Chapter 7

Chapter 7

Post-Bozzini
1809

Introduction
The Road to Success is always under construction.
-Unknown

After Bozzini, a curious thing happens. The history books get a bit sparse from the time period after the lichleiter’s 1806 debut and up until approximately the 1820s. It is difficult to interpret this apparent silence within the endoscopic pioneer community. Perhaps the Napoleonic Wars during this time period served as a disruptive force, for, coincidentally, after the decisive debacle at Waterloo in 1815, within a few short years endoscopic development reemerged, this time with a decidedly quickened pace.

Pierre Segalas
One of the most notable physicians to kick off this post-Bozzini decade was Pierre Salomon Segalas of Paris (1792-1875), the famous French urologist some have cited as one of the “co-inventors” of endoscopy. Other sources however have referred to Segalas’ work as merely a revival of Bozzini’s work rather than an original contribution. Though ultimately it is difficult to tell just how usable Segalas’ scope was, such accusations were in fact typical assaults against these early pioneers and therefore such claims should not be construed as reflecting the entire truth. In any case, Segalas’ innovations were in fact mentioned in the prestigious British Journal, The Lancet. And Segalas’ instrument achieved something that the lichleiter apparently did not; it was easier to use.

Details
Developing these improvements actually took several years of experimentation. Segalas consulted with a highly acclaimed optical physicist in order to understand how best to optimize illumination. Finally, in 1826 he introduced his new and improved endoscopy [1], dubbed “speculum urethra-cystique,” which was designed mainly for inspecting the urethra and interior of the bladder. 

Segalas’ instrument consisted of several important innovations. Not surprisingly, most of the change was to the lighting system, an aspect that remained the weakest feature of the endoscope well into the mid-20th century. To address this issue, five new features were incorporated. Firstly and most simply, two candles were included instead of one. While perhaps seemingly obvious to us today, nevertheless no one else apparently had thought to make this simple change. Secondly, a new double lens system, including the addition of an oblique lens was constructed in order to help concentrate and magnify the light from the candle. To this system Segalas added a large, conical mirror that helped to capture more light and redirect it toward the point of interest. Finally, the viewing tubes were painted black to prevent scattering of the light particles, a feature that was indeed well ahead of his time. Together, these changes did apparently improve visibility. Segalas himself claimed that one could read the finest print from a distance of 15 inches.

To achieve greater ease of use, Segalas departed from Bozzini’s principles in a few key ways. Firstly, a newly designed cannula-catheter was constructed in order to drain the contents of the bladder so that the inspection could commence without that difficulty. Segalas also chose to construct this component out of gum elastic material instead of metal in an effort to add greater safety and comfort [2]. As a result of these elegant innovations, Segalas became one of the few to perform simple therapeutic procedures with his cystoscope, specifically cauterization of the urethra.

Some Drawbacks
One of the most troublesome drawbacks related to the uncovered candles, which presented some danger of burning. This feature however was also the aspect that made Segalas’ device easier to use, for without the large metal lampshade of the lichleiter, the weight of Segalas’ cystoscope was significantly lighter and consequently more maneuverable. Other complaints on the record relate back to the limited number of clinical trials Segalas was actually able to conduct. For instance, during the time period from 1826-1828, he reported only three clinical cases. There is no record to indicate the reasons for such a limited number of clinical cases.  In the worst case, it could suggest that perhaps a greater failure rate occurred than was officially reported. Another discrepancy in the record has to do with the claim that Segalas’ device enabled him to visualize and therefore accurately diagnose a bladder stone in a three-year-old girl [3] who subsequently underwent an operation for its removal. This is a difficult claim to support since most pioneers who emerged after Segalas reported having significant difficulty in obtaining clear visualization of bladder stones in living patients, even with more advanced lenses and lighting systems available. In fact, even decades after Segalas, few others were able to replicate his results.

Other Works
Segalas also invented other devices and techniques. He is cited as one of the first to replace the hammer required for crushing bladder stones during his era with a much more patient and user-friendly screw mechanism.

