Chapter 8

Chapter 8

Desormeaux
1853

Antonin Jean Desormeaux – The First Successful Operative Endoscopic Procedures in Living Patients
There are two ways of spreading light; to be the candle or the mirror that reflects it.
–Edith Wharton

The mid to late-19th century stands out as one of the world’s most extravagant eras of innovative splendor, with breakthroughs in just about every discipline; the invention of the telegraph, advances in germ theory, Darwin’s theory of evolution, Sir James Simpson’s introduction of chloroform (anesthesia) in 1846, all were part of this time period’s great discoveries.

As for our emboldened endoscopic pioneers, this era was equally heady, with a rush of innovative vigor pouring forth from all directions. Leaving off from the sub-specialty of laryngoscopy, we flip a u-turn back out of the esophagus and return to the lower GI as the primary focus for the remainder of our historical survey. By this juncture, the pace was really picking up for endoscopy’s development and no doubt this growing fervor awakened the imaginations of many minds. However, the French urologist, Antonin Jean Desormeaux, stood out as one of the most influential leaders, earning acclaim as one of the “fathers” of endoscopy. Desormeaux’s most outstanding accomplishment is that he put operative endoscopy on the map by performing the world’s first successful operative procedures using an endoscope [1]. Desormeaux is also credited with coining the word “l’endoscopie,” a term he introduced, along with his revamped device, to the Academy of Science in Paris on July 20th, 1853. 

Though Desormeaux’s innovations were not radical deviations from the design principles established by earlier pioneers, he is credited with constructing the first functional endoscope (what we would consider a cystoscope or urethroscope today [2]) which enabled the consistent and successful diagnosis of urethral and bladder diseases in living male patients. In many cases too, he was able to perform simple therapeutic operations endoscopically, some for the first time ever.

Achieving such results marked a clear turning point, for up until this point in time the endoscope had proved to be of very limited clinical value. By refining the endoscope in subtle yet significant ways, Desormeaux was able to demonstrate not only its value as an effective diagnostic tool, but also demonstrated its promising therapeutic possibilities. In this way, Desormeaux helped to significantly transform surgical practices of his era and beyond.  Of course, a change of this magnitude was no small task. Therefore, in order to gain a better understanding of just why Desormeaux represented such an important turning point in the story of endoscopy, let’s review in detail the many formidable obstacles he overcame to bring to life his vision for endoscopy.

Endoscopy’s Great Transformation
As with other innovators, many of Desormeaux’s contributions were not necessarily the first of their kind.  What made Desormeaux’s unique was his ability to recognize just the right combination of adopted technologies needed to improve the endoscope. This point leads us to a detail in the historical record that should be addressed at the onset: Desormeaux is often credited as being the first to have used endoscopy on living patients. However, as previously noted, Bozzini was in fact the first documented to do so. Several others also succeeded in using their endoscopes diagnostically on living patients, such as Segalas, Cruise, possibly Avery, and many of the laryngoscopists already mentioned. 

The most crucial distinction here is that Desormeaux was able to perform the first known operative endoscopic procedure. This was only possible because of Desormeaux was able to achieve better visualization, which allowed him to become one of the few to successfully- and consistently - utilize the endoscope for therapeutic procedures; in other words, operative endoscopy. These therapies consisted of simple but effective operations, including cauterization with chemicals (e.g. silver nitrate), which could be applied through open slits in the shaft of the endoscope [3]. In this way, Desormeaux was able to treat diseases of the urethra, such as strictures and gonorrhea. 

In defining this category of the first ever-operative endoscopic procedure, we do make one key distinction here and exclude the various minimally invasive techniques used in lithotripsy, in which stones had been crushed or removed. Desormeaux’s first operative endoscopic procedure– that of lysing of strictures in the urethra– is different because living tissue is removed.

A Turning Point for Endoscopy: Desormeaux and True Visualization
Some of the amazing firsts Desormeaux is credited with include the first ever endoscopic excision of a urethral papilloma, and one of the first endoscopically-assisted urethrotomies, circa 1865. In addition, our research indicates that Desormeaux did indeed become one of the few to actually endoscopically visualize and treat bladder stones, though this remains as part of the contested history [4]. Desormeaux demonstrated this ability by drawing up diagrams of the bladder neck, bladder mucosa, and bladder stones, all aided solely by peering into his scope. This is important because, prior to Desormeaux, many of the endoscopic therapeutic procedures actually were not always performed with full endoscopic visualization; in other words, many were performed semi or entirely blind. Though Desormeaux too was not always able to reach full visualization in all of his patients (or in all types of procedures), he nevertheless achieved more than any others had at this time as a result of his exceptional skill and development of improved techniques and technologies. Desormeaux’s success in achieving such high quality visualization for his era not only demonstrated endoscopy’s invaluable diagnostic role, but it also raised awareness about its potential therapeutic value. This transformation therefore marks another significant turning point for endoscopy. Finally, his textbook, De l’endoscope, was highly influential and helped to popularize endoscopy.

Technical Details
Concerning the technical aspects, much of Desormeaux’s endoscope was a compilation of technologies that already existed. In fact, several sources claim that Desormeaux derived his idea from the prior work of J.P. Bonnafont. As mentioned previously, Bonnafont’s protests went unnoticed for the most part.  Still others went so far as to say that Desormeaux’s endoscope was essentially the lichleiter resurrected. Cruise, on the other hand, suggested that his idea had come from instead Segalas and Avery. Desormeaux apparently didn’t take such suggestions lightly and in one known instance, countered his critics by calling into question the work of Avery in particular, whose attempts he described as “fruitless.”

