Ronald E. Batt1
(1)
State University of New York at Buffalo, Buffalo, New York, USA
Abstract
The need to unravel the skein of politics by starting from the subjects’ duties rather than the citizens’ rights has recently been stressed. Likewise it is diseases which have stimulated physiology; and it is not physiology but pathology and clinical practice which gave medicine its start. The reason is that as a matter of fact well-being is not felt, for it is the simple awareness of living, and only its impediment provokes the force of resistance. It is no wonder then that Brown begins by classifying diseases. Kant1
The Philosophy of Kant
The need to unravel the skein of politics by starting from the subjects’ duties rather than the citizens’ rights has recently been stressed. Likewise it is diseases which have stimulated physiology; and it is not physiology but pathology and clinical practice which gave medicine its start. The reason is that as a matter of fact well-being is not felt, for it is the simple awareness of living, and only its impediment provokes the force of resistance. It is no wonder then that Brown begins by classifying diseases. Kant1
Scientific objectivity had to be restored to nineteenth century European medical science before diseases – such as endometriosis, adenomyosis, endosalpingiosis, and developmentally misplaced endometrium – could be identified from among the myriad of chronic diseases that ravaged the interior of the human body. Objective research in the biological sciences in many European centers had ground to a virtual standstill during the late seventeenth and early eighteenth centuries as many medical scientists succumbed to the nature philosophy of Friedrich Schelling (1775–1854).2 Schelling’s was a philosophy that deduced all of nature from pure reason.3
The German philosopher Immanuel Kant (1724–1804) laid the foundation for the restoration of scientific objectivity in his mature work of 1790, the Critique of Judgment. Johann Friedrich Blumenbach, professor of medicine at the University of Göttingen from 1778 to 1835, directly incorporated Kant’s philosophy of scientific objectivity into his teaching.4 No less an authority than Kant himself regarded Blumenbach “as one of the most profound biological theorists of the modern era.”5 Blumenbach in turn taught or directly influenced Johann Wolfgang von Goethe, Alexander von Humboldt, and Johann Friedrich Meckel. Students and associates of Blumenbach in turn influenced Johannes Müller and Rokitansky. Such was the philosophical background and scientific genealogy fundamental to the emergence of objectivity in medical science, objectivity necessary for the discovery of adenomyosis and endometriosis.
For years, Rokitansky practiced macroscopic scientific objectivity during thousands of autopsies before he slowly embraced microscopy to examine more closely unusual cases that caught his attention. Such were the circumstances that lead to Rokitansky’s discovery and description of three different phenotypes of endometriosis all containing benign endometrial stroma and glands. One invaded the uterine muscular wall (cystosarcoma adenoids uterinum) and was accompanied by myometrial hypertrophy; another invaded the endometrial cavity forming a polyp (cystosarcoma adenoids uterinum polyposum).6The third phenotype was an ovarian endometrioma (cystosarcoma adenoids ovarii uterinum.7 Recall that at mid-nineteenth century Rokitansky, the first full-time pathologist, had defined sarcoma as benign tissue. Thus, in 1860–1861, Rokitansky identified internal endometriosis: adenomyosis, and a phenotype of external endometriosis: an ovarian endometrioma. His former assistant Chiari described endosalpingiosis in 1887, also known as salpingitis isthmica nodosa.8
The birth of surgical pathology at the end of the nineteenth century facilitated research into this enigmatic disease, research that required the interaction of clinic and laboratory such as that between the gynecologist Carl Ruge and the gynecologic pathologist Robert Meyer, and between the gynecologist Wilhelm Alexander Freund and the pathologist Friedrich von Recklinghausen.9 With specimens provided by Freund, von Recklinghausen popularized Rokitansky’s cystosarcoma adenoids uterinum and Chiari’s salpingitis isthmica nodosa, which he renamed adenomyoma of the uterus and tube, respectively in 1895.10 Cullen challenged von Recklinghausen the following year, a challenge that brought immediate recognition to the fledgling gynecologic pathologist; the scientific debate that ensued introduced the study of endometriotic disease into North America.11
Over a period of 25 years, Cullen studied with varying degrees of intensity all the common phenotypes of endometriosis in the pelvis and abdomen. The Englishman Cuthbert Lockyer wrote an important monograph that summarized the research in all manifestations of endometriosis recognized prior to World War I.12 Cullen arranged for Casler to present his unique case of the menstruating ovary to the American Gynecologic Society in 1919. From this case, John Sampson drew his initial insight for the implantation theory of peritoneal endometriosis. Sampson evolved his complete three-step theory of pathogenesis of peritoneal endometriosis over a 10-year period of intense research. He implicated both uterine and fallopian tubal mucosa in the pathogenesis of peritoneal and ovarian endometriosis as well as the pathogenesis of endometriotic adhesive disease. Sampson also postulated venous and lymphatic dissemination of endometriosis. In debate with supporters of the theory of coelomic metaplasia for a quarter of a century, he strove without success to prove his theory.13
