manner. Cullen as planning further surgery for the oman to fully “shell out the thickening in the right broad ligament, remove the REFERENCES cervix and then a portion of the rectum to which the growth is 1. Sampson J . Heterotopic or misplaced endometrial tissue. m J bstet intimately blended. Unfortunately, the woman became weaker in Gynecol. 1925; 10: 649-664. the post-operative period and died June 19th.” 2. Sampson JA. Peritoneal endometriosis due to the menstrual ith respect to the specific surgical procedure for D R, dissemination of endometrial tissue into the peritoneal cavity. Am J Cullen later stated “The removal of an extensive adenomyoma Obstet Gynecol. 1927; 14: 422-469. of the rectovaginal septum is infinitely more difficult than a 3. Sampson JA. The development of the implantation theory for the hysterectomy for carcinoma of the cervix”. In tackling this disease origin of peritoneal endometriosis. Am J Obstet Gynecol. 1940; 40: Cullen believed that ynaecologists should be trained as fully 549-557. competent abdominal surgeons. He stated “Where the lumen of 4. Sampson JA. The blood supply of uterine myomata. Surg Gynecol the bowel is greatly narrowed, a complete segment of the rectum Obstet. 1912; 14: 215-234. should be removed with the uterus, and an anastomosis should be made.” In such cases “surgeons should perform a “preliminary 5. Sampson J . he influence of myomata on the blood supply of the uterus, with special reference to abnormal uterine bleeding. Surg permanent colostomy... later the pelvic structures can be removed Gynecol Obstet. 1913; 16: 144-180. en bloc” [17, 18]. 6. Sampson JA. The escape of foreign material from the uterine cavity into Ho ever, despite Cullen s anatomical no ledge and the uterine veins. m J bst (and Diseases of omen and Children). surgical expertise, especially that involving bowel anastomoses, 1918; 78: 161-175. he described some unpleasant complications which included 7. Sampson J . Metastatic or embolic endometriosis due to the menstrual vesicovaginal and rectovaginal fistulas. n this pre antibiotic dissemination of endometrial tissue into the venous circulation. Am J era, despite the advanced sterile surgical techniques practiced Pathology. 1927; 3: 93-110. at the Johns Hop ins Hospital, most of the omen ho had 8. ovich J , Ro lands , ingham S, Sillender M, Srinivasan S. complications died, li e the one reported in ondon, ntario in dvanced fibroid study paying homage to John Sampson. Reprod 1913. Biomed Online. 2019; 39: 183-186. This subject of DIER and its surgical management, has recently 9. ovich J , Ro lands , ingham S, Sillender M, Srinivasan S. been analysed [27,10] and it is relevant for this presentation to Pathogenesis of endometriosis: look no further than John Sampson. know that Sampson had quite different views about managing Reprod Biomed Online. 2020; 40: 7-11. this condition albeit that both men were extremely competent 10. ovich J . perating on deep infiltrating endometriosis involving the as abdominal and pelvic surgeons and had exquisitely intimate rectum a debate started 100 years ago bet een Cullen and Sampson. knowledge about the pathology as well as the pathogenesis orld J f aparoscopic Surgery. S 0 1 in press of this sub ect. oth Cullen and Sampson rote about the 11. ovich J . nderstanding endometriosis. Med J bstet ynecol. 0 0. appropriate surgical management of rectovaginal endometriosis, one promoting aggressive surgery, the other indicating a more 12. napp J. Ho old is endometriosis ate 17th and 1 th century European descriptions of the disease. Fertil Steril. 1999; 1: 10-14. conservative management was better; this debate, started more than 100 years ago, still continues today [10], but should not 13. Brosens I, Benagiano G. Endometriosis, a modern syndrome. Indian J if due attention is paid to the publications of John Albertson Med Res. 011 1 5 1 59 . Sampson. 14. enagiano , rosens . History of adenomyosis. est ract Res Clin Obstet Gynaecol. 2006; 20: 449-463. CONCLUSION 15. enagiano , rosens , ippi D. he history of endometriosis. ynecol This historical article is intended to cement the place of Obstet Invest. 2014; 78: 1-9. Sampson into its appropriate position as the exceptional Physician 16. Cullen S. denomyoma of the terus. hiladelphia, . . Saunders. who truly understood the pathogenesis, the pathology and the 1908; 294. clinical manifestations of the perplexing disease of endometriosis. He as the right person, at the right historical moment to achieve 17. Cullen S. denomyoma of the rectovaginal septum. J M . 191 835-839. this wisdom, coming off the sequential work of a number of giants in the world of Pathology and his contemporary clinical 18. Cullen S. denoma of the recto vaginal septum. J M 191 7 01 colleagues in the North America. This article is intended to dove- 406. tail ith its sister article entitled nderstanding ndometriosis 19. Cullen S. he distribution of adenomyomas containing uterine
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mucosa. Arch Surg. 1920; 1: 215-283. 25. att R . rom von Ro itans y to von Re linghausen to Cullen. n A history of endometriosis. Author: Ronald E Batt, Springer-Verlag 20. e hat C, e hat , e hat C. ndometriosis ancient disease, ancient ondon. 011 57 treatments. Fertil Steril. 2012; 986: S1-S62. 26. Cullen S. ddress in ynaecology. Canadian Medical ssociation J. 21. att R . history of endometriosis. Springer erlag ondon. 011 1913; 8; 658-671. 225-229. 27. Roman H, uech J J, Huet , ridou , halil H, Hennetier C, 22. Cullen S. terine hemorrhage and its treatment. Can Med ssoc J. ubenheim M, rinduse . cision versus colorectal resection 1928; 411-420. in deep endometriosis infiltrating the rectum 5 year follo up of 23. Cullen S. Diseases of the mbilicus. 191 . patients enrolled in a randomised controlled trial. Hum Reprod. 019 34: 2362-2371. 24. Cullen S. ne sign in ruptured e trauterine pregnancy. m J bstet Gynecol. 1918; 78: 457.
Cite this article John L Yovich (2020) The History of Endometriosis Preceding Sampson. Med J Obstet Gynecol 8(1): 1131.
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