Such contestations over priority may never be fully resolved. However, certain features of Desormeaux’s instrument were commonly accepted as having roots in earlier works (which in any case does not diminish the validity of newer inventions). For instance, centrally bored concave mirrors - utilized also by Bozzini, Fisher, Segalas and others - had been an established lens technology available since the 17th century.   And of course, the overarching design theme– that of long thin tubes connected to a light source to convey the illumination– had been a shared feature for essentially all endoscopic pioneers since Bozzini.
The distinction then is one relating to subtle refinements that yielded substantial results. Desormeaux’s improved light source is a prime example of this talent for optimizing existing technologies. It appears that Desormeaux was able to achieve better clinical results, mainly due to his incorporation of a new light source, as well as from subtle changes made to the angles of the lenses. Regarding the light source, he had been experimenting with various technologies, but settled upon the “gasogene” lamp, a mixture of four parts 96% alcohol with one part turpentine, which in turn was introduced to a burning flame. As a result of this unique mixture, the light generated was substantially brighter and at the same time more transparent than regular candlelight. This produced a more condensable beam of light that enhanced examinations. Desormeaux was also able to reconfigure the angles used in the lens system so that the light could be concentrated more precisely to one area. This involved changing the positioning of the lenses so that lateral reflection could be achieved. Through the combination of these insightful changes, Desormeaux was able to finally achieve consistently reliable clinical diagnoses. In fact, Desormeaux’s endoscope was the basis for virtually all further designs that used reflected light until the next generation of pioneers arrived (such as Bruck, Trouve and Nitze) whose improvements were in part the result of newly available electrical technologies [5].

Desormeaux’s contributions to the medical literature were also substantial. With his penchant for collecting precise and extensive clinical data, his publications proved to be seminal works. One of his most acclaimed, his book entitled Endoscopy and Its Applications in Diagnosis and Treatment of Diseases of the Urethra and Bladder (Paris, 1865) (“De’Lendoscope et ses applications au diagnostic et au traitement des affections de l’urethre et de la vessie”), was said to have produced “great astonishment among the surgeons.” Another important article, published in the journal The Chicago Medical Journal and entitled “Endoscope’s usefulness in diagnosis and treatment of Urinary Affections” (1867), served to highlight Desormeaux’s considerable progress in therapeutic procedures. Combined, these publications helped redirect the attention of the global medical community to the great potential residing within the world of endoscopy.

Some Technical Flaws and Other Hindrances
Despite such substantial innovations, Desormeaux, like so many pioneers before him, certainly had his share of critics. To begin with, some sources assert that Desormeaux achieved only moderate success, specifically in terms of visualization. One such adverse report claimed that when Desormeaux demonstrated his urethroscopy to German doctors, about “three or four out of the ten present” purportedly could see nothing. In this instance then, that translated to an error rate of approximately 30-40%. Of course, we cannot project our own modern perception onto these results; a 60% success rate was possibly the highest standard achieved at the time and therefore would be considered an extraordinary achievement. Whatever the case, a few similarly described criticisms were voiced by other physicians when Desormeaux’s earlier devices were initially tested.

Concerning the technical flaws, there were a number of drawbacks mentioned as well. The voluminous size has been singled-out as a particularly distracting feature. One source in fact asserted that Desormeaux’s device had been considered “a clumsy monster,” noting its weight as topping one kilogram and measuring 48 cm high, with a 12 cm rectoscope attachment (though nowadays of course rectoscopes are much longer). And while the brighter light was appreciated, it tended to produce a rather sooty, smoking residue. The required positioning of Desormeaux’s endoscope also created some distinct hazards. Because the device had to be held between the legs of the patient, consequently there was always the danger of either burning the face of the physician or the thighs of the patient. In addition, without an effective catheter system, urine would often “extinguish the flame, ruining the examination.”

Summary – Desormeaux
Despite these minor flaws, overall Desormeaux’s work was instrumental in catapulting endoscopy to a greater developmental stage. Though his work was not necessarily the first or most original, Desormeaux was nevertheless able to refine existing endoscopes and adapt better technologies in order to bring to the world one of the most functional endoscopes of his era. Desormeaux’s systematic collection of clear and indisputable clinical data of his experiments  was also a significant contribution, one which no doubt influenced others to conduct similar high quality research.

With respect to the four tasks hindering the endoscope, Desormeaux made considerable headway on multiple fronts. His development of an improved solution for the second task of illumination by using gasogene enabled more accurate clinical outcomes to be achieved. His publications were also highly influential and were said to have revived interest in the subject the world over. And it bears repeating that his vision of the endoscope as a therapeutic technology was quite ahead of his time. Overall, his genius was in demonstrating the enormous potential of endoscopy by establishing sound methods for others to follow. Ultimately of course, time becomes the true arbiter in matters such as these. In this respect, Desormeaux’s endoscope did in fact stand the test of time.  His design principles were displaced only after the next generations of innovators were gifted with the invention of Edison’s electric bulb.

Notes
1. We make a distinction here and exclude the minimally invasive techniques used in lithotripsy, in which stones had been crushed or removed. Desormeaux’s first operative endoscopic procedure– that of lysing of scrictures in the urethra– is different because this is living tissue that is removed.
2. Desormeaux’s cystoscope is synonymous with today’s hysteroscopy, a topic we will cover separately in the next chapter.
3. These same slits were a part of Bozzini’s lichleiter as well. However, unlike Desormeaux, Bozzini was not able to use his device for procedures in living, male patients.
4. The well-respected history of Endoscopy by Reuter indicates that other procedures by Desormeaux were performed blindly, specifically the treatment of urethra scrictures.
5. Some of these referenced electrical technologies, such as galvanized platinum wires, were actually available during Desormeaux’s time. However, at that time, they were considerably more complicated and therefore quite cumbersome for medical usage.