History of the instruments for gastrointestinal endoscopy

0016-5107/91/3702-0S27$03.00 GASTROINTESTINAL ENDOSCOPY Copyright © 1991 by the American Society for Gastrointestinal Endoscopy

History of the instruments for gastrointestinal endoscopy James M. Edmonson, PhD Cleveland, Ohio

Gastrointestinal endoscopy has passed through three principal phases of technical development, each identified by the predominant form of instrument then in use. These periods are: the "rigid endoscope" era (1805 to 1932); the "semi-flexible endoscope" or "Schindler" era (1932 to 1957); and the "fiberoptic" era (1957 to present). This history of the instrumentation documents the principal changes in the forms of endoscopes used to examine the gastrointestinal tract. It also adheres to a predominantly American perspective, as a reflection of A/S/G/E founders' and members' participation in the development of instruments for gastrointestinal endoscopy. The rigid endoscope era, the first period of gastrointestinal endoscopy, is generally agreed to have come of age in 1868 when Adolf Kussmaul introduced the gastroscope. Gastroscope and esophagoscope design by Kussmaul and his contemporaries followed and drew from earlier work on endoscopes, notably the Bozzini lichtleiter (1805) and the Desormeaux endoscope (1853), so that the actual beginning of the era can be traced to the first half of the 19th century. Instruments from that time and subsequent advances in endoscope design, particularly in cystoscopy in the 1870s, led to the development of Mikulicz's gastroscope and esophagoscope. In these instruments, Mikulicz brought together three elements for the first time in the gastroscope: electric light source, optical system, and tubular body of the endoscope. Subsequent development of instruments during the rigid endoscope era consisted of improving upon some a~pect of these components. The semi-flexible endoscope era dawned with the introduction of a new form of instrument by Rudolf Schindler and came to a close only with the advent of fiberoptic instruments in 1957. Semi-flexible instruments, as the name implies, were more pliant than the previous generation of instrument, making them easier to introduce, and thereby facilitated more complete visualization of the stomach interior. Technical imReceived December 20, 1990. Accepted December 26, 1990. From the Cleveland Medical Library Association, Cleveland, Ohio. Reprint requests: James M. Edmonson, PhD, Cleveland Medical Library Association, 11000 Euclid Avenue, Cleveland Ohio 44106. VOLUME 37, NO. 2, 1991

provements by Schindler and his contemporaries made gastrointestinal endoscopy a comparatively safe diagnostic procedure for the first time. In the latter half of the semi-flexible endoscope era several innovations appeared, including the emergence of American instrument makers specializing in the production of endoscopes, the development of the esophagoscope, and the introduction of the operating or biopsy endoscope. The fiberoptic endoscope era commenced when Basil Hirschowitz developed and used (on himself, first) a prototype fiberscope in 1957. Production models were introduced by 1960 and, by the end of the decade, incorporated design features that gave them decisive advantages over conventional semi-flexible instruments. The fiberscope also rendered the gastrocamera redundant and obsolete by 1970. Other important instrumental advances, beyond the improvement and refinement of the basic gastroscope and esophagoscope, took place in the 1970s and 1980s. Chief among these are the side-viewing duodenoscope for ERCP, the fiberoptic colonoscope, and video endoscopic equipment. THE RIGID ENDOSCOPE ERA, 1805 TO 1932

The rigid endoscope era began in 1805 with the invention of the endoscope of Philipp Bozzini (1773 to 1809). The exploration and visual examination of the body's orifices gave rise to various specula before that time, and their use, while not frequent, did date to Graeco-Roman times. Direct visualization of the body's interior with these specula was hampered by ineffective transmission of light and the generally shallow depth of penetration that they afforded. Bozzini's endoscope design promised to overcome these limitations and thus enable those using his instrument to illuminate and see into the inner cavities of the human body. Bozzini developed his endoscope, which he called the lichtleiter, or "light conductor," between 1803 and 1808. 1 It combined a vase-shaped housing for his light source, a candle, and a series of specula suitable for examining the urethra, bladder, vagina, and so forth 2 (Fig. 1). Although the lichtleiter is widely considered 827

Figure 1. Bozzini's "Iichtleiter," 1805 [Source: Peter Rather, Wolfgang Lutzmeyer, and Willard E. Goddwin, Philipp Bozzini (1773-1809) and the Lichtleiter, Urology 3 (1974):116, Fig. 3d].

to be the first "true" endoscope, it never served as a practical instrument. Failure in this regard can be attributed only in part to design or construction flaws. Intra-professional rivalries also contributed, perhaps decisively, to the discredit of Bozzini's instrument. 3 Bozzini's death by typhoid in 1809 sealed the fate of his lichtleiter. While a practical failure, Bozzini's lichtleiter established the principles that guided subsequent endoscope development. The next generation of instrument designs resembled the lichtleiter in that they incorporated a light source, reflective surface, and a graduated series of tubular specula. The endoscopes of Segalas and Fisher, for example, are instruments that adhered to the design precedents set by Bozzini. 4 In 1826 Pierre Salomon Segalas (1792 to 1875) demonstrated his "speculum urethro-cystique" to the members of the Academie des sciences in Paris. 5 Segalas devised his endoscope to visualize stones in the bladder which he would then crush with a lithotrite. According to a contemporary report in the Lancet, "M. Segalas informed the Institute that the light accumulated at the extremity of the urethral tube would enable a person to read the smallest printing type at the distance of fifteen inches, and that in the most obscure place."6 Segalas must have sounded convincing, for his instrument inspired rivals who challenged 828

his priority and originality.7 He claimed to have used the endoscope to identify and treat a variety of urethral and cystoscopic disorders (Fig. 2). Contemporaneously, across the Atlantic, John D. Fisher (1797 to 1850) toyed with the design of an endoscope. 8 Through descriptions in the medical press, Fisher may have been familiar with the instruments of Dr. Borrini [sic], M. Segalas, and M. Bombolzini, as noted by a commentator in the Philadelphia Journal of the Medical and Physical Sciences. This same observer indicated, however, that "we have not seen any of these instruments, nor met with a particular description of them; we cannot, therefore, say whether they are formed on the same principle [as Fisher's endoscope], nor how far they may be useful in ascertaining the pathological state of dark cavities."g Fisher, in a letter to Professor Horner in Boston, explained that "an instrument involving the same principles as Segalas, was thought of by me three years ago [in 1824], when a student of medicine. I then had under my charge a woman who had a disease of the neck of the uterus, and so great were her feelings of delicacy that I could not prevail upon her to suffer me to make an examination with a common speculum."l0 Fisher therefore devised his endoscope, which not only facilitated a better view for the physician, but also placed him at a sufficiently discrete distance to satisfy the patient's modesty. Like both Bozzini and Segalas, Fisher used a candle, reflective mirrors, and tubular specula; his principal innovation was the addition of a double convex lens to sharpen and enlarge the image. The contemporary description of the instrument does not include mention of its clinical application; in fact, its actual usefulness is questioned: "Whether or not this instrument can be ever so perfected as to be very useful, we cannot undertake to say, but it is evidently susceptible of improvement.... Our friend, Professor R. M. Patterson, has suggested to us galvanism as a means of illuminating dark cavities, and we have been endeavoring to devise an instrument for this purpose, but we have not as yet been able to have one constructed"ll (Fig. 3). Despite the inventive endeavors of Bozzini, Segalas,

Figure 2. Segalas's "speculum urethro-cystique," 1826 [Source: P. S. Segalas, Traite des retentions d'urine (1828); iIIus. in Ernest Desnos, L 'Histoire de I'urologie (1921), 284, Fig. 189]. GASTROINTESTINAL ENDOSCOPY

Figure 3. Fisher's endoscope, 1827 [Source: I. H. [Isaac Hayes], Instruments for illuminating dark cavities, Philadelphia Journal of the Medical and Physical Sciences 14 (1827):410; and Ernest Desnos, L 'Histoire de I'urologie (1921), 285, Fig. 190].

The Endoscope. The operator:- examinin~ alPallent.ready wIth

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a and Fisher, endoscopy remained a little-used diagnostic aid until the time of Antonin J. Desormeaux (1815 to 1881). In 1853 Desormeaux introduced an improved form of the endoscope, intended for a variety of applications, and he performed a still greater service by preparing his text, De l'endoscopie, which played an important role in popularizing endoscopy. Desormeaux began work on his endoscope in late 1852 and presented it before the Academie des sciences in Paris on November 29, 1855 12 (Fig. 4). For inspirat~on and example he credited Segalas, with whom he discussed endoscope design. For illumination Desormeaux utilized a lamp fueled by "gazogene," a mixture of alcohol and turpentine. He had originally considered and rejected electricity: as he later recalled, "before I settled upon this [gazogene] lamp, I thought of the electric light, but it is too cumbersome to be carried around, and requires an assistant [to regulate the batteries]. It would, moreover, double the price of the instrument."13 Research and experimentation, begun in 1852, took on new importance when Desormeaux became surgeon at the Necker Hospital in Paris in 1862. There he employed his endoscope to diagnose and surgically treat urological disorders, which he documented in his monograph, De l'endoscopie, in 1865. 14 In America, the principal proponent of the Desormeaux endoscope was Robert Newman of New York. 15 VOLUME 37, NO.2, 1991

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Figure 4. Top and bottom, Desormeaux's endoscope, 1853 [Source: Top, J. H. Gemrig, Illustrated catalogue of surgical instruments (ca. 1870), pI. xxx. Bottom, Robert Newman, The endoscope considered particularty in reference to diseases of the female bladder and urethra, Transactions of the Medical Society of the State of New York for the Year 1870, Fig. 2].

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Newman stressed that success in endoscopy depended upon the instrument and he lamented that "but few of these instruments are to be had, properly constructed' while there are many of an inferior quality, or wholly worthless, even, in skillful hands that have been used in testing, and that the results of these failures have been the condemnation of the perfect instrument."16 While good quality endoscopes were available from several American instrument-making establishments by the 1870s, use of the instrument was far from widespread. 17 Cruise, of Dublin, made some modifications to Desormeaux's instrument with a view toward improving the light while reducing the heat generated by the lamp. In place of Desormeaux's gazogene lamp he substituted a paraffin, or kerosene, lamp. The light was not only brighter, but hotter as well, so Cruise fashioned a housing with wood for better insulation. One contemporary observed that "this contrivance makes the machine almost too clumsy for manipulation."18 Introduction of the gastroscope: from Kussmaul to Mikulicz

The rigid endoscope era is generally agreed to have come of age when Adolf Kussmaul made his first successful attempts at gastroscopy in 1868. 19 A few years earlier Kussmaul had treated dilation of the stomach successfully by introducing a flexible tube and pumping out the stomach contents. 20 Turning from treatment to diagnosis, he ventured to insert a rigid tube down the throat, into the stomach. With the help of a cooperative sword swallower, Kussmaul successfully demonstrated gastroscopy before a meeting of the medical section of the Society of Naturalists of Freiburg, Germany. In the process, he established that the curving passages from mouth to stomach could be traversed with a straight tube. Not many of his contemporaries appreciated the significance of this demonstration, perhaps because it remained unpublished, and the search for the ideal tube configuration-flexible, angled, or articulated-continued through the beginning of the semi-flexible endoscope, or Schindler era. Other problems frustrated Kussmaul's efforts, particularly illumination. For that he utilized a modified version of the Desormeaux endoscope, attaching the lamp portion of Desormeaux's endoscope to the long (47-cm) rigid tubes, which he had inserted down the subject's throat to the stomach21 (Fig. 5). The weakness of this light, combined with obstruction of visibility by stomach fluid, led Kussmaul to abandon gastroscopy, leaving to others the resolution of the technical difficulties involved. For the next decade or so the development of gastrointestinal endoscopy virtually stalled, hampered by 830

