International Medical Conference
Endometriosis 2024:
Elevating Sampson’s Century Legacy via
Deep Dive with AI
For the benefit of Endometriosis Foundation of America (EndoFound)
May 2-3, 2024 - JAY CENTER (Paris Room) - NYC
Morning before presenting my story regarding the relevance of John Sampson. Let me show you where the enigma of endometriosis is currently cited. Sadly, it is beyond comprehension to me as an old school gynecologist who admired the studies and presentations of Samson and carefully examined the debates concerning diagnosis and management a century ago. These two recent breakthroughs, one from the Harley Trusted Economist Weekly news periodical. The other reporting from the Vatican by a respected journalist are each attracting large numbers of young women into their trial. In presenting the subject of John Sampson and his relevance to the endometriosis story today, I offer my credentials. Having graduated in medicine in 1970, I gained my specialty qualifications with the RCOG in 1976, following training at the King Edward Memorial Hospital in Perth, Western Australia. That was following an unforgettable stint in the remote northwest on the Royal Flying Doctor Service, where I became bitten with the need to improve both obstetric and gyne services for those courageous women for the outback of Australia.
With my new specialty credentials, I proceeded directly to London with a view of exposure to the very pioneers currently advancing reproductive medicine, finding a home at the Royal Free Hospital School of Medicine with Professor Ian Craft to advance my skills in hysteroscopy and laparoscopy, he enabled me to train in microsurgery with his colleague Robert Winston at the Hammersmith Hospital and with Stuart Campbell at the King's College Hospital for ultrasound. As a secondary interest, we took the opportunity of establishing IVF utilizing the resources of the animal embryologists at Wolfson House in London and the animal research station in Cambridge, providing me with enough data to complete my PhD entitled Generating Human Pregnancies from IVF. In the 42 years since returning to Australia and establishing my Pivot Medical Center devoted to the treatment of infertility, I have been pleased to have progressed the development of IVF as the current mainstay.
Whilst most cases of infertility are categorized as poorly explained, the conditions of endometriosis, adenomyosis and fibroids underlie around 20% of the women. With respect to endometriosis, our early studies indicated that the condition was a relevant cause of the problem and furthermore required definitive treatment to improve the chances of IVF. Particularly for those higher grades three and four and absolutely where deep infiltrating endometriosis was found in Australia, there has been widespread adoption of laparoscopies for either pelvic pain or infertility for both diagnostic and treatment purposes. Many women had numerous laparoscopies until the Australian Gyne Endoscopies Society ages became established and eventually posed a grading system with the attention of steering women towards accredited gynecologists who acquired level six with the capacity to excise nodules completely and safely. Nonetheless, as the journalist covering Aaron Barnett's story describes the process is not yet running optimally. Another hot off the press publication is that of 50 big debates in reproductive medicine by Cambridge University Press.
The debate between experts, Stefan Gortz from Belgium and Matthew Lenardi from McMasters Canada, shows that there is actually no high level evidence supporting the value of laparoscopic surgery to improve infertility or its treatment by assisted reproduction. Despite the earlier publications from Pivot, high level work obviously needs to be undertaken and with an awareness of the numerous confounders which operate for infertility outcomes. When one looks to the authorities in reproductive medicine around the world, the advice is not yet clear or helpful neither to the doctors treating endometriosis nor to those women harboring the condition in the United Kingdom. An all party parliamentary inquiry has recently 2020 concluded that diagnostic and medical management processes must be improved and the 1.5 million women with endometriosis in the UK required to be better looked after from puberty throughout their adult lives, including the menopausal years. So what is the chance of fulfilling the demands of the British Parliamentary Inquiry?
I personally attended the pre Congress course on endometriosis by Esri in Vienna in 2 0 1 9 and came away with a massive inundation of biomedical studies best summarized by the Oxford Scientific Group, headed by cleaner Zondervan reporting in the New England Journal of Medicine in 2020. They state the development of endometriosis involves interacting, endocrine, immunologic, pro-inflammatory, and pro angiogenic processes. But whether these factors are pathogenic, meaning causal or merely represent secondary feature of the pathophysiological process typically measured years after the symptom onset remains uncertain, but actually suggesting unlikely. Against this inauspicious background, I would respectfully suggest that it is time to review the 68 publications of John Samson to understand endometriosis and its infiltrative process as well as its spread to peripheral even remote sites of the body requires grasping Samson's. Three unique observations. Firstly, his publications of 1913 and 1918 while studying Myta revealed a unique venous system operating within the uterus, specifically his revelation of the anemic zone surrounding the endometrium acts as an effective protective valve against products from the endometrial cavity unless disrupted.