Summary 
Even with the limited technologies available in the 1820s, Segalas was still able to achieve significant progress for the endoscope.  His technical innovations were almost unrivaled for his day. In fact, even decade’s later, later practitioners were still relying on many of his original design principles. As well, the clinical success he achieved on living patients, though limited in number and shrouded in some uncertainty, was still a unique accomplishment for his time.

In 1828, Segalas also became one of the earliest to publish a textbook which included some chapters highlighting endoscopic techniques [4]. And perhaps just as importantly, after an almost twenty year absence, it was Segalas who became the main force in helping to revitalize interest in the subject of endoscopy.

Other 19th Century Pioneers from France – Civiale and Bonnafont
Other pioneers contemporaneous with Segalas were continuing France’s long tradition of leading the world in medical innovation.

Endo-Urological Surgery
French established the foundations for endsocopic procedures with their blind treatment of ureter, prostate, and bladder stones. Among others were Pare, Frere Come, Dionis, Mercier, Leroy D’Etiolles, and Maisonneuve. Cornay De Rochefort developed the first aspirator (1844).

Jean Civiale (1792-1867)
Jean Civiale, a surgeon and urologist from Paris, was one such pioneer considered to be among the foremost genito-urologists of his day. With his 1823 substantial improvement to the lithtrite invention of a lithotrite, or modification of the same, Civiale was able to achieve one of the first successful, endoscopic transurethral lithotripsies (though his technique was still actually performed ‘blindly’). For this, Civiale is considered as the founder of early modern lithotripsy.

The method itself was apparently invented for the most part by Leroy D’etiolles, also of Paris, in approximately 1822. D’etiolles also received a prize from the Academy for this work. Other aspects of the instrument were said to be derived from Heurteloup’s device. Civiale incorporated D’etiolles main design principles of a wire loop basket with rotating milling cutter, a concept that harked back to the principles set by Fournier and Gruithausen. One of the most important of Civiale’s innovations was the inclusion of two irrigation channels that helped evacuate the contents of the bladder. Civiale’s device, which he dubbed a Litholabe or Trilabe also crushed the stones rather than attempting to extract them (extracting was always more risky). During this time it was also common to use a hammer to assist in the breaking of the stones. It seems part of Civiale’s innovation was that the use of a hammer was no longer necessary. Civiale was also apparently able to treat bladder tumors with his device as well.

Civiale wrote extensively on his findings as well, including articles on pathological lesions of the urethra, prostate pathologies, and bladder conditions. Civiale’s innovation marked a clear and crucial turning point for endoscopy, one distinguished for moving surgical practices more decisively toward minimally invasive methods, a shift which spelled near extinction for the abdominal lithotomies of the past. Indeed, by 1833, just ten short years after Civiale’s invention, endoscopic lithotripsy had swept through the medical world, effectively supplanting the old-fashioned – and more deadly – lithotomies. The technique is found highlighted in the literature from as far afield as Russia and New York, as well as in the more traditional arenas of Austria, Edinburgh and England.

Despite his significant contributions– and awards from Paris’ Academy of Medicine- Civiale too apparently met with some degree of hostility from the medical establishment. It seems that surgeons of the day were particularly opposed to the new-fangled idea of litrotripsy, since they were trained to perform lithotomies, which involved the complete surgical removal of the stones rather than just crushing them. Such hostility is apparent with the 1828 decree by Vincenz von Kern, the imperial physician in Vienna, who stated that lithotripsy was “high treason against the arts and humanity.”

In any case, it appears others before Civiale achieved moderate success using similar techniques. Yet Civiale’s combination of elegant design and greater clinical success set him apart, marking him as one of the first to perform minimally invasive surgery for urology. Civiale continued to innovate, making improvements to techniques and instruments some twenty years after his initial invention, including a sophisticated retracting scalpel for the treatment of urethral strictures in 1844.

Despite his pioneering ways, Civiale was no renegade. When it came to applying these endo-urethral instruments, he demonstrated great circumspection, making it clear in his publications that surgical incisions of prostate pathologies especially, were to be done only in rare cases and with the utmost of prudence. 