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Figure 5. Top and bottom, Kussmaul's gastroscope, 1868,

and technique of introducing the rigid instrument, 1896 [Source: Rudolf Schindler, Gastroscopy. The endoscopic study of gastric pathology (2nd ed., 1950), 3, Fig. 1; and Victor R. von Hacker, LJeber die Technik der Oesophagoskopie, Wiener Klinische Wochenschrift 9 (1896):92, Fig. 3].

the difficulties in lighting and optical systems. Contemporaries of Kussmaul focused their efforts on devising esophagoscopes, which were generally much simpler in design than gastroscopes. 22 For illumination, oil lamps and candles gave way to a variety of generally bright, but otherwise troublesome light sources. In 1867 E. Andrews of Chicago tried to improve Cruise's endoscope (apparently without great success) by lighting it with burning magnesium wire. 23 Another solution, attempted by Bruck24 of Breslau and by Milliot2s of Paris in that same year, was borrowed from galvanocautery and consisted of using a loop of platinum wire as an electrical lamp filament. When charged with direct current the platinum would glow intensely, providing a bright, almost blinding light. Managing the white-hot filament required improvements in the electrical supply and led to the development of cooling systems, modifications devised chiefly by Gustav Trouve, engineer of Paris, and the collaborative efforts in Vienna of Josef Leiter, instrument maker, and Johann von Mikulicz, surgeon. Gustav Trouve designed a variety of electrical and scientific instruments, including the "polyscope" introduced in 187026 (Fig. 6). In this endoscope Trouve improved the intensity and stability of the electrical supply, yielding a more manageable source of illumination. Although the polyscope was presented as an instrument for examining the stomach, there is scant evidence of its clinical use. GASTROINTESTINAL ENDOSCOPY

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Figure 6. Trouve's polyscope, 1870 [Source: J. Baratoux, De I'oesophagoscopie et de la gastroscopie, Progres medica/10 (1882):400, Figs. 23 and 24].

In the early 1860s, Vienna emerged as the center of innovation in esophagoscopy and gastroscopy. While technical advances occurred sporadically elsewhere, the Vienna medical scene offered a stimulating milieu VOLUME 37, NO.2, 1991

that fostered and sustained creative efforts in new instrument design. Laryngology and urology were but two of several nascent specialties that promoted the development of endoscopy. From these came the laryngoscope (Turck, Czermak, 1858) and the cystoscope (Nitze and Leiter, 1879), elements of which were borrowed and incorporated in new esophagoscope and gastroscope designs. Carl Stoerk (1832 to 1899) and Friedrich Semeleder (1832 to 1901), former students of Ludwig Turck, founder of laryngology in Vienna, began experimenting with various primitive forms of esophagoscopes as early as 1861. 27 Stoerk recommenced his work on esophagoscope design after 1870, developing a series of esophagoscopes (Fig. 7). Despite all his efforts, Stoerk's designs never succeeded in gaining acceptance for esophagoscopy.28 Inadequate illumination, from available light reflected by a mirror down the tube, constituted the chief impediment. Stoerk communicated this to von Mikulicz, who set out to remedy this defect in endoscope design. Johann von Mikulicz (1850 to 1905), surgeon and student of Theodor Billroth, enjoyed a distinct advantage over Stoerk; he was able to collaborate with Josef Leiter (1830 to 1892), the leading instrument maker of Vienna. Leiter had worked with Maximillian Nitze (1848 to 1906) on the development of the cystoscope, which they introduced in 187929 (Fig. 8). The success of the Nitze-Leiter cystoscope depended upon the combination of a platinum wire loop lamp and a water cooling system, which gave it a decided advantage over cystoscopes then in use. Widespread acclaim for the ingenuity of the instrument brought Nitze and Leiter to blows, each claiming personal credit for the design and its success. Before the two parted company in 1879 Leiter also constructed a gastroscope with a segmented, flexible shaft that would be straightened after insertion30 (Fig. 9). The break between Nitze and Leiter precluded any collaboration on further design refinement, however. Leiter proceeded to offer for sale an as yet untried version of the flexible gastroscope anyway. It was soon discredited as an ineffective and possibly dangerous instrument and this repudiation jeopardized the subsequent acceptance of gastroscopy in general. Fortunately, Leiter found a new collaborator in von Mikulicz, who would carry out careful clinical trials before offering any new instruments. Von Mikulicz and Leiter started to work together in 1880 and by the next year they produced both an esophagoscope and a gastroscope. 31 They patterned the gastroscope after the Nitze-Leiter cystoscope, incorporating the light at the distal end of the instrument. Like the cystoscope, it also featured a bend or angle of 30 degrees in the last third of its length (Fig. 10). Despite these and other modifications, including the addition of the "mignon" light, the Mikulicz-Leiter gastroscope was not a success; Mikulicz conducted 831

Figure 7. Stoerk's esophagoscope, 1870 [Source: S. J. and J. 1. Pearlman, Johann von Mikulicz and the development of the esophagoscope, Quarterly Bulletin of the Northwestern University School of Medicine 31 (1957):268].

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brief trials on healthy subjects and then abandoned its use. Chevalier Jackson later offered a damning indictment of this instrument: At the door of the Nitze cystoscope must be laid the blame of the practical failure of gastroscopy up until the present day. The attempt to adapt the cystoscopic principles to the totally different conditions in the stomach resulted in the misdirection of the earnest, able, scientific efforts of Mikulicz, Rosenheim, and Rewidzof. 32

Mikulicz' development of the esophagoscope did not meet with the same fate as his work on the gastroscope. In effect, he reverted to a simple straight tube similar to Kussmaul's original instrument. The straightened rigid shaft, though more difficult to in832

Figure 8. Nitze-Leiter cystoscope, 1879 [Source: Max Nitze, Lehrbuch der kystoskopie (1889), Fig. 14]. GASTROINTESTINAL ENDOSCOPY

instrument forms for gastrointestinal endoscopy in the ensuing half century. According to L. Walk, who made the most comprehensive examination of this period of instrument development, three principal varieties of gastro- and esophagoscopes vied for acceptance: straight open tubes without lenses, flexible endoscopes' and rigid straight tubes with optical systems. 34 The first category of instruments, open tubes devoid of any optical system, facilitated direct visualization of the esophagus. These same instruments served as gastroscopes, too, Chevalier Jackson, premier American bronchoscopist, championed the open tube esophago- and gastroscopes 35 (Fig. 13). Jackson's overall endoscopic virtuosity accounted for his success with this instrument, a success not repeated by his students or contemporaries. In Britain, W. Hill, a surgeon, collaborated with a gastroenterologist to experiment with the open tube gastroscope. Their efforts, like those of Jackson in this country, found no following. The second type of instrument form prior to 1932 was the so-called flexible tube endoscope. Recurring use of the term "flexible" to describe gastro- and esophagoscopes causes confusion, since the degree of flexibility, and hence the appropriateness of the term, varied from one phase of endoscope development to

Figure 9. Nitze-Leiter gastroscope, 1879 [Source: Josef Leiter, Elektro-endoskopische Instrumente (1880), 33, Fig. 52].

troduce than a flexible one, permitted direct visualization of the esophagus without a complicated optics system of lenses and prisms (Fig. 11). In addition, Mikulicz's esophagoscope benefited from the introduction of the incandescent electric light, invented by Edison in 1879. Leiter, who had first seen the Edison lamp at the 1883 International Electrical Exhibition in Vienna, adapted it for use with the cystoscope by 1886. 33 Installed at the distal end of the instrument, the small, or mignon, bulb eliminated the platinum loop lamp and its cumbersome water cooling system. In 1887 Leiter introduced the panelectroscope, a universal light source for all plain endoscopic tubes, featuring the Edison lamp (Fig. 12). It provided illumination by reflecting light from a diminutive electric lamp built into its handle. Substitution of Edison's incandescent light bulb for the platinum wire loop in 1886 rendered von Mikulicz's instrument the first truly usable esophagoscope. Later variants of the rigid endoscope

In addition to the promising advances introduced by von Mikulicz, there persisted quite a variety of VOLUME 37, NO.2, 1991

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Figure 10. Mikulicz-Leiter gastroscope, 1881 [Source: Rudolf Schindler, Gastroscopy. The endoscopic study of gastric pathology (2nd ed., 1950), 4, Fig. 2]. 833

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b Figure 11. Top and bottom, Mikulicz's esophagoscope, 1881 [Source: Max Einhorn, The inspection of the oesophagus and the cardia, New York Medical Journal 66 (1897):797, Figs. 1 and 2].

834

the next. During the rigid endoscope era, a flexible endoscope remained pliant as an aid to insertion; once in place, it would be straightened. The principle of flexible tube endoscopy is best represented in the instruments of Kelling, Kuttner, and Sussmann. Rigid straight tubes with optical systems, the third category of instruments, took the lead next in gastroand esophagoscope development and dominated the field right up to the close of the era in 1932. Experimentation with this instrument form had been revived by Rosenheim in 1895. He succeeded in confirming Kussmaul's original assertion that, "by proper manipulation even straight rigid instruments could be introduced in the stomach."36 Rosenheim's gastroscope consisted of three concentric tubes; the center one GASTROINTESTINAL ENDOSCOPY

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Figure 13. Jackson's gastroscope and esophagoscope, ca. 1900 [Source: George P. Pilling & Son Co., Pilling instruments and equipment for surgeons and hospitals (1932), 86].

carried the optical system, the middle tube housed both a platinum wire loop lamp and its water cooling system (this feature comprised a retrograde step in illuminating methods), and the outer tube featured a scale along its side to indicate the depth of penetration3 ? (Fig. 14). Rosenheim utilized this instrument first on cadavers and then on patients, examining over 100 cases before stopping his work in gastroscopy. As with so many pioneer endoscopists, rumors intimated that an accident caused Rosenheim to abandon the procedure. Safety had not yet reached an acceptable level and a fear of similar accidents caused others to shy away from the rigid tube gastro- and esophagoscope for over a decade. In 1911 Elsner reintroduced the use of the rigid form of gastroscope and, in the words of Schindler, it "remained the mother of all instruments until 1932"38 (Fig. 15). It was, in essence, a modified Rosenheim gastroscope; the principal improvement consisted of adding a rubber tip at the end of a straight tube. Elsner's instrument incorporated its lens system and light, like that of a cystoscope, in a separate inner tube. The principal disadvantage was that viewing through the lens was difficult when soiled. Elsner and several of his contemporaries utilized this instrument with few mishaps, and their success prompted Rudolf Schindler's entry into the field of gastroscopy. Schindler introduced his version of the rigid gastroscope in 1922, following initial trials with an Elsner instrument "which had lain unused in a shop for ten years."39 His interest in gastroscopy stemmed from wartime experiences, when many of his patients complained of stomach disorders. During World War I VOLUME 37, NO.2, 1991