Secondly, Samson's unique photo micrographs within publications of 19 13, 19 18 and 1925, some in color display metastatic spread of viable endometrium into peripheral uterine veins via receiving sinuses forming in the anemic zone when this area has been disrupted by various processes. Thirdly, after cajoling from eminent gynecologists of his day, such as Emil Novak, Joe Meggs, and Robert Meyer, Samson undertook his uterine studies on hysterectomy specimens performed during menses rather than the previous interval procedures. He then published the story of retrograde spill by the fallopian tubes in 1927 and 1940 with some cases demonstrating implantation into peritoneal onto peritoneal and ovarian surfaces, as well as progressing to invasion. Key to understanding the metastatic pathogenesis of endometriosis requires a close evaluation of uterine vascularity. The arterial system is conventional with the sequential branching of radial arteries to arterials finishing in a fine arterial network within the endometrium being straight basal arteries in the basal zone, spiral arteries in the spongy layer of the functional zone with a protective valvular effect and the terminal fine arteries in the compact layer of the functional zone to be decimated.
During menses, however, the venous drainage shows a relatively sparse number of annuals, retrieving blood from the rich ular network, draining the endometrium feeding into a rich radial plexus in the outer two thirds of the uterus with the most peripheral plexus feeding backward into the arcuate plexus plexus, which finally drains into the uterine plexus or distribution into the main uterine veins. Once ultrasound progressed from B mode to high quality phased arrays, a clear halo could be identified. The hyper echoic endometrium more recently developed as the junctional zone of the endometrium JZE with advanced scanning combined with MRI. This thickened JZE signifies a disrupted anemic zone and has a telltale association with adenomyosis. Furthermore, the mechanism for fibroids causing mania was long held by Samson to be due to a disrupted anemic zone enabling retrograde blood loss back into the endometrial cavity rather than the suggested idea of hypertrophic endometrium, which is not found at hysteroscopy evaluation.
This slide depicts the relevant publications from Samson's 68 articles leading to the three unique observations I have presented. Samson's earliest works involved him injecting a gelatin bismuth mass containing pigments being Venetian red for arteries and ultramarine blue for veins. Apart from his macroscopic differentially colored view, Samson followed with stereoscopic radiographs in this work. He started at Albany New York State in 1905. Do note that Samson had two publications in 1927 S one dealing with his metastatic theory and S two dealing with his retrograde menses phenomenon. In these publications, Samson applied the term endometriosis, which he had started using two years earlier in 1925, albeit he had described chocolate cysts since 1921. In order to progress from the idea of endometriosis being an enigmatic disease, I present the abstract from my open access article of 2020 explaining Samson's two mechanisms. I note that for unclear reasons, but probably because of the way Samson himself avoided covering old ground along with the difficulty until now of tracing those earlier publications.
Most modern day authors have focused on the second implantation theory and criticized its relevance as it fails to explain many forms of endometriosis outside the peritoneal cavity. However, I believe all eight locations of endometriosis, both common and uncommon can be explained from Samson's earlier extensively reported studies. This table describes all sites of endometriosis, both common and uncommon, along with the likely pathogenic mechanisms from which they are derived. S one refers to Samson's first described mechanism of metastatic spread by the uterine veins. S two refers to Samson's second described implantation mechanism following retrograde menstruation by the fallopian tubes. S3 refers to metaplasia or thalamic epithelium or from malian rests or rarely from stem cells. Let us s Samson's personal evolution. Karl von Roski was the pathologist who in 1860 described benign sarcomas within the female pelvis of some of his 60,000 autopsy cases. Although the relevance of these descriptions have been challenged, esteemed authors of today, IVA Broons and Giuseppe Beano in 2 0 1 8 concluded that these are indeed the first clear descriptions of endometriosis.
However, one needs to understand that autopsies at the time were only allowed in the Protestant part of Europe, so-called Holy Roman Empire not in the Vatican controlled Catholic south. In fact, a very popular Empress Maria Teresa acting on behalf of her husband Thereafter, her son created a state mandate in 1753 requiring an autopsy to explain every death in Vienna's public hospitals, both first and second enabling Ro kansky to amass his large series. Most of the autopsies were macroscopic procedures, although Ro Kansky did introduce microscopy at a later stage after visiting centers in France, albeit in a relatively primitive form awaiting thin section preparations by Microtome along with the evolution of advanced compound microscopy on this slide are the amazing characters around which the endometriosis story unfolds each having an incredible story to tell summarized in my open access article, Frederick von Reckling Hausen is worthy of special mention having followed OV in Berlin, then adding thin section histology and improved microscopy when he set up his own facility in Strassburg at times a French or German city.