In summary, this type of procedure was overall really looked down upon and looked at with great skepticism based on the literature of the era. It wasn’t until almost thirty years later that we “hear of fresh undertakings in this field.”

Conclusion 19th Century Early Endo-Urological (Transurethral) Surgery
The medical historian and early endo-urologist Gutierez brings to our attention that during these days cases for employing endo-urethral treatment (before electrocautery which stopped the bleeding) had to be chosen “as a matter for very cautious considerations,” and “must be rare and exceptional…” The urologists of this era did recognize that the obstruction had to be cut out, but that only by those with skill using the endo-urethra instruments and method.

Jean Pierre Bonnafont and his Otoscope – 1834
Recently, another physician of this era has secured some recognition for his work, though to most he still remains lost in historical obscurity. Jean Pierre Bonnafont, a French physician specializing in otolaryngology, had been using his own self-designed otoscope [5] in clinical practice for twenty years, since he first presented it to the Paris Academie du Medecinel in 1834. Considered by many to be a forerunner to Desormeaux’s endoscope of 1853, Bonnafont’s work had been overlooked until Desormeaux arrived on the scene twenty years later to claim priority on similar design principles. Indeed, upon witnessing the acclaim Desormeaux received, Bonnafont protested to the Academie, stating that Desormeaux’s device was “only an exact copy” of his own otoscope.

The important difference was that Bonnafont’s instrument, being solely designed for ear inspections, may have been perceived as less qualified to handle more complex procedures.

Referring to his invention as a “speculum autostatique,” Bonnafont’s device was essentially a two-leaved otoscope that he improved by adding a sophisticated lens system adapted from microscopes and the simple but important detail of a conical mirror (in the style of Segalas), which enhanced illumination considerably. Unfortunately the historical records are again rather muddled concerning the usability of Bonnafont’s otoscope. Some have claimed that Bonnafont was in fact able to perform simple therapeutic procedures within the ear cavity, including paracentesis, a procedure not of the ear, but of the abdomen. However, other sources note quite distinctly that Bonnafont’s device was only a working model not yet suitable for clinical trials. Consequently, Bonnafont has not (yet) earned the same level of acclaim as Desormeaux. Notwithstanding these contested aspects, overall Bonnafont’s part in endoscopy’s history cannot be readily dismissed, for his instrument was said to have “displayed all the technical sophistication” of endoscopes presented by other innovators two decades later. Moreover, years before others, he recognized the importance of incorporating the optical systems of microscopes.

Early 19th Century Gynecologic Endoscopy
Other Early Practitioners
Others mentioned during this early 19th century time period include the French gynecologist, Guillon, who apparently used a Bozzini-inspired illumination device along with his newly designed speculum. His innovations and use of an early endoscopic device were highlighted in lecture notes from the Academy of Medicine in Paris in 1827, and later from his own 1827 publication.

Once Upon a Time When Prudery Prevailed in America
Reality is merely an illusion, albeit a very persistent one.
-Albert Einstein

A Peripheral Obstacle to Endoscopic Exams - Societal Exigencies
Up until this point it seemed Europe was having all the fun when it came to endoscopic development. Before pursuing endoscopy in earnest, American physicians, more so than Europeans, faced another unanticipated hurdle: strict societal mores. Physicians in the disciplines for women’s health would have to overcome a great deal of resistance stemming from entrenched societal concerns about proper decorum. “False modesty and prudery,” as one ACOG past president described it, would limit research into ob-gyn fields for quite some time. For instance, as late as 1850, it was actually considered improper to show live births in U.S. medical schools. One famous case demonstrating this intense unease involved one of the first documented live births as part of the curriculum in a New York teaching college, which led to a flurry of censorship and claims of scandalous conduct. Referred to as “demonstrative midwifery,” the progressively-minded clinical professor responsible for this new teaching method thought it would be instructive to present a woman in active labor to his room full of medical students. This action resulted in an immediate call for the suspension of his license, while a strong rebuke was issued in the local Buffalo Medical Journal, which reported as follows:

”The propriety of the exhibition of the living subject before the graduating class…does not in our view admit of a public discussion…and ... the practice does not commend itself to the cordial approbation of the medical profession. We deem it unnecessary for the purposes of teaching, unprofessional in manner and grossly offensive alike to morality and common decency.…We hope that this innovation will not be repeated in this or any civilized country,” (Mengert presidential address, vol 7, no 3, march 1959). 