Figure 15. Elsner's gastroscope, 1911 [Source: Hans Elsner, Die gastroskopie (1911), 44, Fig. 16].

soldiers came under his care and Schindler became convinced that their maladies, often grouped under the imprecise and often controversial diagnosis of gastritis, were quite real, rather than imagined or feigned. 40 Immediately following the war Schindler encountered large numbers of patients, this time women and children, with similar complaints. Once again, he pondered the cause of their discomfort and concluded that visual examination of the stomach's interior might prove instructive. He quickly encountered the faults of the Elsner gastroscope and by 1923 developed a modified version that included an air outlet to clear the lens. 41 His instrument also differed in that its rubber tip was used only as a guide for the introduction of the instrument and would be withdrawn and the inner tube with lens and lamp would then be inserted (Fig. 16). Schindler later recalled the response to his improvements of the rigid gastroscope: In an extremely short time we were able to carry out more than four hundred gastroscopies. Even the patients demanded the examination, and there was a growing confidence in both the patients and the doctors. Many German and foreign physicians were aware of this enthusiasm, and the method was soon adopted in many hospitals. 42

Schindler's subsequent renown was based principally upon his Lehrbuch und Atlas der Gastroskopie of 1923, which provided descriptions and pictures of a wide variety of stomach disorders. According to his fellow 835

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~ Figure 16. Schindler's rigid gastroscope, 1922 [Source: Rudolf Schindler, Gastroscopy. The endoscopic study of gastric pathology (2nd ed., 1950), 10, Fig. 6].

pioneer gastroscopist, Jean Rachet, Schindler also gained a wide following by establishing endoscopic protocol and teaching it to others and by compiling and publishing his results. 43 The technique of gastroscopy, from an instrumental standpoint, remained a potentially life-threatening event, nonetheless. Accidental perforations of the esophagus resulting in fatalities threatened to bring about the abandonment of the procedure, as Schindler recognized: "Death from a diagnostic method is a severe setback to the procedure. It seemed, however, that such a useful and perhaps necessary method should not be discarded because of an occasional fatality but should be developed to the point where it was entirely safe."44 Schindler was determined that gastroscopy would not be abandoned and therefore committed himself to refining and perfecting the instrument. The semi-flexible gastroscope would be the result of his efforts.

THE SEMI-FLEXIBLE ENDOSCOPE OR SCHINDLER ERA, 1932 TO 1957 Development of the semi-flexible gastroscope by Schindler and Wolf

The semi-flexible endoscope era, lasting from 1932 to 1957, was so dominated by the contributions of Rudolf Schindler that the period has also been called, appropriately enough, the Schindler era. During this interval Schindler shaped the field of gastrointestinal endoscopy, transforming it from a risky and seldompracticed diagnostic procedure into an essential component of gastroenterology. He achieved this by means of technical innovation in endoscopic design, chiefly his semi-flexible gastroscope of 1932, and by his personal promotion of the "gospel of gastroscopy," particularly after his arrival in the United States in 1934. Schindler's name still evokes admiration and respect among physicians who entered the ranks of gastrointestinal endoscopy before his retirement and return to Germany in 1965. They recognize that while Schindler's contributions to instrumental design were significant, even crucial, to the development of endos836

copy, he is also to be remembered for the personal example that he set for all fellow endoscopists. Schindler's dissatisfaction with his rigid tube gastroscope of 1922 led to the development of the semiflexible gastroscope in the period from 1928 to 1932. Schindler took his problem to Georg Wolf (1873 to 1938) a talented instrument manufacturer in Berlin responsible for making the Sussmann flexible gastroscope of 1911. 45 Wolfs experience with the Sussmann instrument had been discouraging; as Schindler later noted, "the Sussmann gastroscope proved to be unusable because the conceptions upon which its construction had been based were wrong."46 The design fault resided chiefly in the mechanical arrangement used to straighten the flexible tube once inserted. Schindler noted that, "... the straightening procedure was very dangerous and the optical system was easily dislocated."47 After this negative experience with the Sussmann gastroscope, until the time of his collaboration with Schindler, Wolf confined his work to less complicated or daring innovations. During that period he did work on one version ofthe semi-flexible gastroscope incorporating prisms in a movable tube, a design inspired by observations made by Michael Hoffman of Munich in 1911, but the instrument proved impractical at the time. 48 When Schindler came to Wolf in 1928, he did not have a completed design in mind. Starting with a fully flexible gastroscope, they moved at Schindler's urging toward a semi-flexible instrument. Schindler, basing his calculations upon the earlier determinations of Hoffman, concluded that "... the instrument had to be flexible from a point about 3 cm. above the cardia to the distal end of the tube."49 Schindler and Wolf achieved flexibility by making the lower or distal half of the gastroscope tube out of a spiral of bronze, with a protective outer cover of rubber. For the optical system for a semi-flexible instrument, they "discovered that a tube filled with very thick lenses, with a short focal distance, could be bent in several planes to an angle of about 34 degrees without distortion of the image.,,5o By 1932 the instrument reached a sixth and final version, known as the Wolf-Schindler semi-flexible gastroscope, and in that form was patented by Georg Wolf 51 (Figs. 17 and 18). Schindler, always the consummate promoter of gastroscopy, began instructing other physicians in the use of the Wolf-Schindler semi-flexible instrument in 1932. By the summer of 1933, 50 clinicians from throughout Europe and North America had learned the technique of using the new instrument under his tutelage in Munich. In turn, many of these fledgling gastroscopists promoted the instrument and its use upon returning home. In addition, the Wolf-Schindler gastroscope found its way into the clinics of larger hospitals throughout Munich, enabling Schindler to begin compiling case studies for analysis. GASTROINTESTINAL ENDOSCOPY

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ceptance of gastroscopy in this country, early enthusiasm among a small circle of American physicians also played a role in spreading the "gospel of gastroscopy." In 1933 Chester Jones and Edward B. Benedict conducted the first American trials of the Wolf-Schindler gastroscope at Massachusetts General Hospita1. 53 They had received a Wolf-Schindler gastroscope for trial use, courtesy of Carl Zeiss, maker of the optics used in the instrument, and performed a gastroscopy with it for the first time on April 6, 1933.54 Benedict, who became an ardent supporter of Schindler, later recalled the event and its impact on his own career: As luck would have it, our first patient was a man who was later proved to have a gastric lymphoma. We did not make the diagnosis, needless to say, on our first gastroscopic attempt. In fact, I believe we could do it now only with gastroscopic biopsy. Anyway, from then on my work in gastroscopy was started; Dr. Churchill suggested that I add bronchoscopy and oesophagoscopy and Dr. Allen suggested peritoneoscopy too. So I gave up general surgery altogether and devoted myself entirely to endoscopy. 55

Over the next year Benedict and his colleagues at the hospital made over 75 gastroscopic examinations, finding that "the greatest field of usefulness for the gastroscope is probably in gastritis, but it is also useful Figure 17. Top and bottom, Wolf-Schindler flexible gastroscope, 1932 [Source: Rudolf Schindler, Gastroscopy. The endoscopic study of gastric pathology (2nd ed., 1950), 34, Fig. 29].

Schindler brings the gastroscope to America

Schindler was barely able to begin enjoying the accolades bestowed upon the semi-flexible gastroscope, however. Seized in a Nazi purge of citizens of Jewish descent, Schindler was placed in "protective custody." While in detention for 6 months, as his nonJewish wife sought his release, Schindler made overtures to American colleagues, hoping for refuge in the United States. He contacted Marie Ortmayer and Walter Palmer, of the University of Chicago, both of whom had visited him in Munich during the 1920s, and they secured an appointment for him as visiting professor of medicine. 52 Upon release from custody, Schindler and his family departed Germany and headed for Chicago. Once there, Schindler found his Chicago colleagues to be interested in his work and supportive of his efforts to promote gastroscopy. In particular, Walter Palmer helped with the preparation of Gastroscopy, his first monograph published (1937) in this country. Schindler's presence in Chicago made that city a mecca of gastroscopy for the next decade, much as Vienna had been for endoscopy in general at an earlier date. Although Rudolf Schindler's immigration to the United States contributed immeasurably to the acVOLUME 37, NO.2, 1991

FIG. SO.-Blind areas. 1, blind area of posterior wall; :2, blind area of lesser curvature of antrum; .J, blind area of lower pole; 4, pseudo-blind area of t'ornix (becomes visible with deep inspiration or if hilt little air is illflah·d). Figure 18. Portions of stomach not visualized with the Wolf-

Schindler semi-flexible gastroscope [Source: Rudolf Schindler, Gastroscopy. The endoscopic study of gastric pathology (2nd ed., 1959), 56, Fig. 50]. 837

as an adjunct to the x-ray in gastric ulcer and the various benign and malignant tumors of the stomach."56 As Benedict was publishing the results of his early clinical trials, other American physicians began their own. 57 James L. Borland brought the first Wolf-Schindler gastroscope to Baltimore in 1934 and his colleagues at Johns Hopkins Hospital, John Tilden Howard, E. B. Freeman, and Moses Paulson, soon acquired one for their clinic. 58 Physicians trained in the use of the gastroscope at such academic centers would then take the technique to other locales, thereby stimulating the development of gastrointestinal endoscopy. James L. Borland, for example, gained valuable experience and competence in endoscopy before leaving Baltimore for Jacksonville, Florida. He subsequently became an enthusiatic spokesman for gastroscopy, proclaiming at the 1937 meeting of the Southern Medical Association that "we believe that examination by the flexible gastroscope should be offered to every patient with gastric complaint, without definite contraindication. "59 Later instrumental developments of the semiflexible era

The latter part of the Schindler era, from the early 1940s through the 1950s, is sometimes treated as a period during which no important advances took place in the field of gastrointestinal endoscopy.6o Although now eclipsed by the technical revolution wrought by fiberoptics, the innovations of this period demonstrate that endoscopy was advancing steadily in the decade or so preceding 1957. Indeed, instrumentation underwent continued improvement and new procedures were added to the repertoire of gastrointestinal endoscopy. The most important of these included refinements of the standard gastroscope and its production by American instrument companies, the development of esophagoscopes, introduction of gastroscopic color photography, and the advent ofthe operating or biopsy endoscope. American endoscope design and manufacture

Development of the flexible gastroscope and related instruments in this country depended upon a successful collaboration between physicians and instrument makers. Schindler emphatically stressed that his working relationship with Georg Wolf was crucial to the outcome of his own work, and he reminded fellow endoscopists of the bitter rancor that ensued in the wake of the Nitze-Leiter split: The cornerstone of endoscopy was laid by Joseph Leiter, an electro-optician of Vienna, who worked with Nitze and built the first cystoscopes. Together with Mikulicz, he also inaugurated the second phase of gastros838

copy.... It is useless to ask whether the technician or the physician has the greater merits.... The ugly disagreement between Nitze and Leiter is well known. It would have been unnecessary if both men had considered that the one cannot exist without the other. 61

