Chapter 9

Chapter 9

~ After Desormeaux ~
Dublin’s Francis Cruise
The St. Petersburg Trio
Hysteroscopy

Francis Cruise - More than the Luck of the Irish
Nothing is gained from Certainty. All affairs turn upon Hope.
-Rumi

The year 1865 was remarkable for a number of reasons. Americans were just beginning their recovery and reconstruction from the aftermath of The Civil War. This same year too, Lister of London began conducting experiments with antiseptics in surgery. And just a short jaunt away, in Dublin, Ireland, another innovator was devising new strategies to address the shortcomings of our dear subject the endoscope. The urologist, Francis Richard Cruise, having found earlier models insufficiently illuminated, introduced an improved version of Desmoreaux's endoscope in approximately 1865. In fact, his work was so fruitful that, next to Desormeaux, Cruise was considered the most successful endoscopist of his time. 

According to Cruise himself, he derived his construction principles mainly from Fisher. However, unlike many of his predecessors, Cruise’s clinical successes were almost unmatched. Like Desormeaux, Cruise focused mainly on work with male patients for urological procedures. And just as Desormeaux achieved many firsts, so did Cruise. Along with Desormeaux, Cruise achieved great acclaim for performing some of the world’s first operative endoscopic treatments successfully in living patients. Among the most notable was one of the world’s first endoscopically-assisted urethrotomies that Cruise claimed to have been performed with full visualization. Cruise was also among the first and the few capable of endoscopically evacuating the bladder, treating strictures of the urethra, and performing other modest operations.

Using his newly improved endoscope, Cruise could also diagnose for the first time varicose vessels, granules, columnar bands, saccular offsets, tumors, and observe the orifice of the neck of the bladder. 

There remain discrepancies in the historical records as to whether Cruise was able to fully visualize any of this operative procedure or actually see bladder stones. Some sources assert that he was able to achieve this, while but most emphatically disagree with this claim. Of course, questions about whether bladder stones were truly visualized accompanied the careers of many early endoscopists, including Segalas, Bozzini and others. What is fairly well established is that the first endoscopic removal of bladder stones– with full visualization- was not achieved until after Cruise, about a decade later. 

As for Cruise’s technical innovations, his endoscope differed from Desormeaux’s device on several grounds. For example, Cruise came up with the idea of using a mixture of petroleum and a bit of dissolved camphor to replace Desormeaux’s bright but bothersome gasogene mix. This resulted in a more powerful light source that also transmitted colors more accurately. Cruise’s petroleum-camphor mix generated a flatter flame that projected light better (compared to the smaller, more round flame produced by the gasogene flame). This feature magnified illumination tremendously, while at the same time eliminated much of the mess, though its significantly heightened heat level did become somewhat problematic. Cruise also significantly enhanced the lens system by becoming the first to successfully incorporate a binocular system, a system which Cruise apparently used for the first time in one of the earliest reported cases of an endoscopically performed thoracoscopic surgery. If the historical record is accurate on this point, this thoracoscopic surgery by Cruise would have been an astonishing achievement, light years ahead of the time. However, no other records of repeat performances of such a surgery during this early time period could be found, nor were further details or citations uncovered [1]. Alas, further research is necessary before deciding on the validity of this aspect of Cruise’s history. 

Still, Cruise’s other innovations to the lens system were equally impressive. In addition to the aforementioned binocular device, another modification entailed having the light from the narrow side fall directly onto a collimating lens without a reflector. Adding a mechanical clamp of sorts, the reflector could be adjusted higher or lower to perfect the reflective properties. Cruise differentiated from both Segalas’ and Desormeaux’s devices by dividing his lens apparatus into two separate systems; one part was used as the reflecting module, while another concave lens was set up specifically to focus the light more intensely onto the field of view. Cruise improved upon the earlier endoscopes in other nuanced ways too, from changing the bistoury device, to rounding off some of the endoscope’s edges, and improving the wadding system for the cautery delivery mechanism.   

Summary - Cruise
Though limited in quantity, Cruise’s publications also attracted a great deal of interest. The 1865 article entitled “The utility of the endoscope as an aid in the diagnosis and treatment of diseases,” was particularly well received and helped to establish Cruise as one of the leaders in the field. Notice too that Cruise added the treatment of disease as part of the endoscope’s usage, not just diagnostic, as had long been the predominant trend. This in itself demonstrates his visionary brilliance concerning the scope’s potential. Overall, the scope and ingenuity of his innovations were a resounding hit on the endoscopic playing field, marking Cruise as one of the few to have made endoscopy a practical technique at this time. 

Precursors to Electro-Surgery
The St. Petersburg Trio

In many histories of endoscopy, medical discoveries outside of European centers have often been greatly overlooked. Thanks to the outstanding research by such experts on endoscopy’s history as Litynski, Figdor, Reuter and Storz, we now have a greater depth of knowledge about endoscopy’s other superstar innovators. One such overlooked metropolis of innovation was St. Petersburg, Russia, one of the 19th century’s most preeminent centers of science and medicine. Three of St. Petersburg’s most outstanding contributors to endoscopy were Alexander Ebermann, Alfred Couriard, and Tarnowsky. 