However, his idea that endometriosis termed adenoma at the time arose from remnants of the wolf and ducks was shown to be incorrect by Thomas Cullen, who utilized the even thinner tissue sections with superior mounting and more advanced compound microscopy. At the Johns Hopkins Hospital in Baltimore, Maryland. Cullen specimens were cut with a microbiome utilizing a diamond cutting blade and mounted in soin, whereas Von Lingus were hand cut with a razor and mounted in amyloid liver. Robert Meyer, William Welch, a colleague of Cullen at Johns Hopkins, who also had studied under Von Ling Hausen, along with Emal Novak, all recognized that Cullen's specimens were superior demonstrating a Malian origin, but none were courageous enough to point this out to their former teacher and mentor. However, Vaughn ing Hausen eventually acknowledged their superiority after presentations by his former students, but not directly to Cullen whom he regarded as not a suitably trained pathologist.
It was then widely considered that endometriosis was a new disease reported by Von Roky in 1860. However, historical tracking perhaps best displayed by the Nazar brothers in their t and Sturt article of 2012 indicates the condition has undoubtedly been with us throughout the millennia. Hippocrates from the Greek island of costs indicated that the ancient Egyptians described the clinical conditions of strangulation of the womb, which he endorsed and his protege. The Athenian Plato, although not a clinician, promoted a similar term of suffocation of the womb. These terms persisted until German Dr. Daniel Shreen in 1690 provided the first popular descriptions of peritoneal ulcers, mainly on the uterosacral ligaments in the pelvic cavity of such women. These were later termed sanguine cysts by French doctors through so and velco in the early 18 hundreds prior to the definitive descriptions of benign sarcomas by roski. I should however point out that the Greco-Roman Galen describes such cysts on the Uterosacral ligaments of McCart monkeys whilst working in Alexandria Egypt around one 50 AD closer to modern day.
The three most prolific authors at the turn of the 19th century included two others apart from Samson most prominent was Thomas Cullen, a Canadian gynecologist who graduated in Toronto thereafter studying pathology in Gottingen Germany under Professor Johan t, whilst awaiting a promised position at the Johns Hopkins University, he held the inaugural directorship in gyne pathology for 16 years whilst awaiting retirement of the highly esteemed Howard Kelly in 1919. Thereafter, holding the chair in clinical gynecology for 20 years until retirement. Cullen described adenomyosis of the recto vaginal septum in 1914. He believed gynecologists should be trained as fully competent abdominal surgeons and encouraged complete resection of the constricted segment of the rectum. At the hysterectomy, Samson provided glowing reviews to Cullen's 1908 book on adeno myoma of the uterus. Also was British gynecologist Kaper Laia trained at Charing Cross Hospital in London. He received secondary training in various German centers, including Berlin and Vienna.
Prior to returning to Charing Cross as consultant ONG physician, he taught and wrote prolifically and contributed thousands of gyne specimens to the Chaing Cross Hospital Museum by his retirement in 1930, both Cullen and Laia used the term adenomyosis extensively between 1913 to 1918, the man whose relevance we are considering here. John s Samson was born in Troy near Albany, which is the capital city of New York state. He graduated at Johns Hopkins Medical School and conducted his residency for seven years under Howard Kelly. He did not undertake any tour of Europe, but was exposed to the lectures and publications of Thomas Cullum favorably reviewing his book on Adenoma Ter from 1906, he held a chair in gynecology at Albany Medical College and conducted his extensive surgical procedures at the Albany Hospital on the same campus. I have already described his three main contributions to the understanding of endometriosis, but would also acknowledge his early utilization of x-rays from 1905.
Bearing in mind, Rinkin described these only 10 years earlier, and the first machine was established in the UK in Glasgow only five years earlier, only five, five years. I'm a bit lost here from 90 days. I've already described the first machine established in Glasgow five years earlier. Even the advent of electrical power used to drive the machines had a recent history with the historical alternating current power line established in 1896 from Niagara Falls to Buffalo. New York state had occurred less than a decade prior, utilizing large scale hydroelectric generators built by George Westinghouse after he had bought the patents from Nicola Tesla. These are some of Samson's micrographs from his publications of 1925 and 1927, which support his metastatic tic mechanism for endometriosis. They display endometrial tissue within receiving sinuses in the disturbed anemic zone. The main points of this slide introduces the retrograde menstruation implantation theory, which Samson described in a second study in 1927, then presented at the behest of the American College of Obstetricians and Gynecologists in 1940.