In the United States surgical instrument manufacture was generally on the decline in the 1930s and only a few firms were equipped to take on the kind of work called for by gastrointestinal endoscopy. A handful of companies specialized in instruments that incorporated optics in their design and it was to them that gastroscopists turned for help in developing new instruments or modifying existing ones. Reliance upon American instrument enterprises increased abruptly with the curtailment of instrument importation from Germany during the Second World War. The most important of these firms during the Schindler era included Cameron Surgical Specialty Co., Eder Instrument Co., Metro Tec, and American Cystoscopic Manufacturers Inc. The first company to begin making gastroscopes in America was Cameron, founded as the American Surgical Specialty Company in 1915 by William J. Cameron. The firm originally produced transilluminators, a diagnostic instrument using electric light, and only turned to the manufacture of gastroscopes as the supply from Germany was suspended in time of war. Schindler worked with Cameron to design the first flexible gastroscope to be made on this side of the Atlantic. 62 Introduced in 1940, this version of the Schindler flexible gastroscope featured several minor changes, deemed improvements by Schindler. Most important was a reduction of the angle of view from 90 degrees to 45 degrees, which made for a narrower field of vision but eliminated distortion at the image edge and increased the magnification appreciably. Schindler, quite pleased with the new gastroscope, proclaimed that "with the construction of this instrument the hope of securing an American built gastroscope has been fulfilled."63 Contemporaries referred to this instrument as the Cameron-Schindler flexible gastroscope. 64 Cameron also produced a new instrument, the "omniangle" flexible gastroscope in 1943. 65 This gastroscope featured a mirror (in place of the usual prism) that could be flipped within the instrument's tip, so as to scan the stomach interior without moving the gastroscope. The Cameron omniangle soon proved quite popular and became the standard instrument for gastrointestinal endoscopy at clinics around the country.66 One ofthe most talented individuals associated with Cameron at this time was Louis Streifeneder, who did much of the design work with Schindler. For American gastroscopists, Louis Streifeneder's role was broadly similar to that played by Georg Wolf in Germany. He GASTROINTESTINAL ENDOSCOPY

collaborated not only with Schindler, but with several other inventive endoscopists, including A. Ray Hufford, Eddy D. Palmer, and Donald T. Chamberlin. Streifeneder struck out on his own at the close of the World War II, forming the Eder Instrument CO. 67 In 1945 the company introduced its first instrument, the Eder semi-flexible gastroscope, model 105. According to A. Ray Hufford, it was lighter, more flexible, smaller in diameter (10.5 mm in flexible section), and, overall, provided a better image than either the SchindlerWolf or the Schindler-Cameron instruments. 68 With the success of this gastroscope behind him, Louis Streifeneder went on to help endoscopists improve upon basic instrument design. The Eder-Chamberlin controlled tip gastroscope, the American version of the Hermon Taylor gastroscope, is among Eder's most notable technical achievements of the late 1940s. Its precursor, introduced in 1941 by London surgeon Hermon Taylor and built by the Genito-Urinary Manufacturing Company, featured a controllable flexible portion of the gastroscope. 69 This modification facilitated a more complete view of the stomach, bringing into sight areas that had been blind spots using conventional flexible gastroscopes. With this improvement came problems, however. The mechanism for moving the flexible portion of the gastroscope increased its diameter (to over 15 mm) and the rigid portion was longer than was the case for Schindler-designed instruments. Taken together, these design changes spelled trouble. Schindler condemned the instrument, while Edward B. Benedict called for reports on its use before issuing a similar indictment. 7o Streifeneder overcame their objections when he and Donald T. Chamberlin introduced an American counterpart of the Hermon Taylor gastroscope in 1949. The Eder-Chamberlin gastroscope also featured a controlled tip, but did not exceed 11 mm in diameter. 71 Metro-Tec of Chicago became a manufacturer of gastroscopes for a period beginning in 1944, when Schindler had the company build a modified version of his instrument. 72 This firm, a manufacturer of picture frames, geared up to produce just this one gastroscope by adding an instrument department under the direction of Edwin F. Bicknell. Production stopped in 1959 when Cameron acquired the company, making Bicknell head of Cameron's research and development department. 73 American Cystoscope Makers Incorporated (ACMI) was the oldest of the group, having been founded by Reinhold Wappler in 1900 and incorporated in 1908. 74 It got a start, as the firm's name indicates, with the introduction ofthe Otis-Brown cystoscope, which was patterned on the Nitze- Leiter model and produced by Wappler in cooperation with urologists William K. Otis and F. Tilden Brown. 75 By the late 1940s the VOLUME 37, NO.2, 1991

company had added gastrointestinal endoscopy to its product line, featuring the ACMI semi-flexible examining gastroscope and the semi-flexible infant gastroscope. 76 ACMI soon offered other new instruments, including esophagoscopes and operating or biopsy gastroscopes, as described below. 77 Esophagoscopes of the semi-flexible era

In the late 1940s esophagoscopy became the province of gastrointestinal endoscopists for the first time. Until about 1947 esophagoscopy had been practiced almost exclusively by specialists in otolaryngology, individuals who were adept in the passage of the instrument but who were not particularly interested in diseases of the digestive tract. Over time esophagoscopy, as closely allied as it was to the surgically inclined specialty of laryngology, came to be regarded as a surgical procedure. Gastroenterologists also feared that by using the rigid instruments then in vogue they might perforate the esophagus or inflict other injuries reminiscent of those encountered in the days before Schindler's semi-flexible gastroscope. Instruments developed by Boros, Schindler, and Hufford in the late 1940s did much to alleviate these fears and thus brought esophagoscopy into wider practice by gastrointestinal endoscopists. Edwin Boros introduced a "flexible esophagogastroscope" at the annual meeting ofthe American Medical Association in Atlantic City, New Jersey in June 1947. 78 Boros' esophagoscope was not truly flexible, despite the appellation he gave it; in fact it was patterned on the rigid esophagoscope of Chevalier Jackson. 79 What rendered the instrument flexible, hence facilitating its insertion, was that it ended in a soft, pliant tip of spiral coiled meta1. 80 With this feature, introduction of the esophagoscope could proceed in much the same manner as for the semi-flexible Schindler gastroscope. Once in place, the esophagoscope could be straightened by a metal rod and, after insertion of a separate light-carrier, inspection could begin. According to Boros, this instrument facilitated a view of the esophageal lumen not attainable with the gastroscope. Boros also observed that, "moreover, neither biopsy, removal of foreign bodies nor local treatment can be carried out with the use of the [gastroscope 1 lens system."81 By the end of 1948 he claimed, "... it has been possible to effect safe, easy, successful esophagoscopies in over 350 patients."82 Despite Boros' conviction that he had devised a practical, safe esophagoscope, his model was considered obsolete within a few years. 83 Several competing esophagoscopes, with designs based on different principles, were soon available. 84 The most widely used models were those of Rudolf Schindler and A. Ray Hufford. Rudolf Schindler began work on designing a new 839

esophagoscope in 1943 but the instrument did not take its final form until some years later. 85 As Schindler saw it, the designer of an esophagoscope faced two possibly contradictory criteria. The introduction of the instrument had to be made easier and safer, which called for a slender diameter. He set the upper limit at 11 mm, the diameter of his 1922 rigid gastroscope. However, an instrument with this small a diameter did not afford a satisfactory image. As Schindler explained, If the diameter of an esophagoscope is reduced so much [to 11 mm] the image observed becomes very small. Clear visualization and interpretation is not easy even with larger instruments and may be still more disturbed by secretion or bleeding. The internist, accustomed to the large brilliant pictures of cystoscopy and gastroscopy, often experiences diagnostic difficulties if confronted with the small esophagoscopic pictures. If a diameter of 11 millimeters or less is chosen the picture becomes too small. Yet, such a diameter is desirable not only from the viewpoint of safety but also for the comfort of the patient. Therefore, construction of a magnifying optical apparatus seemed desirable. 86

Confronted with these opposing design factors, Schindler and instrument makers at ACMI had to devise an esophagoscope that was both simpler to introduce and conveyed large, clear images. As first introduced in 1948, the Schindler esophagoscope consisted of a rigid hollow tube and an obturator with a flexible, rubber tip.87 The finger-like tip facilitated "blind" or palpatory introduction, a procedure already familiar to endoscopists with experience using a Schindler gastroscope. After introducing the outer tube of instrument, an inner tube carrying the optical system was inserted. 88 In this respect, Schindler's instrument resembled, and in fact was largely patterned upon, the Henning esophagoscope. This instrument, introduced in 1932, enjoyed little following in this country; a complicated arrangement to keep the lens clear proved its downfall. 89 To protect the lens Schindler devised an alternate arrangement, consisting of a clamshell-like cover; this would be closed upon insertion, and then the two half shells would open to facilitate clear viewing. It proved to be an imperfect solution to the problem, so Schindler resorted to use of a telescope optical system. 90 By the time that he had made this modification, most gastrointestinal endoscopists in the United States were already turning to the Eder-Hufford esophagoscope. The Eder-Hufford esophagoscope shared many of the same features found in the Boros and Schindler instruments, but combined them in a way that rendered it a more serviceable and popular endoscope. In 1943 A. Ray Hufford began experimenting with various optical systems and forms of obturator for use with a rigid esophagoscope. 91 By 1946 he developed a 840

prototype esophagoscope and began conducting preliminary clinical trials. Experimentation and refinement over the next 2 years, in collaboration with Louis Streifeneder of Eder Instrument Company, brought Hufford's original design to the point of completion. 92 As introduced in its commercial form in 1949, the Eder-Hufford combined a rigid endoscope tube (like Schindler's esophagoscope) with an obturator that ended in a flexible metal coil (like the end of Boros' tube) tipped with a rubber finger (Fig. 19). By increasing the flexibility of the end and tip of the instrument, it became possible to introduce the esophagoscope in much the same manner as one would a Schindler semi-flexible gastroscope. As Hufford noted, "... the length and flexibility of the obturator simulates that of the flexible gastroscope.... "93 Among American gastroscopists, this aspect of the instrument's design promoted acceptance of the EderHufford esophagoscope. The only limiting factor at the time of its commercial introduction was the optical system. At the outset, the Hufford-Eder esophagoscope featured an inner lens tube incorporating the optical system; this was soon abandoned in favor of a telescopic optical system, as would happen in the case of the Schindler esophagoscope. 94 The telescopic eyepiece provided x4 magnification and eliminated the problems associated with a lens tube optical system. With the development of the Eder-Hufford instrument, esophagoscopy progressively became a routine part of gastrointestinal endoscopy.95 One interesting consequence of this was a combination of esophagoscopy and gastroscopy in one procedure, called transesophagoscopic gastroscopy. The idea behind this was the desirability of performing both endoscopic procedures with the same instrument, or at least of introducing only one instrument, the esophagoscope, and then passing the other, the gastroscope, through it. Two instruments for this purpose, a semi-flexible transesophagoscopic gastroscope and a rigid trans-

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Figure 19. Eder-Hufford esophagoscope, 1949 [Source: Rudolf Schindler, Diagnostic esophagoscopes for palpatory introduction, Surgical Clinics of North America 37 (1957), 1201, Fig. 307]. GASTROINTESTINAL ENDOSCOPY

EDER-PAUIER TRANS-ESOPHAGOSCOPIC FLEXIBLE GASTROSCOPE

Requested by tile I'rofessioll! Intruducing the new Truns-t:sophaJ.:m'cupic C:I~lroscopc and ils oUhlanding rcalurt'll: l. Dc",ij:tllCd to fit. through our :
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Figure 20. Eder-Palmer transesophagoscopic flexible gastroscope, 1953 [Source: advertisement, Bulletin of the American Gastroscopic Society 5 (1958):28].

