Ronald E. Batt1
(1)
State University of New York at Buffalo, Buffalo, New York, USA
Abstract
This essay is offered as a foundational history for the field of endometriotic diseases. It is addressed to an international professional audience of physicians and scientists, their younger colleagues, fellows and residents, medical students and nurses, and importantly, historians of medicine and science and their graduate students. The scholarly apparatus contains informational and explanatory as well as documentary notes.
The Foundational History of Endometriosis
This essay is offered as a foundational history for the field of endometriotic diseases. It is addressed to an international professional audience of physicians and scientists, their younger colleagues, fellows and residents, medical students and nurses, and importantly, historians of medicine and science and their graduate students. The scholarly apparatus contains informational and explanatory as well as documentary notes.
The complexity of endometriosis is easier to understand when viewed as the major expression of five closely related benign müllerian diseases: endometriosis, adenomyosis, endosalpingiosis, endocervicosis, and müllerianosis. From this perspective, this is a story of lumping and sorting, of imposing order on individual expressions of disease in order to devise a program for diagnosis and treatment. For 500 years, there was an attempt at statistical grouping of signs and symptoms on the basis of objectivity. The shift from treating symptoms to treating diseases brought order out of chaos through the application of macroscopic morbid pathology and microscopic surgical pathology. Creation of endometriotic disease as a clinical entity – which explained why patients had endometriosis-associated pain, infertility, and health problems and how physicians could relieve some of the problems – was a giant leap forward during the era from 1860 to 1946.
The future of endometriosis research is unknown. However, the past can be captured to anchor the history of the disease and highlight the intellectual quest to understand endometriotic diseases. In doing so, we are consolidating what we know and do not know. John Sampson’s rich contribution to the pathology and pathogenesis of endometriosis and endosalpingiosis has been reduced to a caricature in textbooks, where his theory of retrograde menstruation and implantation is mentioned among other theories of pathogenesis. Thomas Cullen’s formidable contributions to the pathology of uterine adenomyosis and extrauterine adenomyomas are seldom mentioned. European contributions that preceded those of Cullen have been largely forgotten. It took 86 years to move from the morbid pathology of Rokitansky to the pathophysiology of Cullen and Sampson, and then another 64 years of consolidation till now, we are preparing for another leap forward to personalized medicine. We are entering an era of new understanding and it is time to take stock of where we have been and to understand what we have done. Ivo Brosens insightfully noted that most of the twentieth century was spent trying to prove the implantation theory of Sampson.
In the twenty-first century as medicine moves from treatments based on statistical evidence-based medicine and returns to the Hippocratic concept of individual dyscrasias, of personal disease based on the individual’s genome and environmental exposures, organized medicine must reorder ideas for the future. However, for the time under consideration – 1860 to 1946 – the pathophysiology of endometriosis only began to be understood during the era of Thomas Cullen and John Sampson, an era when surgery was the only treatment.
The story is real and I understand the reality of that time. I have treated thousands of patients with endometriosis. Field research for this history began in the early 1970s when I developed a close professional relationship with my professor of pathology, Kornel Ludwig Terplan. I learned that Dr. Terplan traced his ancestry in academic pathology directly to Carl Rokitansky. Terplan was the premier assistant of Anton Ghon, who was the assistant of Anton Weichselbaum, who in turn was the assistant of Joseph Engel, the most brilliant assistant of Carl Rokitansky. Dr. Terplan introduced me to central European pathology. During that time, I took mini-sabbaticals to study surgery on the service of Professor Husslein at the II Frauenklinik, University of Vienna; at the University of Graz, Austria with Professor Navratil; and at the University Hospital in Strasbourg, Alsace, France. This preliminary fieldwork helped immensely. It is the author’s hope that this scholarly essay will open the history of endometriosis to critical debate, refinement, and further contributions.