Paradoxically, many fairly advanced gynecologic operations had actually been performed by pioneering Americans as early as the 1800s; the first ovariotomy was performed in 1809 by Ephraim Macdowell; the first successful myomectomy with preservation of the uterus took place in 1844 by Washington Atlee of Philadelphia; and two of the first documented and successful abdominal hysterectomies were achieved by Walter Burnham of Massachusetts in 1853, and a few years later by William J. Baker of Tennessee in 1856. 

Still, lingering sentiments concerning propriety persisted. Some reports published by medical societies of the late 19th century suggest that vaginal examinations were considered “too great an infringement of the woman’s person to be attempted.” Some physicians even believed that such examinations might “induce a lax moral sense in the patient.” It is no wonder that many aspiring American medical students of the 19th century flocked to Europe to obtain their medical educations.

Modesty Aside, Americans Join the Fray  - John Fisher, an American Pioneer
Against this backdrop of ultra-conservatism within American medicine, there arose a physician from Boston named John D. Fisher (1798-1850), whose work captured the attention of the world’s medical centers [6]. Fisher, like many of his contemporaries, was able to provide care for many different ailments since medicine had not yet divided into sub-specialties. As such, his clinical work focused on ailments of the bladder, urethral, esophagus, as well as gynecologic disorders.  As reported by an article from The Lancet, Fisher conceived of his “instrument for the illumination of dark cavities” (a name later changed to the more prosaic “esophagus mirrors”) in 1824 while still a medical student. He subsequently published his findings in 1827 in the Philadelphia Journal of Medical and Physical Sciences.

Though some of his designs were not necessarily the first of their kind, many credible sources have referred to Fisher’s instrument as particularly impressive, even superior to that of Segalas’ work. In fact, some of endoscopy’s most important pioneers, including Cruise, credit Fisher specifically gave credit as being the original inspiration behind their own ideas. Some of his most salient innovations include the incorporation of a lens system derived from a periscope. To improve the ability to examine difficult and awkward angles of the body, Fisher also devised a clever mechanical system of wires attached to the bottom of the candle light source itself that served as levers to move the candle up or down, so as to easily direct the focal point of the light. Ever the visionary, Fisher also suggested the use of galvanized wire (aka, precursor to electricity) as an improved source of light.  However, like Segalas and others before him, Fisher was unable to modify galvanized wires into a form safe enough for medical procedures. This should not be considered too surprising, considering that Edison’s electric bulb– an encased and tamed galvanized wire system of sorts- was still six decades away.

When Chivalry Met Endoscopy
An interesting glimpse into Fisher’s sensitive personality (as influenced by the aforementioned prevailing social attitudes) comes to light in a unique account of one patient, who became the inspiration for his innovation. As the story goes, Fisher stated that his modified device was created to accommodate one of his female patients, whose shyness was so great that a medical examination of her was proving to be impossible. As one journal relays the account, Fisher developed his instrument “in response to the need to examine the cervix of an unusually shy young woman who could not countenance him coming so close to her pudenda as was required by the standard vaginal speculum.” Fisher by his own words wrote that he had “a strong and chivalrous desire to protect the feelings of delicacy of this maiden.” To achieve this, he designed an elongated and angulated speculum and added a double convex lens to sharpen the image, so that the examination could take place from a greater distance from the patient. Though no further information was given about this incident, Fisher nevertheless paints a lovely romanticized rendition of how the history of endoscopy became forever untwined with a chance encounter with chivalry.