esophagoscopic gastroscope, were devised by Louis Streifeneder at the request of Eddy Palmer in 195396 (Fig. 20). Soon after, in 1954, Hufford became a leading proponent of this approach to gastrointestinal endoscopy, which he chose to call "integrative esophagogastroscopy."97 For this he recommended use of the Eder-Chamberlin Model #400 controlled tip semi-flexible gastroscope, which helped the endoscopist to visualize more of the stomach, in conjunction with the Eder-Hufford esophagoscope (Fig. 21). Despite his preference for this instrument, Hufford reminded his colleagues that they would probably need to employ a variety of endoscopes: Since all men and all instruments have definite limitations it is most important to recognize them and to deploy that which we have available so that it can be correlated and integrated for the greatest amount of good and usefulness for which it was intended. It will be the responsibility of the esophagogastroscopist to have the training, experience, and possession of the essential equipment which will enable him to make a complete inspection of the entire esophagus and stomach. 98

suction tube alone was introduced by I. J. Wood in Australia and by J. Tomenius. 99 The methods and suction tubes of Wood and Tomenius did not prevail, however. Benedict's biopsy gastroscopy remained the preferred, if not often used, instrument of choice on into the 1960s. 1oo The idea of the operating or biopsy gastroscope did not originate with Benedict; several years earlier, in 1940, Bruce Kenamore had devised a biopsy forceps for use with the Schindler semi-flexible gastroscope. 101 Kenamore's forceps was not integral to the gastroscope, but instead was clamped onto the shaft of a standard gastroscope (Fig. 22). The principal disadvantage of this arrangement was its potential for mechanical problems. Benedict overcame this by incorporating the biopsy forceps and suction tube within the housing of the gastroscope (Fig. 23). This improvement only served to create another problem; the diameter of Benedict's operating gastroscope was thereby increased to 14 mm. Objections were voiced about the instrument's large diameter and its oval cross-section, both of which made its use more difficult

Instrument ta.hle S<'t up for l.'ndoscopk' l·xmnination. TIlt' instrnlllt'nts fWIIl top (hack of table) to bottom ,1Ft' ,arran~cd as follows.-Edl·r light Wt'i~ht standard Ht'xihh· ~astroscope. Eder·Chumhc-rlin Mudd # 4(~]. (..o . ntrollt·d 8l·xihlc gastw~·(Jpt'. Drainap;e tuheo. Eder.FIt.·xirig:id gl.lstms<.'0pt' and the Edl'r-lIuR'nrd Al'xihll' C"snr.hagos<.'o[>C with flt·:tihle obturator in plat.'(' and tdl'S(''Opc..· attll(.'ht'd. A )t'ns ohtufillor ( or uptional '1St") '''ylll in the fore~round. The rheostat ;'lnd ("ords are to tlU' riJ.:ht.

Figure 21. Selection of instruments for combined esophagoscopy and transesophagoscopic gastroscopy, 1954 [Source: A. Ray Hufford, Integrative esophagogastroscopy, American Journal of Gastroenterology 22 (1954):117, Fig. 1].

a

Biopsy or operating gastroscope

The use of gastric biopsy to confirm visual, or gastroscopic, and roentgenographic diagnoses of esophageal and gastric disorders became a part of gastrointestinal endoscopy in the late 1940s. The idea of obtaining specimens of gastric mucosa for examination was not new, but gastroenterologists had only surgical means available to them. Then, in 1948, Edward B. Benedict introduced the operating gastroscope, an instrument that incorporated a biopsy forceps and suction tube. Shortly thereafter biopsy by VOLUME 37, NO.2, 1991

b

Figure 22. Top and bottom, Kenamore biopsy forceps, 1940 [Source: Rudolf Schindler, Gastroscopy. The endoscopic study of gastric pathology (2nd ed., 1950), 70, Figs. 68, 71, and 69].

841

plained by Benedict, gastroscopic biopsy was most valuable for the differential diagnosis of lymphoma, diffuse carcinoma, and gastritis. 107 Diagnosing gastritis by means of biopsy was perhaps the most significant of the three; between 1932 and 1948 gastroscopy had been accepted as the only means of diagnosing gastritis by most investigators. Now, with the advent of the operating gastroscope, endoscopists had an important additional diagnostic tool. Gastroscopic biopsy compelled gastrointestinal endoscopists to reevaluate the meaning and terminology of "gastritis," which had been a subject of much disagreement for some time. For some gastrointestinal endoscopists, the biopsy or operating gastroscope became an important adjunct to the gastroscopic examination, superior to the suction biopsy.108 Recognizing the advantages and limitations of the procedure, endoscopists did not make it a routine part of their protocol, however. 109 Obtaining biopsy material would become a simpler and more frequent practice only with developments in fiberoptic instrumentation and gastroscopic brush cytology in the 1970s. 110 .~"""A't

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Figure 23. Benedict operating or biopsy gastroscope, 1948 [Source: advertisement, Bulletin of Gastroscopy and Esophagoscopy 6 (1959):23].

for endoscopist and patient alike. 102 C. Wilmer Wirts, discussing the instrument in 1950, observed that "as to technic, ...we certainly have had to consider the use of the operating gastroscope, something totally different from the standard flexible gastroscope of the Schindler type... We find the size of the instrument, and the bayonet shape, when rotated in the esophagus, increases the discomfort and to a certain extent permits the regurgitation of air."103 Despite these initial design problems, Benedict contended that the advantage his instrument offered, of providing diagnostic certainty in many situations where conventional gastroscopy fell short, more than justified its use. 104 Biopsy aroused considerable debate among gastroscopists in the early 1950s. Enthusiasm for gastric biopsy led some to advocate its routine use in every gastroscopic examination; to do otherwise, they argued, was irresponsible. lOB Benedict, after considerable experience, concluded that while gastroscopy itself is not a routine diagnostic procedure and "should be reserved for difficult problems in differential diagnosis," he nonetheless concluded that "gastroscopic examination is not complete unless the gastroscopist has some means of biopsy readily available."106 As ex842

Endoscopic photography

Gastroscopic photography also came of age during the Schindler era, with the first acceptable color photographs of the inside of the stomach being taken in 1937. 111 The earliest attempts at intragastric photography date to 1898 when Lange and Meltzung introduced a small camera into the stomach, but success ultimately lay in the development of external, not internal cameras. Photography through the gastroscope, from the earliest attempts in the 1920s through the first truly successful effort by Henning and Keilhack in 1937, was limited to animal subjects and as yet had little clinical application. This changed after 1948, when Harry L. Segal and James S. Watson of the University of Rochester introduced an apparatus for taking color transparencies through a semi-flexible gastroscope. 112 Their efforts were, by their own explanation, stimulated by the advent of the Wolf-Schindler semi-flexible gastroscope and advances in color photography over the previous decade. The key to the success of their efforts resided in their outstanding technical assistance: Segal and Watson benefited from the cooperation of the Carl Zeiss Company, the Eastman Kodak Company, and the Bausch & Lomb Optical Company. These companies improved the light transmission capability of the gastroscope optics, enhanced the light power supply, and developed a synchronizing unit so that changes in the light supply, gastroscope prism, and camera shutter would occur in unison. With this photographic installation, Segal and Watson reported that 61 % of the exposures yielded good color reproduction. GASTROINTESTINAL ENDOSCOPY

THE FIBEROPTIC ERA, 1957 TO PRESENT Early development of the fiberoptic gastroscope by Basil Hirschowitz

Fiberoptic technology transformed gastrointestinal endoscopy in ways even more profound than its most ardent advocates might have imagined. Endoscopic procedure became more safe and hence more commonplace, and virtually no region of the gastrointestinal tract remained unexplored. Moreover, the expanding diagnostic capabilities of endoscopy have in recent times been complemented by new therapeutic applications. Fiberoptic endoscopy entered the realm of practicality in February 1957 when Basil Hirschowitz passed the first prototype instrument down his own throat and, a few days later, down that of a patient (Fig. 24). The fiberoptic era itself dawned later that same year when Hirschowitz demonstrated his new gastroscope, which he called the "fiberscope," at a meeting of the American Gastroscopic Society. Members of the society had been alerted to the potential significance of Hirschowitz's instrument by their president, John Tilden Howard: I shall forego my prerogative of boring you with a presidential address, so that Dr. Hirschowitz may, at half past eight o'clock, tell you about what I understand to be a new principle of gastroscopy. I hear that fiberglass conducts light around corners and that Dr. H. has used this material in a new type of gastroscope. 1 13 As announced by Howard, Hirschowitz and his colleagues, Larry Curtiss and Marvin Pollard, demonstrated the instrument to fellow endoscopists on May

16, 1957, at their meeting in Colorado Springs. 114 Hirschowitz described briefly the design and construction of the fiberscope and then enumerated the advantages it offered over conventional gastroscopes. These included (1) complete flexibility, which made it easier on the patient and safer to use; (2) better light transmission, an especially useful property for photography; and (3) greater range of viewing, including the duodenum. Hirschowitz did not relate the key innovation that made the fiberscope work: the development by Larry Curtiss of a method to optically insulate the individual fibers that made the light-transmitting bundle. Without this, the Hirschowitz fiberscope would have been no more successful than any of its failed precursors, beginning with that of Heinrich Lamm and Rudolf Schindler some 50 years earlier. ll5 Fiberscope development by Hirschowitz began in 1954 when he was on a fellowship with Marvin Pollard at the University of Michigan. After reading an article by Hopkins and Kapany, which described recent advances in fiberoptics, Hirschowitz visited the authors in Britain and discussed the application of fiberoptics to endoscopyYs Over the next. 3 years, Hirschowitz and his associates in Ann Arbor, physicist C. Wilbur Peters and his student, Larry Curtiss, devised a makeshift, but effective method of drawing out their own glass fibers. In late 1956 Curtiss succeeded in producing the glass-coated fiber with the optical qualities required for the fiber bundle of a gastroscope. Following the demonstration of the new fiberscope incorporating this advance, Hirschowitz began to consult instrument makers to see if any might produce the fiberscope commercially. In this country, Eder Instrument and American Optical balked, as did GenitoUrinary Manufacturing Ltd. in Britain. Then, in the summer of 1957, ACMI expressed serious interest. For the next 3 years ACMI worked toward the goal of putting a fiberscope on the market. Finally, in October 1960, Hirschowitz received the first production model. In a somewhat modified form, as the ACMI 4990 Hirschowitz fiberscope, this instrument was the subject of an article by Hirschowitz in Lancetll7 (Figs. 24 and 25). There he confidently asserted that "the conventional gastroscope has become obsolete on all counts."1l8 Commercial introduction and subsequent development of fiberoptic instruments

Figure 24. Basil Hirschowitz examining patient with the fiberscope, 1961 [Source: Basil I. Hirschowitz, Endoscopic examination of the stomach and duodenal cap with the fiberscope, Lancet 1 (1961 ):1 075, Fig. 2].