In 1949, just 3 years after Sampson died, Carl Javert noted “there has been a great tendency to favor only one [theory]; namely, the coelomic–metaplasia theory of Iwanoff, Meyer, and Novak.”14 Javert argued that “no single theory entirely explains the pathogenesis of endometriosis.”15 He combined several theories into a composite theory.16 In 1949, Robert Meyer also addressed the validity of Sampson’s theory. “Let us not forget the impulse that gave us Sampson’s theory of endometriosis. Who is right is of no importance; what is right is what matters. This axiom I applied then, forty years ago [with reference to von Recklinghausen]. It is more important that the work of a man stimulates others to go on working than that his own conceptions become established. It is true that I have now changed my mind with respect to the question of adenomyosis. Some critics maintain that this is not right and stress the fact that the new points of view were reached indirectly, in the theory of adenomyosis as well as other problems. I have always thought that as long as a man can change his clothes standing up and can change his mind he is not yet really old.”17
Early in his career, Sampson had noted: “cancer of the cervix…unfortunately is a disease of midlife, occurring most frequently between the ages of thirty and fifty years.”18 At about the same time, Cullen came to the conclusion that uterine fibroids and uterine adenomyoma also occurred most frequently between the ages of 30 and 50 years. The regular occurrence of uterine fibroids, cervical cancer, uterine adenomyoma, and adenomyoma of the rectovaginal septum all within the same time frame in a woman’s life, led to the perception that all such were midlife diseases. Consequently, it was not until 1946 that endometriosis was diagnosed at laparotomy in adolescents,19 and not until the 1970s and 1980s – with laparoscopy – that adolescent endometriosis was recognized more widely. At Sampson’s death in 1946, diagnosis was based principally on an acquired awareness of endometriosis, its signs and symptoms, and by careful pelvic and rectal examination. There were no ancillary diagnostic modalities; peritoneoscopy (laparoscopy) had been abandoned due to poor equipment. Surgical treatment remained the same as Sampson practiced: conservative surgery for infertility on a selective basis, otherwise hysterectomy and removal of both tubes and ovaries when symptomatic treatment failed. In 1944, Miller advocated the use of testosterone hormone prior to operation to aid surgical treatment.20 An attempt at medical suppression of endometriosis using diethylstilbestrol would not be introduced by Karnaky until 1948.21 The concept of prevention developed relatively late. In 1948, Meigs, an early advocate of the prevention of endometriosis-associated infertility, recommended early marriage and pregnancy, urging parents to subsidize newlyweds instead of leaving them an inheritance. This may be considered a first attempt to prevent the disease by a cultural strategy.22 On the other hand, great strides were made in continuing medical education for returning WWII veterans eager for specialty training in gynecology and obstetrics.23
Physician awareness and empathy for patient’s complaints increased dramatically when gynecologists could diagnose endometriosis following the reintroduction of laparoscopy in North America in the 1960s by Melvin R Cohen,24 and the popularization of laparoscopy in 1970s by Jordan M. Phillips.25 Direct patient involvement began auspiciously in 1980 with the initiative of Mary Lou Ballweg, founder of the Endometriosis Association with International Headquarters in Milwaukee, Wisconsin.26 From the beginning, this organization provided information to patients with endometriosis and within the first decade sponsored sophisticated research into the pathophysiology of endometriosis, especially as related to environmental toxicology.27
Maurice A. Bruhat and Michel Canis of Clermont-Ferrand, France with Veasy C. Buttram of Houston, Texas; Paul Dmowski of Chicago, Illinois; and Alain Audebert of Bordeaux, France convened the First International Symposium on Endometriosis at Clermont-Ferrand, France, November 19–21, 1986. The organizers recognized the need for more coordinated and sophisticated research, in order to achieve a “deeper understanding of this many-sided disease. By bringing together in Clermont-Ferrand the most advanced specialists in the world in this field and giving them three days to tackle all the facets of this mysterious ailment, they would be able to compare hopes and disappointments, come to a consensus on certain points, and agree on the major lines for research in the future.”28