Summary - Fisher
Despite these positive reports, the record on Fisher’s work is nevertheless mixed. For instance, it is not known whether Fisher achieved success with his device on living patients. As well, other sources described Fishers’ instrument for the urethra in particular as “impractical.” And despite his sophisticated design principles, Fisher’s work apparently failed to garner much attention within the medical establishment of his time. Fisher himself suggested that his instrument was “easily susceptible of improvement.” Perhaps the long-standing difficulties associated with poor visualization were still perceived as insurmountable obstacles that may have persuaded the medical community to dismiss the endoscope in its formative years.

Notwithstanding these unresolved contestations of history, looking back, one can recognize that by adapting the more advanced lens technology derived from periscopes, Fisher did in fact make significant contributions that marked an important transition away from simplistic lens systems and closer toward modern endoscopes with greater visibility and magnification. For example, when comparing Fisher’s work to that of Segalas, it is clear that Fisher’s endoscope was not just a rehashing of Segalas’ work; it was indeed an instrument clearly unique in its design and sophistication. Fisher also achieved a crucial milestone for the United States in particular, as he was one of the first in the country to successfully initiate interest in the field of endoscopy.

British Give It a Go - British Pioneer, John Avery
I am easily satisfied with the very best
-Winston Churchill

Meanwhile, back across the great pond, John Avery of London was making some headway in endoscopy’s development, though, like Fisher, there remains some difference in opinion as to just how significant his contributions really were.

The laryngoscope Avery introduced in 1840 [7] was designed as an illumination device for urethroscopy and laryngoscopy. Avery’s main innovation seems to have been his addition of a large head reflector as a supplementary light source [8]. This modified reflector (called a Palmer’s lamp, used by miners for years) intensified and redirected the candle light toward an attached Bozzini-inspired speculum. As for the overall design, Avery credited Segalas as the inspiration behind the underlying design principles.

Avery’s colleagues however were apparently far from impressed with the rest of his design features. Henry Thomspon, the leading British urologist at the time, observed one of Avery’s procedures, and noted that the urethroscopic device was “impractical and too thick in diameter.”  Thompson also noted that urine was getting in the way and as a result, “very little could be seen in the bladder,” an observation which indicates that Avery’s instrument may not have included a properly constructed catheter.

Yet the record is not so clear-cut, for others cited Avery’s design ideas as inspirational to their own work. And his device could not have been a complete failure, for, based on the content of instrument catalogues during this period, Avery’s instrument was made and marketed by the most prominent instrument makers of his day  despite these modest advances and the fact that many other pioneers continued to incorporate Avery’s large head mirror into their instrumentation, it seems that Avery’s work was otherwise deemed impractical.

First Trials With Electrical Applications in Surgery - Precursors to Electro-Surgery 
The British lithotripist, George Robinson of Newcastle upon-Tyne accomplished what appears to be one of the earliest documented cases of harnessing electricity (in the lab) for the treatment of bladder stones. Described in 1855 as what he called electro-lithotrity, he apparently was able to crush all types of stones (again, not in living patients) with this method by sending repeated discharges of electricity from his leyden jar. He led two isolated copper wires through a flexible catheter to accomplish this. Their ends were then brought into contact with the stone, which was pre-positioned in a water-filled bladder. He suggested this to surgeons, but at the time most were not willing to try this method on living subjects.

Notes
1. It was actually a cystoscope.
2. It may seem that polished metal may have been used with greater ease. However, the ability to make highly polished and smoothed metal was limited during this time. Therefore, gum elastic must have been seen as a reasonable substitute. 
3. This claim derives from Reuter source, which refers back directly to Segalas’ own publication on the matter.
4. The textbook was called Traite des retentions et des maladies qu'elles produisent suivi d'un
grand nombre d’observations
(Treatise on urinary retentions, diseases caused by it, followed by a great number of observations).
5. The record is unclear as to whether this instrument was used for other endoscopic disciplines besides otoscopy.
6. A few different dates have been cited, including both 1821 and 1823. However, the most credible source, The Lancet, approximated the date as sometime around 1824. In addition, some sources cite 1797 as Fisher’s date of birth.
7. Jahn source cites the date as 1844.
8. The reflector was not worn on the head, but was instead repositioned to stand in front of the candle stick.