VOLUME 37, NO.2, 1991

Although Basil Hirschowitz's prediction was ultimately correct, the disappearance of the conventional endoscope and its replacement with the fiberscope proceeded somewhat slower than Hirschowitz foresaw. In the ranks of endoscopists, many adhered to the conventional gastroscopes. A report in November 1958 offered what would be the most frequently raised points of comparison between the fiberscope and the 843

conventional gastroscope; ostensibly, the former facilitated a better view of the duodenum, while the latter afforded a better quality visual image. As stated by Robert S. Nelson, "it is at present conceded that vision in the duodenum with the Fiberscope will probably never be as clear as through the gastroscope in the stomach, but a duodenal ulcer has been reportedly visualized, and there is considerable optimism regarding the future development and practical use of the instrument."119 In his comments upon Nelson's paper, Marvin Pollard, Hirschowitz's associate at Ann Arbor, voiced a note of caution against over optimistic expectations as to what the new instrument could achieve: The endoscopy material of Dr. Nelson is excellent. A word of modification regarding the Fiberscope should be added. The information came from our unit that it was possible to see and to photograph through the Fiberscope. Whether or not we ever actually saw into the duodenum has not been authenticated....Much more has to be done in order to make it a usable instrument. In this respect, several technicians at the present time are working on its perfection, and possibly developments of importance will soon be reported. 12o Even some staff of the instrument's maker, ACMI, did not foresee that the fiberscope would render optical endoscopes obsolete. ACMI's John Hett, in his presentation on fiberscope design at the 1958 meeting of the American Gastroscopic Society, voiced a positive, though still tentative prediction for the universal use of the new instrument: We believe that these developments [in fiberoptic technology] rendered possible the design and construction not only of gastroscopes and duodenoscopes, but also of ureterscopes, choledochoscopes, proctoscopes and bronchoscopes. Because of the inherent limitation in definition of the fiberscope we believe that the use of fiberscopes will be limited to those situations where a conventional optical system is not possible. 121

such as Cameron, Eder, etc."124 The effect was that they, too, would be compelled to introduce their own fiberoptic instruments, or face the prospect of being eclipsed. Eder Instruments, for example, began work on a fiberoptic gastroscope and anticipated making delivery on a finished instrument by November 1963. 125 Ironically, the flexible fiberscope, first marketed as ACMI's Hirschowitz FO-4990 gastroduodenoscope, did not prove to be nearly as useful for inspection of the duodenum as was at first hoped (Fig. 25). Some found that "...the instrument is not really suitable for duodenoscopy.... In its present form the fiberscope is too big and bulky.,,126 A 1966 report on a series of 1000 fiberscope examinations concluded that "the duodenum was not entered with certainty in any examination."127 One of the most frequently voiced criticisms regarding the Hirschowitz Fiberscope was that it was perhaps too flexible. While flexibility was a definite asset during the process of insertion, experience soon showed that this was not always the case once inside the stomach. In a very few cases flexibility led to instrument impaction, as the instrument tip doubled back on itself to form a J within the stomach. 128 Fortunately, this occurred only in rare in-

a new and dramatic advance in gastroduodenal visualization

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Over the next few years the fiberscope had to be proven convincingly superior to supplant the conventional gastroscope. In 1962 and 1963, reports comparing the two technologies indicated that "no significant difference in the diagnostic accuracy was noted."122 Even as late as 1969, a major text in gastroenterology devoted several pages to a relative comparison of conventional and fiberoptic gastroscopes. 123 Client loyalty to the instrument companies that made endoscopes was one factor contributing to the survival of conventional gastroscopes and esophagoscopes. Arthur M. Olsen, as Secretary-Treasurer of the A/S/G/E, saw that the new fiberoptic technology posed a challenge. In a memorandum to the governing board of the A/S/G/E in March 1961, Olsen stated that "it is conceivable that this instrument [the fiberscope] may make our present gastroscope obsolete. One wonders what effect this may have on companies 844

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stances. Less life-threatening and far more common was the difficulty of examining the duodenum. The instrument either needed to be somewhat stiffer or to have a controllable tip, according to a 1962 report in Lancet by Robert Kemp:

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The excessive flexibility means that one cannot control the position of the fiberscope head or push it directly forward. Rotation is, of course, possible, but the instrument naturally lies in the stomach along the greater curvature; hence pressure from above is as likely to increase the length of the bend as to advance the tip. 129

Kemp suggested the incorporation of a controllable tip that could be manipulated from the viewer's end of the instrument, as was already done on some semiflexible conventional models, like the Eder-Chamberlin and Hermon Taylor gastroscopes. 130 Addition of a controlled tip was also the single most called for improvement in a survey of American gastroscopists conducted by Arthur M. Olsen. 131 The controllable tip, and other desirable modifications made to the fiberoptic gastroscope, would soon give the instrument an incontestable advantage over conventional semi-flexible gastroscopes (Fig. 26). Fiberoptic endoscopes finally came of age after 1966 and the early 1970s witnessed a series of significant design changes that assured its widespread acceptance among endoscopists. John F. Morrissey observed that the most important change introduced in this period was "the conversion of the forward-viewing fiberesophagoscopes into panendoscopes. 132 Hirschowitz had first introduced a fiberoptic esophagoscope, made by ACMI, in 1963 and Philip A. LoPresti modified this instrument in 1964 to create the foroblique fiberoptic esophagoscope 133 (Fig. 27). In addition to altering the angle of vision, LoPresti incorporated a channel for suction and air or water to keep the lens clear. Contemporaneously, instruments by Olympus and Machida in Japan featured similar changes and added a short controlled tip. The Olympus fiberoptic esophagoscope (model EF), introduced in 1968, effectively displaced the gastrocamera, as will be discussed below. From that point on, fiberoptic gastrointestinal endoscopes were developed with even greater rapidity, as American and Japanese manufacturers leap-frogged past one another with new instrumental advances. By 1971 instruments had been lengthened to 105 cm (Olympus model GIF), so that the duodenum could be routinely visualized; four-way controlled tip was introduced (ACMI model 7089 P), tip deflection was increased to 180 degrees (ACMI model 7089 J), and the so-called "masterscope," through which a smaller (7 mm) fiberscope could be passed for either diagnostic or surgical procedures, had been introduced. 134 William Haubrich, recalling this period of instrumental ferment, observed that "improvements in endoscopic design were so numerous and rapid during the early VOLUME 37, NO.2, 1991

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1970s that one could hardly purchase a new instrument and become acquainted with its use before that instrument was rendered obsolete by a new model."135 The range of technical developments in gastrointestinal endoscopy was so extensive across a broad front that John F. Morrissey was prompted to claim that "I think we are approaching a plateau in instrument development."136 This conclusion may have been premature, and subsequently shown to be mistaken, but nonetheless conveyed the amazement that Morrissey and his fellow gastrointestinal endoscopists felt when surveying the recent instrumental development of their field.

Gastrocamera

The gastrocamera became a part of endoscopic practice in the United States in 1962, having been developed in Japan after 1950 and introduced to endoscopists here in 1958 at the First World Congress of Gastroenterology in Washington, D. C. l37 John F. Morrissey, who first saw the gastrocamera in 1962 845

A Single Instrument for Both Esophageal and Gastric Visualization

LoPRESTI DIRECT VISIO GASTRO-ESOPHAGEAL PANENDOSCOPE

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second factor, could not be eliminated by any instrumental design changes, however. This, according to Bernard Schuman, was an almost insurmountable obstacle to its adoption, especially among endoscopists impatient for instantaneous documentation. 140 The gastrocamera was ultimately superceded by fiberoptic instruments. 141 Improvements in the quality of the image and lighting advanced markedly in this period. Endoscopists soon determined that it was possible to simply attach a 35-mm camera to the endoscope's eyepiece, and thus obtain photographs that rivaled those of the gastrocamera. Within a short period, the gastrocamera was rendered obsolete, like conventional optical lens instruments, falling victim to fiberoptics.

ERCP

The development of fiberoptic instrumentation ultimately led to new applications of gastrointestinal endoscopy that would have been barely conceivable during the era of semi-flexible instruments. The greatly increased flexibility of the gastrointestinal fiberscope, combined with the controllable head, finally

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Figure 27. ACMI LoPresti panendoscope. 1970 [Source: advertisement, Gastrointestinal Endoscopy 16 (1970):129].

when Yoshio Hara visited the University of Wisconsin, quickly became the leading proponent of the gastrocamera in this country. He described the Olympus gastrocamera as follows:

World's only intragaslric camera wilh in leg,., fiberscope for simultaneous viewing and hOlography. • Sha'P"I deftntffon. 1'he' umer" k WIthin the $Ubjea. not f'Xtemoal • New hIahet (l2.SX) INIlnifl(itiOn.

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lamp, air valve, and film capsule, which was attached to a control unit by means of a 75cm vinyl-covered tube. The camera lens had an 80 degree angle of view, and the tip could be deflected upward or downward 35 degrees to increase further the field of view. A series of 32 5-mm color transparences was obtained at each examination. 138

The gastrocamera yielded excellent photographic images 139 of the stomach but its widespread acceptance was impaired by at least two factors. First, the endoscopist could not directly view what was being photographed and, second, developing the film took time. The first of these impediments was overcome in 1963 by Olympus Corporation of America, who produced a gastroscope (model GFT and GFTA, the latter with movable tip) that featured both fiberoptics and gastrocamera within one instrument (Fig. 28). Time, the 846

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facilitated direct vision of the interior of the duodenum. Once into the duodenal bulb, it became possible to view the papilla (or ampulla) of Vater and the orifice of the pancreatic duct, as reported by W. C. Watson of Glasgow in 1966. 142 Watson concluded that "endoscopic examination of the ampulla of Vater could be helpful in the diagnosis of biliary and pancreatic disorders," but did not elaborate upon the technique. Nonetheless, Watson's report prompted others to develop a dramatic new diagnostic application of endoscopy: endoscopic retrograde cholangiopancreatography, or ERCP. Pancreatography, achieved by the injection of radiopaque material into the pancreatic duct, was a comparatively new technique at the time. Moreover, as a surgical procedure requiring the sectioning of the sphincter of Oddi for placement of a cannula in the pancreatic duct, its clinical use could not be routine or widespread. 143 With the successful peroral cannulation of the papilla of Vater by Rabinov and Simon in 1965, which rendered the technique a non-operative procedure, this situation changed. Rabinov and Simon monitored and guided the cannula to its intended site with the assistance of television fluoroscopy. They admitted that since "the ampulla is ordinarily not identified fluoroscopically even with barium," they had to probe blindly for their target. 144 Endoscopy offered a remedy for this problem and was soon put to use. In 1968 William S. McCune and his colleagues at George Washington University fashioned a makeshift instrument for endoscopic cannulation of the pancreatic duct. They attached a cannula housing onto an Eder fiberoptic duodenoscope, which permitted visualization of the papilla of Vater during cannulation. Despite this advantage over previous methods, they acknowledged that "the technic is not easy and requires considerable experience. We have been able to pass the instrument into the duodenum in not more than 50 per cent of individuals examined."145 Much greater facility in the use of the technique came with improvements in the instrument, including four-way tip control and a lever for directing the cannula, which were incorporated into a production versions available from Machida (model FDS) and Olympus (model JF and JFB-2) after 1970. Japanese endoscopists Itaru Oi and K. Takagi assisted these companies in instrument development and contributed much to the subsequent adoption of the technique through publication. 146 Their work, and that of other leading endoscopists in Japan, prompted several endoscopists in this country to add ERCP to their repertoire. In particular, Jack A. Vennes and Stephen E. Silvis became vocal advocates ofERCP in the United States, publishing in 1972 the record of their first 80 attempts at cannulation. 147 Vennes would later receive the Schindler Award of the A/S/G/E in recognition of his VOLUME 37, NO.2, 1991