It became widely known such that most gyne trainees like myself initially believed that this was Samson's gospel. He did not refer to his former metastatic theory, nor did he mention his findings regarding the venous system of the uterus. He confined his presentation and the ensuing publication to the brief requested by the American College. When I began my search into understanding endometriosis, the 1940 article was readily available. All the others I found in the fifth level underground of the dungeon in the library of the Royal Society of Medicine in Wipo Street, London. Happily, they have now become digitized and available courtesy of grounding peoples grayling peoples of El Sylvia and Andrea Musel from the American College of Surgeons, deeply invasive endometriosis involving the rectum. DIER has become a subject of major interest recently and exposes a debate started by the differing viewpoints concerning its operative management by Thomas Cullen, who promoted bowel resection and John Sampson who promoted conservative surgery writing.
I have purposely kept close to the uterus, undoubtedly sometimes leaving adenoma in the rectal wall, but also strongly advising not to leave any ovarian tissue in order to ensure that the endometriosis tissue would regress. Samson's colored pictures from 1918 reproduced in his first article of 1927 from a case of DIER and shows the metastatic endometrium within the retrieving sinuses and uterine veins with attachment and penetration of the vessel walls. The blueberry nodules within the posterior fornix are pathic mnemonic of endometriosis within the so-called recto vaginal septum. This slide expands on Samson's 1940 presentation describing a process for the retrograde menstruation and implantation theory. Samson also notes there are many other interesting unsolved problems associated with the pathogenesis and life history of endometriosis of all types. Since it is my desire to adhere, I'm quoting him directly since it is my desire to adhere strictly to the text which has been assigned me.
I have not discussed any of these referring to his earlier works. However, we would all have a better view about the relevance of Samson if he mentioned the dissemination of endometrial tissue into the uterine veins required an aberration in the sub mucus collecting veins displaying a feature Samson described as receiving sinuses, which could harbor pieces of endometrial slough, which thereafter travels to peripheral venous plexuses within the myometrium. In modern day. We would understand this as the MRI defined thickened junctional zone of the endometrium, so where have we come to in modern day concerning the operative treatments of endometriosis commencing with Maurice Bha from Clemont Ferran, France, but also Kurt Sem from Munich and Keel Germany, and later Harry Rich from the USA have been important contributors. Brewer established his dream team of now famous Gyne Laparoscopies, and conducted the First World Congress on endometriosis in 1986.
I attended his facility and workshops in 1989 presenting my work on laparoscopic embryo transfer procedures, but this was competitive with other IVF related conferences, and I had to choose which specialty discipline to follow. It might explain why I prefer not to engage in rectal resections despite the evolution of smart star devices, despite the excellent results reported from Anier from his ER ad facility in Strasburg and Horace Rahman's facility in Bordeaux with the almost complete avoidance of serious surgical complications. I follow the advice of Samson and shy away from resections. I'm in good company as this is the same view of eminent laparoscopic surgeon, Jacque Donne from Brussels who in 2020 describes rectal shaving as sufficient for the vast majority. Although Cullen advocated rectal resection, he failed to report on the very high mortality rising from his operations as the women were mostly okay at the time they left his operating theater.
Either way, the important aspect of managing these cases is long-term hormonal suppression after the excisional surgery, MPA Provera, sometimes in concert with G Rh, analog being my preference. A further area of special interest relates to the excision of focal or nodular adenomyosis, laparoscopic myomectomy. Despite neat operative outcomes, two of my 40 cases whose subsequently achieved IVF pregnancies experienced uterine rupture, one explosive at 37 weeks. The other silently discovered at elective cesarean delivery. Fortunately, both mothers and their babies have survived well, but it appears that healing of the myometrium without adenomyosis can be deficient or suboptimal. We have not experienced this problem for more than 350 post myomectomy pregnancies. In conclusion, I believe that the studies of John Sampson are the most relevant to our understanding of endometriosis and its appropriate management today. His discovery by unique studies on post hysterectomy specimens revealed the anemic zone concerning the venous drainage of the uterus, underlies his reporting of the first mechanism of pathogenesis of endometriosis that of metastatic spread into the uterine veins.
When he changed the timing of his hysterectomies to coincide with menses, he was able to demonstrate his second mechanism that a retrograde spillage of endometrium by the fallopian tubes and subsequent implantation and penetration along with some cases of thalamic metaplasia. Virtually all cases of endometriosis can be explained, however, there remains a requirement of further advanced studies to explain why endometriosis mostly stays confined to the pelvic region and whether there is an involvement of lymphatics to contain its spread. Furthermore, another idea proposed by Samson in 1912 for menstrual control was that of a pelvic venous network controlled by the uterus, acting like a pelvic heart with pulsation. This also requires clarification one way or the other. I thank you for your attention.