In the preface to the proceedings of the First International Symposium on Endometriosis, Professor Bruhat revealed the circumstances that lead to the Symposium. “Why did Endometriosis 1986, International Symposium come into being? Because the remarkable work of one of the doctors in our department meant that we read 500 articles on endometriosis. To our astonishment we found that the pathogenesis was not always clearly perceived, even if some workers have made some progress in the fields of immunology and hormonology; that the evaluation of endometriosis goes no further than a ‘geographical’ description, which is necessary, yes, but how limited! For how then can microscopic forms be taken into account? How can the evolutivity of a lesion be assessed? That treatments were judged by subjective criteria such as pain, or were often poorly assessed as in the case for sterility!”29
Who had performed that remarkable work? It was Michel Henri Jean Canis, now Professeur Michel Canis of the C.H.U. Clermont-Ferrand Polyclinique, Clermont-Ferrand, France. His thesis for the Doctorate in Medicine provided the stimulus for the pathbreaking International Symposium in 1986.30 Surely, his must be the most powerful academic thesis ever written on the subject; for in the ensuing years, research in all phases of endometriosis: pathogenesis, pathology, pathophysiology, genetics, environmental influences, evolutionary developmental biology, improved diagnostic techniques, laparoscopic and robotic surgery, and new medical treatments flowed from the concerted academic coordination of clinical and laboratory research. Ten World Congresses on Endometriosis were held in countries in the four corners of the world between 1986 and 2008. Under the leadership of Professor Hans Evers, The World Endometriosis Society will sponsor the Eleventh World Congress on Endometriosis in Montpellier, France, September 4–7, 2011.31
Footnotes
1
Kant, Werke, Akdemie Ausgabe, 15(2), Anthropologie, in the ‚Handschriftlicher Nachlass’, circa 1798, p. 964. Kant cited by Georges Canguilhem, The Normal and the Pathological. Trans. Carolyn R. Fawcett in collaboration with Robert S. Cohen [New York: Zone Books, 1991], 141.
2
Karl Sudhoff, “Goethe and Johannes Müller,” in Essays in the History of Medicine trans. by various hands and ed. Fielding H. Garrison [New York: Medical Life Press, 1926], 371. “As if lost in dreams, the medicine and natural history of those days rested quietly in the shadow of the system of Nature Philosophy expounded by the gifted Friedrich Wilhelm Joseph Schelling. This system evolved all natural phenomena from the idea of the absolute and endeavored to spiritualize all natural laws and turn them into laws of perception and cogitation, in consequence of which all natural phenomena seemed to disappear. Even the greatest investigators had fallen before the power of this theory and research came to a standstill, as people were chiefly concerned with bringing everything into line with this system. In this confused era, Goethe, the scientist, had kept himself free from all such philosophic fragments of imagination. Upon him fell the task of saving the great principle of observation.” See also: Erna Lesky, The Vienna Medical School of the 19th Century [Baltimore, MD: Johns Hopkins University Press, 1976], 80.
3
Friedrich Wilhelm Joseph Schelling, First Outline of a System of the Philosophy of Nature. Trans. Keith R. Peterson [Albany, NY: State University of New York Press, 2004].
4
Timothy Lenoir, The Strategy of Life: Teleology and Mechanics in Nineteenth-Century German Biology [Chicago, IL: University of Chicago Press, 1989], 13. See: J. Bronowski and Bruce Mazlish, “Kant and Hegel: The Emergence of History.” In The Western Intellectual Tradition [Dorset Press, 1986], 472–3. Kant founded the tradition of philosophy in Germany. “The problems of philosophy in the seventeenth and eighteenth centuries were related to the advance of science then. Much work in philosophy was an attempt to find foundations for the new science, and many philosophers were scientists. Kant was among these, and his philosophy was such an attempt to close a gap in the foundations of science which had been opened unexpectedly in his boyhood.” J. Bronowski and Bruce Mazlish, 477. “Kant himself was trained as a mathematician and physicist, and for much of his life he earned his living as a lecturer in physics. He made an original contribution to science in 1775, when he put forward for the first time the theory that the planets have been condensed from a mass of gas, which Laplace formulated more accurately in 1796. Only at the age of 45, in 1769, did Kant begin to trouble himself with the philosophical difficulties in the foundations of science which Hume had thrown up. In that year Kant had the great revelation, that some knowledge must be a priori in order to make empirical science possible at all, which turned his career to philosophy. In the following year, in 1770, Kant was elected to the chair of logic and metaphysics in his native university of Konigsberg in East Prussia, and he outlined his approach in his inaugural lecture and published it fully in his book The Critique of Pure Reason in 1881.” J. Bronowski and Bruce Mazlish, 479. “The question that drove Kant was, ‘How does it come about that the human mind so naturally understands what goes on outside it.” J. Bronowski and Bruce Mazlish, 477. Kant greatly influenced German scientists in the nineteenth century. See also. Ronald H. Brady, “The Idea in Nature: Rereading Goethe’s Organics.” In Goethe’s Way of Science: A Phenomenology of Nature, edited by David Seamon and Arthur Zajonc, 83–111:90. [Albany, NY: State University of New York Press, 1998], 83–111:90.