part in advancing this new domain of gastrointestinal endoscopy.148 Initially, ERCP was intended as a purely diagnostic tool. In this regard, it proved an effective diagnostic aid for biliary tract obstruction, jaundice, problems subsequent to biliary surgery, recurrent pancreatitis, and obscure epigastric pain. 149 The technique was not without its complications, however. The A/S/G/E conducted a survey of its members in 1974 and concluded that the total complication rate was 2.2%, considerably higher than for other endoscopic procedures. 15o The survey results pointed to the need for assessing prophylactic measures, such as administration of antibiotics in cases of sepsis and control of pressure of injection to reduce the likelihood of pancreatitis. A survey documenting 10,435 procedures published the following year revealed that acute pancreatitis and cholangitic and pancreatic sepsis were indeed the most common post-endoscopy complaints, followed by instrumental injuries, drug reactions, and aspiration pneumonia. 151 Criticism of the technique was balanced by its demonstrated usefulness in diagnosing malignancies of the biliary tract and pancreas. 152 The increasing use and acceptance of ERCP in turn gave rise to therapeutic variants of the technique in the mid-1970s. The most striking of these were endoscopic sphincterotomy (or papillotomy), the wire cutting of the papilla of Vater by means of electrocoagulation and non-surgical removal of biliary calculi by endoscopic means. Clearing ducts blocked by calculi had been achieved choledochoscopically in the operating room by a combination of means, including balloon-tipped catheter, back-flushing catheter, basket forceps (in effect, a multiple-wire snare) or Dormia basket catheter, and stone grasping forceps.153 Endoscopists soon found that successful stone removal could be accomplished with the same methods after endoscopic sphincterotomy (or papillotomy), as first reported upon in the United States by Zimmon et al. 154 in 1975. To some endoscopists the therapeutic versions of ERCP have assumed an importance greater than that of its diagnostic capabilities. Developments in ultrasonography and computed tomography have eclipsed, in many circumstances, the usefulness of ERCP for diagnostic purposes alone. As Bernard Schuman observed recently, "it appears that ERCP has diagnostic utility only insofar as it serves as a preliminary maneuver for endoscopic therapy."155 The range of endoscopic therapy has in fact continued to develop significantly over the past decade. Endoscopists have added new procedures for removal of even large stones, by means of chemical dissolution and mechanical, electrohydraulic or pulsed dye laser lithotripsy, and bile duct cancer treatment has been undertaken with iridium-192 wire placement. 156 847

Colonoscopy

Colonoscopy did not begin with the advent of the fiberscope, but its development over the past 25 years has been more rapid and dramatic as a consequence of fiberoptic instrumentation. Simple anal and rectal specula were a part of the surgeon's instruments found preserved in the ruins of Pompeii, and the form of these instruments changed little before 1900. The long (30-cm) rigid sigmoidoscope was introduced in this country by Howard A. Kelly of Johns Hopkins University in 1894, and referred to as "Kelly tubes" by his contemporaries. For illumination, Kelly utilized the light of an ordinary lamp reflected off a head mirror and down the tubular body of the sigmoidoscope. 157 Rigid sigmoidoscopes with integrated electric lighting systems, developed by James P. Tuttle of New York, in association with the Electro-Surgical Instrument Company of Rochester, have been used since the turn of the century.158 The most widely used of the rigid instruments include the Strauss proctosigmoidoscope manufactured by George Wolf of Berlin and the Lynch proctosigmoidoscope of Electro-Surgical Instrument Company.159 The rigid sigmoidoscope served well for the examination of the first 20 to 25 cm of the bowel and, indeed, this instrument still has utility for examining the rectum in some circumstances. Although H. C. Hoff had succeeded in passing a flexible tube as far as the cecum in 1928, penetration that far was not practicable with endoscopes before the 1960s. 160 In the late 1950s F. Matsunaga attempted to visualize the colon with a modified gastrocamera, but this technique met with only limited success. 161 Development of fiberoptic sigmoidoscopic and colonoscopic instruments began in the United States and Japan after 1960. In Japan, Machida and Olympus developed prototype models in the early 1960s and introduced market versions of these instruments in 1965, with prominent roles being played by Oshiba, Wanatabe, Niwa, and Kanzawa. In that same year Luciano Provenzale and Antonio Revignas in Sardinia, Italy performed the first total colonoscopy. They achieved this by having a subject swallow the end of a piece of polyvinyl tubing, which ultimately emerged from the anus. To this they attached a side-viewing Hirschowitz gastroscope and gently pulled it through the entire colon to the cecum. 162 While dramatic in itself, this technique was hardly suitable for routine endoscopic examination of the colon; the gastroscope would have to be adapted for the purpose of sigmoid and colon exploration, taking into account the particular contours to be traversed. In the United States, Robert Turell devised a fiberoptic illumination system used on rigid sigmoidoscopes produced by ACMI and was initially hailed as a pioneer in the application of fiberoptics to colonoscopy.163 In the report on this instrument, published in 848

1963, Turell also featured a "flexible fiber optic coloscope," which was little more than an ACMI Hirschowitz fiberoptic gastroscope adapted for use as a colonoscope. 164 Turell remained circumspect about the clinical value of the flexible instrument, commenting in 1967 that "at the present time the flexible fiber optic coloscope is undergoing extensive studies and, unlike the rigid sigmoidoscope, is not yet ready for routine clinical use."165 Bergein F. Overholt espoused a far more sanguine view of the instrument's future and this confidence sustained his truly pioneering design efforts, beginning with the development of a flexible fiberoptic sigmoidoscope with the Eder Instrument CO. 166 Overholt, using this instrument in its prototype form, found that patients experienced far less discomfort during examination. This was an especially welcome outcome, for patient discomfort had been Overholt's overriding concern when he first decided to try the more flexible fiberoptic instruments. Importantly, it also permitted deeper entry into the sigmoid and descending colon. In May 1967 Overholt presented the first series of 40 patients to fellow endoscopists at the A/S/G/E meeting in Colorado Springs, Colorado. 167 By 1969 Overholt could report favorably on the utility of the newly introduced Olympus colonoscope (model CF_SB).168 (The longer versions of this instrument models CF-MB/LB, introduced in 1970, incorporated four-way tip deflection for the very first time in any fiberoptic endoscope. 169 ) In 1970 P. R. Salmon and his colleagues in England confirmed Overholt's experience with the Olympus instrument. l7O The following year, Overholt cooperated with ACMI in the development of their version of the flexible sigmoidoscope. Soon after these initial reports by Overholt and Salmon, several endoscopic units adopted the new fiberoptic instruments and documented their experience with them. Wolff and Shinya used both a short (CF-SB; 86 cm) and a long (CF-LB; 187 cm) version of the Olympus instrument in their first 241 "colonfiberoscopy" examinations, encountering no complications, while Berci, Panish, and Morgenstern reported a comparably favorable record during their first 210 endoscopic cases. l71 ACMI soon had its own improved version ready for the market; by the close of 1971 it introduced the "single lever polydirectional coloscope."172 Indeed, according to Overholt, "it was not until American Cystoscopy Makers Inc. (ACMI) of New York entered the field in the late 1960s that colonoscopy began to flourish."173 From this point on, fiberoptic sigmoidoscopy and colonoscopy steadily became important features of gastrointestinal endoscopy. Evidence of the superiority of the fiberoptic sigmoidoscope over rigid instruments was presented in 1977 by Bohlman et al.,174 who conducted a trial of sigmoidoscopes, rigid and GASTROINTESTINAL ENDOSCOPY

flexible fiberoptic, to compare the patient tolerance, distance of inspection, procedure time, and diagnostic yield of the two instruments. In this trial they employed an Olympus fiberoptic sigmoidoscope (model TCF, introduced in 1976; 60 em) and they concluded that "the results of this study demonstrate definite superiority of the flexible instrument." In particular, there was a dramatic increase in diagnostic yield, owing to a combination of design features. This advantage was sufficiently compelling to provide a mandate for the adoption of the instrument. If the diagnostic potential of the fiberoptic sigmoidoscope has not been fully exploited, it is not because it failed to prove demonstrably "better" than the rigid sigmoidoscope. Fiberoptic sigmoidoscopy, as a procedure, has been effectively complemented by total fiberoptic colonoscopy. The compelling need for the colonoscope was, according to Bohlman and his colleagues, "because colon cancer remains the most common form of internal cancer in America today with 100,000 new cases diagnosed yearly and with 8% to 15% of the adult population harboring colonic polyps, it is imperative that newer diagnostic tools be made available which will allow the physician to diagnose these problems at an earlier, curable stage."175 Over time, colonoscopy proved to be not only an extremely useful diagnostic procedure, but also a safe technique, as confirmed in three published studies from 1975 to 1979 documenting nearly 75,000 cases. 176 The therapeutic potential of colonoscopy became apparent almost immediately with the development of improved colonoscopes. In 1971 William 1. Wolff and Hiromi Shinya inaugurated removal of colonic polyps with a wire loop snare in the biopsy channel of a fiberoptic colonoscope. 177 By mid-1972 they could report having performed over 300 polypectomies with very few complications and no mortality. In the hands of a competent, experienced endoscopist, Wolff and Shinya asserted, the technique could eliminate the need for surgery or laparoscopy and therapy could follow immediately upon the heels of diagnosis. However, Robert Turell and Richard H. Marshak, a radiologist, expressed the opinion that colonoscopic polypectomy was being irresponsibly promoted by its overly enthusiastic adherents and consequently performed far too frequently.178 They claimed that the dangers of the procedure-significant bleeding, perforation, and potentially fatal intracolonic gas explosions-were being down-played by "a few who are publicizing coloscopy aggressively." William 1. Wolff, one of those "few," sprang immediately to the defense of the procedure, indicating that at his endoscopic unit over 1600 procedures had been performed without complication. 179 Moreover, as Wolff concluded, "colonoscopy, or 'coloscopy,' will find its proper level in medicine based on its intrinsic merits and not on the VOLUME 37, NO.2, 1991

opinions of those who have been unable to master its technic or regard it as a threat to their diagnostic acumen." Wolffs assertion was borne out by experience. A survey of more than 6200 polypectomies conducted by the A/S/G/E in 1974 found no mortality, a very low level of complications overall, and no reported explosions of colonic gas. 180 Laparoscopy