Alexander Ebermann
Alexander Wilhelm Ferdinand Ebermann (1830-1902) designed some of the most cutting-edge and technically demanding endoscopes the world had ever seen for his time. Utilizing uniquely modified electrical technologies, along with devices of mechanical precocity, Ebermann generated a long list of firsts that rivaled the work of such leaders as Desormeaux and Cruise. Having learned of Desormeaux’s work and recognizing its significance, Ebermann made the long, treacherous road trip to Paris to visit Desormeaux himself so that he could learn from the reigning master. Soon thereafter, Ebermann began his prolific outpouring of innovations. Ebermann was in fact one of the earliest to adapt the newly available electrical technologies for use in endoscopic applications. In approximately 1865, he modified an electrical illumination device, called a jablonchkow light, to be worn as either a headlamp or attached directly to the endoscope. The light itself was described as an “electrical ball of light,” with a center composed of carbon tips. Devising a way to wear a light source as a headband was in itself an excellent innovation, evoking the quintessential image of 20th century surgeons wearing the similar apparatus. And yet just as striking is Ebermann’s early adaptation of electrical light (though battery generated at this point) for use with endoscopy, which is a groundbreaking milestone in endoscopy’s history, one that preceded the more famous work of Nitze and Trouve in this department by at least a decade. 

However, despite this prescient precursor to modernity and despite supplying the bright light endoscopy so desperately needed, the system apparently never gained much popularity due to its expense and the cumbersome nature of the heavy batteries (needed to electrify the wires) which limited mobility. Equally impressive, Ebermann was also one of the earliest to introduce an endoscopically-guided (though still blind) punch instrument used to excise and evacuate urethra polyps, strictures, and prostate bars. The device consisted of a scalpel attached to a modified cystoscope and a rubber balloon operated like a mechanical vacuum to aspirate and remove the excised tissue. Modified versions of this method actually were still in use as late as the 1960s, testament to Ebermann’s remarkable acumen. Other inventions include a uniquely designed ureter clamp.  Though further accounts of his work have been difficult to uncover, it is clear from what records we do have that Ebermann stands out as one of endoscopy’s most brilliant and prolific innovators.

Alfred Couriard
Alfred Couriard contributed subtle yet sophisticated technical expertise relating to the physics of light especially. Determined to improve the quality of the reflected images, Couriard concentrated on refining subtle design details. In 1864 he discovered a way to have the light source directly reflect its light into the shaft of the scope. This was achieved by attaching a convex lens inside a covered lens case, which was then attached to a kerosene lamp. The collected light now could be reflected directly into the examination probe, rather than being redirected to another set of lens housed inside of the scope. Couriard found other ways to improve upon Desormeaux’s original design, including one simple but brilliant change that considerably improved the quality of the reflected image. By expanding the outward ends of the scope’s distal shaft ever so slightly, there was a significant decrease in the blurring and distortion of the reflected images. Couriard was also able to increase the light’s ability to penetrate more deeply down the scope making the side shafts of the scope fully cylindrical.

Couriard is also famous for being one of the first to deviate from the prevailing norm of a unified scope, established by Bozzini sixty years prior [2]. Determined to make the scope more nimble and compact, Couriard split up its three central components- the light, the lenses, and the scope– into separate units. By detaching the scope from its awkward base, physicians were no longer burdened with the cumbersome tasks required of earlier unified models, such as holding the light or scope steady in peculiar positions. In this way, the actual scope itself was rendered more mobile; in other words, it transformed into a ‘user-friendly’ device that could then yield superior diagnostic and operative results. This change actually established a new methodology, what is referred to as direct endoscopy. This referred to the fact that since the scope itself no longer housed an internal lens, this meant that the images were obtained directly rather than indirectly as was the case with internally-placed reflecting lens. Amazingly, a version of this Couriard-inspired direct endoscope was still in use well into the 1930s.

Tarnowsky
Together with Couriard, they changed the Bozzini-inspired endoscope to a more compact version that separated the light source and other components.

Others Involved in the Post-Desormeaux Era
Robert Newman of New York is also mentioned as being quite influential in popularizing endoscopy in America. Also from America was E. Andrews of Chicao who in 1867 attempted to improve Cruise’s endoscope by lighting it with burning magnesium wire, though ultimately his tinkering was to no avail.

Hysteroscopy: The Mysteries of the Un-Wandering Womb Revealed
Hysteroscopy takes special pride of place within gynecologic surgical history, for obstetric-gynecologists (and urologists) practitioners were the driving force behind many of endoscopy’s most important developments. We can mark the formative years of hysteroscopy as officially starting with Desormeaux’s introduction of one of first working cystoscopes in 1853. Other instruments were designed with mainly obstetrics in mind. In 1863, EJ Aubinais claimed to have “watched a baby’s head emerging from the cervix by inserting an instrument in the vagina,” a description of possibly the first vaginoscopy.

However, it is Commander DC Pantaleoni of Ireland who is credited with performing the first truly successful diagnostic and operative hysteroscopy. As described in an 1869 publication, Commander Pantaleoni utilized a modified cystoscope lit with reflected candle light to examine the uterine cavity of a patient with post-menopausal bleeding. Using silver nitrate, he cauterized a hemorrhaging “polypous” uterine growth. Though the cauterizing was actually performed blindly, Pantaleoni’s success nevertheless paved the way for greater advances in women’s health. 

Though hysteroscopy debuted long before laparoscopy, later its development stalled somewhat until such time that more effective methods for uterine distension could be found. We will return to hysteroscopy in the 20th century, when new technologies became available to catalyze its development even further.

Notes
1. Since such a surgery was apparently never repeated by others in the field, and since detailed reports are lacking concerning this surgery, we must approach these claims with some conservatism.
2. The source states that all three St. Petersburg pioneers made the change from a unified scope, though it is not clear which one was the first to do so. Based on other texts, it appears that Couriard was most probably the first.