5
Timothy Lenoir, The Strategy of Life: Teleology ad Mechanics in Nineteenth-Century German Biology [Chicago, IL: University of Chicago Press, 1989], 17, 18.
6
Carl Rokitansky, Ueber Uterusdrüsen-Neubildung in Uterus- und Ovarial-Sarcomen. Zeitschift Gesellschaft der Aerzte in Wien. 1860;16:577–581. See also: Emge LA. The elusive adenomyosis of the uterus: its historical past and its present state of recognition. Am J Obstet Gynecol 1962;83:1541–1563:1542.
7
Carl Rokitansky, Lehrbuch der Pathologischen Anatomie III. Auflage 1855–1861. III. Band p. 488–491. Also cited by Pick L. Arch f Gynaek 1905;lxxvi:251–275, and Sampson JA. Heterotopic or misplaced endometrial tissue. Am J Obstet Gynecol 1925;10:649–664:655.
8
Chiari H. Zur pathologischen Anatomie des Eileiter-Catarrhs. Pager Ztschr. Heilkunde 1887;8:457–473. That same year, Martin reported cases similar to Chiari. Martin. Uber Tubenkrankung. Zeitschr für Geb und Gynak 1887;13. S. 299. Martin cited by: Cuthbert Lockyer, Fibroids and Allied Tumours (Myoma and Adenomyoma): Their Pathology, Clinical Features and Surgical Treatment [London: Macmillan and Company, 1918], 284.
9
Robert Meyer, Autobiography of Dr. Robert Meyer (1864–1947): A Short Abstract of a Long Life. With a Memoir of Dr. Meyer by Emil Novak, MD. [New York: Henry Schuman, 1949], 33. Friedrich v. Recklinghausen, Die Adenomyome und Cystadenome der Uterus- und Tubenwandung ihre Abkunft von Resten des Wolff’schen Korpers. Im Anhang: Von W. A. Freund, Klinische Notizen zu den voluminosen Adenomyomen des Uterus [Berlin: Verlag von August Hirschwald, 1896.]
10
Von Recklinghausen F. Ueber die Adenomyome des Uterus und der Tuba. Wiener Klinische Wochenschrift 1895;29:530. In 1925, Oskar Frankl recommended that the designation “adenomyoma uteri” be reserved for encapsulated adenomyoma and that diffuse adenomyosis be called “adenomyosis.” Frankl O. Adenomyosis uteri. Am J Obstet Gynecol 1925;10:680–684. See also: Benagiano G, Brosens I. History of adenomyosis. Best Practice Research Clinical Obstet Gynaecol 2006;20:449–463.
11
Friedrich v. Recklinghausen, Die Adenomyome und Cystadenome der Uterus- und Tubenwandung ihre Abkunft von Resten des Wolff’schen Korpers. Im Anhang: Von W. A. Freund, Klinische Notizen zu den voluminosen Adenomyomen des Uterus [Berlin: Verlag von August Hirschwald, 1896.] Cullen, TS. Adeno-myoma uteri diffusum benignum. Bulletin Johns Hopkins Hospital 1896;6:133–157:139.
12
Cuthbert Lockyer, Fibroids and Allied Tumours (Myoma and Adenomyoma): Their Pathology, Clinical Features and Surgical Treatment [London: Macmillan and Company, 1918],
13
During Sampson’s life time, Robert Meyer, Emil Novak, Peter Grünwald, GH Gardiner, Brooks Ranney, and Joe V Meigs supported the theory of coelomic metaplasia. See Robert Meyer, Autobiography of Dr. Robert Meyer: (1864–1947): A Short Abstract of a Long Life [New York: Henry Schuman, 1949], 78. “Peter Grünwald, the embryologist in Boston, insists that endometriosis may arise from coelomic epithelium.”
14
Javert CT. Pathogenesis of endometriosis based on endometrial homeoplasia, direct extension, exfoliation ad implantation, lymphatic, and hematogenous metastasis. (Including five case reports of endometrial tissue in pelvic lymph nodes). Cancer 1949;2:399–410:407.
15
Javert CT. Cancer 1949;2:399–410:407.
16
Javert CT. Cancer 1949;2:399–410. See: Benagiano G, Brosens I. History of Adenomyosis. Best Practice & Research Clinical Obstetrics and Gynaecology 2006;20:449–463:460. See also Brosens IA, Brosens JJ. Endometriosis. Eur J Obstet Gynecol Reprod Biol 2000;90:159–164. Though much of the twentieth century research has “focused on the finding evidence for Sampson’s regurgitation theory…the underlying mechanism, implantation, and/or induction, remains unsolved.”
17
Robert Meyer, Autobiography of Dr. Robert Meyer: (1864–1947): A Short Abstract of a Long Life [New York: Henry Schuman, 1949], 33.
18
Sampson JA. The clinical manifestations of uterine cancer. International Clinics 1908;(Series 18(2):176–201:199.
19
Fallon J. Endometriosis in youth. JAMA 1946;131:1405.
20
Miller JR. Preoperative use of testosterone propionate as aid to surgical treatment of endometriosis. JAMA 1944;125:207–208.
21
Karnaky, KJ. Use of stilbestrol for endometriosis: preliminary report. South M J 1948;41:1109.
22
Meigs JV. Endometriosis. Ann Surg 1948;127:795–809:805.
23
Catch-up and continuing medical education for returning WWII veterans was provided by Joe Vincent Meigs and Somers H. Sturgis, editors of Progress in Gynecology. New York: Grune & Stratton, 1946. Also in 1946, Nicholas J. Eastman and Emil Novak founded and edited the Obstetrical and Gynecological Survey.
24
Cohen MR. Culdoscopy vs. peritoneoscopy. Obstet Gynecol 1968;31:319–21.
25
In 1971, Jordan Phillips founded the American Association for Gynecological Laparoscopy, and through the AAGL taught laparoscopic and later microsurgical skills to thousands of gynecologists. Ronald E. Batt. Jordan M Phillips, MD – Postdoctoral educator-at-large. Journal of Reproductive Medicine 1992;37:626–628. (Translated by Dr. Han Yu Chi of Tianjin Medical, College Library People’s Republic of China for the Translation Journal, 1993). Ronald E. Batt. Jordan Matthew Phillips, MD: Visionary, Founder of the AAGL, Organizational Genius. Journal of Minimally Invasive Gynecology 2007; 14:536–7.
26
Endometriosis Association. International Headquarters, 8585 N. 76th Place, Milwaukee, Wisconsin, USA 53223.
27
Rier SE, Martin DC, Bowman RE, Dmowski WP, Becker JL. Endometriosis in rhesus monkeys (Macaca mulatta) following chronic exposure to 2,3,7,8-tetrachlorodibenzo-p-dioxin. Fundam Appl Toxicol 1993;21:433–41.
28
Maurice A. Bruhat and Michel Canis, eds. Endometriosis [Basel, Switzerland: Karger, 1987], ix–x.
29
Maurice A. Bruhat, “Preface,” in Maurice A. Bruhat and Michel Canis, eds. Endometriosis [Basel, Switzerland:Karger, 1987], ix–x.
30
Michel Henri Jean Canis, Thesis pour le Doctorat en Medecine (Diplome d’Etat) par CANIS Michel, Henri, Jean. Ne le 3 Octobre 1957 a Chamalieres (PUY-DE-DOME) Presentee et soutenue publiquement le 30 octobre 1894. “TENTATIVE DE MISE AU POINT SUR L’ENDOMETRIOSE EN 1984.” [Doctorat en Medicine. Universite de Clermont I Faculte de Medicine, 1984]. [An Attempt to Launch an Investigation into the State of Endometriosis].
31
The World Endometriosis Society was founded in 1998 to promote the exchange of clinical experience, scientific thought, and investigation among gynaecologists, endocrinologists, scientists, biologists, and other qualified individuals interested in advancing the field of endometriosis.