Laparoscopy did not become an accepted part of gastrointestinal endoscopy in this country until the 1960s. Long before that time this technique had been used for intra-abdominal inspection, however. Dimitri Oskarovich Ott, using a gynecologist's head mirror and speculum, performed the first documented laparoscopy in 1901. 181 Ott, a Russian gynecologist, called the procedure "ventroscopy," only the first of many terms used to describe it over the years. Far more influential in the early development of laparoscopy was Georg Kelling, of Dresden, who is generally credited with having introduced it as a gastrointestinal procedure. In 1901 Kelling demonstrated the technique, which he termed "Koelioskopie," by examining the abdomen of a dog with a Nitze cystoscope. 182 Later, in 1910, Kelling performed laparoscopies on human subjects. Significantly, he made the technique both practicable and safe by refining the detailed aspects of the pneumoperitoneum procedure; specifically, he utilized a separate needle to produce a pneumoperitoneum with filtered air. By the time Kelling introduced these technical advances, several other Europeans were utilizing the technique as well. Chief among them was Hans Christian Jacobaeus, who coined the term "laparoscopy." His 1910 report, containing 45 cases, demonstrated both the clinical practicality and diagnostic utility of laparoscopy.183 By means of laparoscopy, Jacobaeus asserted, one could confirm diagnoses of cirrhosis, metastatic tumors, tuberculous peritonitis, and Pick's disease. The first attempt to perform laparoscopy in the Untied States took place in 1911, as reported by Bertram M. Bernheim at Johns Hopkins University.184 Subsequent diffusion of the procedure did not take place for two decades, however. One of the principal impediments was instrumental; almost all early laparoscopies were performed with the cystoscope, which limited the angle of vision to 90 degrees. The forward-viewing instrument, introduced around 1927 by Kremer and modified in 1929 by Kalk, increased viewing angle to 135 degrees. 185 The laparoscope would remain essentially the same for the next three decades, with only minor refinements and changes. In the 1930s John C. Ruddock and Edward B. Benedict became the most vocal proponents of laparoscopy in North America. Ruddock played the larger role, redesigning existing instruments for use in lapa849

roscopy and publishing his results beginning in 1934. 186 Working with ACMI, Ruddock modified the McCarthy cystoscope and added the "foreoblique visual system." By 1937 Ruddock could report on over 500 cases using the "peritoneoscope," his version of the laparoscope.1 87 He demonstrated that the instrument greatly enhanced diagnostic accuracy (91.7% with the peritoneoscope vs. 63.9% without peritoneoscopy) without necessitating the more costly and traumatic procedure of laparotomy. Edward Benedict, a contemporary of Ruddock, became an ardent advocate of laparoscopy in gastroenterologic diagnosis. Benedict reported that laparoscopy with Ruddock's instrument could be useful in diagnosing liver diseases, ascites, neoplasms of the stomach and colon, in addition to its more widely accepted gynecological applications. 188 Laparoscopy won adherents slowly among gastrointestinal endoscopists, or any other specialists for that matter, until the instrumentation improved. Adequate illumination, a major problem, improved in two phases. In 1952 N. Fourestier and his associates introduced the quartz light rod, which replaced the distal lamp in bronchoscopes of their design. 189 This new method of light transmission, which was applicable to other types of endoscopes, including laparoscopes, supplied brilliant, but cool illumination. Its adoption eliminated potential electrical hazards and at the same time facilitated color cinematography and television of the abdomen. ISO Despite these evident advantages, the Fourestier quartz light rod was not universally incorporated in endoscope design; it proved quite expensive and often fragile, and the necessary placement of the light source near the eyepiece created still other problems. The advent of fiberoptics initiated a new phase of technical improvement in lighting and laparoscopic instrument design generally. Initially, a fiberoptic bundle was simply substituted for the quartz rod as a means of transmitting light. Howard Balin, writing in 1966, just as the fiberoptic revolution was getting under way, observed the dual advantage that this new material offered: The light-conveying fiber optic glass bundles are increasingly finding utilization for general illumination purposes in surgery and dentistry, as well as for microscopy and endoscopy. The fiber optic glass bundle as a light-carrying device alone incorporates all the advantages of the quartz rod light-carrier without its several disadvantages. However, the ability of the fiber optic bundle to be adapted for image return, in addition to light conveyance, extends the horizons of its use far beyond those of any of the technics presently being utilized for endoscopy... 191

With the progressive expansion of fiberoptic technology, laparoscopy could not remain unaffected for too 850

long. The flexibility of fiberoptic instruments emerged as a desirable feature in laparoscopy, as it had been in other domains of endoscopy. A flexible instrument would increase the range of laparoscopy, while at the same time obviate the need for an expensive laparoscopy table. One solution was simply to adapt a small diameter controllable head fiberoptic gastroscope; Robert A; Sanowski and his colleagues did just this in 1981, utilizing a pediatric model Olympus endoscope (model GIF-P2) as a laparoscope. 192 Sanowski found that the endoscope was "readily adapted to laparoscopy without major modification." He was not entirely satisfied with this solution and, in cooperation with Machida America, Inc., developed a fiberoptic endoscope designed specifically for laparoscopy in 1986. 193 Olympus soon had its own version of the flexible laparoscope in the process of development, as well. Whether or not these instruments replace the current generation of rigid models, as produced by Eder, ACMI, Wolf, Storz, and others, remains to be seen. Some endoscopists even speculate on the future of laparoscopy, given the diagnostic advances of computed tomography and ultrasonography. Still others have asked if the incidence and nature of complications associated with laparoscopy have been accurately assessed. 194 Charles J. Lightdale addressed these concerns and made a strong case for laparoscopy remaining part of the endoscopist's repertoire. Despite recent advances in imaging technology, he argued, laparoscopy still offers important advantages in diagnostic precision. 195 PEG Percutaneous endoscopic gastrostomy or PEG, by recent estimation, has become "the second most common indication for upper endoscopy in hospitalized patients in the United States."196 That PEG was adopted so widely in a comparatively short period of time suggested that the procedure successfully constituted a method of assuring parenteral nutrition that is significantly less traumatic than previous surgical forms of gastrostomy. Michael W. L. Gauderer and Jeffrey Ponsky, originators of "incisionless gastrostomy," developed PEG specifically for the long-term enteral feeding of pediatric patients at Rainbow Babies and Children's Hospital in Cleveland. According to their account of these developments, the technique had to meet three criteria: "control of the site of the placement in the stomach, protection of surrounding organs from accidental injury, and a reliable approximation of the gastric serosa in the abdominal wall."197 Gauderer, a pediatric surgeon, believed that this could be achieved by gastroscopy and therefore enlisted the cooperation of an endoscopist, Jeffrey Ponsky; together they refined and simplified the procedure, first performed upon pediatric patients at University HosGASTROINTESTINAL ENDOSCOPY

pital in June 1979. 198 Soon after, Ponsky employed the method successfully in adults. In this procedure, as developed by Gauderer and Ponsky, the endoscopist identified the needle puncture site in the gastric wall, snared a suture from a cannula inserted into the stomach, and withdrew the suture, carried by the endoscope, out the patient's mouth. 199 The gastrostomy tube was then attached and drawn retrograde down the esophagus and stomach' exiting at the puncture site in the abdominal wall. Other methods of PEG, principally the "push" procedure of Sacks and Vine 200 and the "introducer" technique of Russell, Brotman, and Norris,201 have been devised, but the Gauderer-Ponsky method remains the most widely practiced. Video endoscopy

Has the introduction of video endoscopy signaled the beginning of a new phase in gastrointestinal endoscopy? Will video endoscopy prove to be as revolutionary as Schindler's semi-flexible instruments in the 1930s and fiberoptics in the 1960s? The response to these questions may well be both yes and no, depending upon whom one asks. To the partisan of video endoscopy, there is no question that it is but a matter of time until the new technology proves its worth convincingly. A more conservative voice would argue that conventional fiberoptic instruments perform quite adequately and are, moreover, far less expensive and troublesome than the video endoscopy equipment. Video endoscopy developed as a by-product of technical advances in microelectronics dating to the late 1960s. The video endoscope dispenses with the lens and fiberoptic bundle of conventional instruments in favor of an electronic sensor, or charge-coupled device, at the tip of the instrument. This sensor transmits the image electronically to a video processor and the image is projected on a television monitor. 202 The first video endoscope was introduced in 1983 by Welch Allyn, Inc. of Skaneateles, New York, long-time maker of diagnostic instruments, and they were soon followed (and ultimately surpassed) by Fujinon and Olympus. The manual manipulation of the instrument is performed in essentially the same manner as with fiberoptic endoscopes, particularly since the tip deflection controls and locking mechanism of the conventional instrument have been adopted for video endoscopy. Endoscopists using the video instrument for the first time noted a difference in their stance; instead of holding the eyepiece of the instrument to their face, video instrument operation takes place at waist level while endoscopist (and patient) watch the television monitor (Fig. 29). Early reports concluded that "the [videoscopic 1instrument was acceptable for diagnostic and therapeutic colonoscopy in virtually all respects.,,203 More recent assessments indicate that the VOLUME 37, NO.2, 1991

Figure 29. Video endoscopy at the Cleveland Clinic, 1984 [Source: Michael V. Sivak, Jr., and David E. Fleischer, Colonoscopy with a videoendoscope: preliminary experience, Gastrointestinal Endoscopy 30 (1984):2, Fig. 2].

two technologies are likely to coexist for the near future and that experience with the fiberoptic instrument enhances the fledgling endoscopist's facility with the video endoscope. At present, video endoscopy holds forth the promise of great potential for altering the way in which endoscopists work. By virtue of being linked with the computer, work in the endoscopic unit may be organized along new lines, as noted by Michael V. Sivak, Jr.: Three operations within the endoscopy unit that could be performed by a computer are report generation, image management, and data management...Computer programs are already available for the retention and management of the type of endoscopic data found within the procedure report and other more sophisticated programs are currently under development...A completely automated system for generation of procedure reports, management of the information generated by procedures, and management of endoscopic images is still a concept rather than a reality since various technical problems must be resolved. 204

CONCLUSIONS

Several conclusions emerge from the historical study of gastrointestinal endoscopic instruments. First is the central importance of the vital, creative alliance of physician and instrument maker. As William Haubrich noted, "almost without exception, advances in endoscopy have come about by virtue of a close collaboration between clinician and artisan; neither could have succeeded alone.,,205 One need only mention the names of Leiter and Mikulicz, Wolf and Schindler, and Palmer and Streifeneder, to illustrate the validity of Haubrich's observation. 851

Second, the technical advance of instrumentation did not always proceed in a unilinear or logical fashion, despite the semblance of order imposed by the aid of 20-20 hindsight. Instrumental development often occurred in repeated fits and starts, frequently in a fadlike manner. The pattern should be familiar to many: original skepticism regarding a new instrument or endoscopic technique would often give way in the face of endorsement by respected clinicians, who published enthusiastic initial reports. As a new instrument was used more widely among endoscopists, it received closer scrutiny and more careful documentation of its efficacy and safety, which in a number of instances precipitated a decline in its application. This fad phenomenon is by no means peculiar to gastrointestinal endoscopy.206 However, since the field is so closely identified with instrumentation, several examples come to mind readily: operating gastroscope, laparoscopy, transesophageal gastroscope, and fiberoptic esophagoscope to mention but a few examples. Third, the standardization of instrumentation remains an elusive idea1. 207 The way in which instruments are developed tends to impede progress toward this end, as observed by Morrissey: "I have been concerned for years about the way manufacturers make decisions about instrument design. They tend to rely on the opinions of well-known individuals who are not often experienced with the instruments of more than one manufacturer."208 In this circumstance, the closeness of the clinician-artisan relationship cited above may have discouraged comparative trials leading to greater standardization, conformity, and compatibility of instruments. Lack of agreement upon technical specifications and standards persists as a problem today, plaguing even the current generation of video endoscopes. 209 Last, important changes in instrumentation have been prompted by technical advances occurring outside the recognized domain of gastrointestinal endoscopy, and even beyond medicine per se. For example, the fiberoptic revolution was prompted by Hirschowitz's recognition that innovations in physics could be applied to endoscopy. He seized upon the work of Hopkins and Kapany, and pursued the development of the first instrument with Curtiss, all physicists. More recently, innovations far beyond endoscopy, in the development of the charge-coupled device and video processing, have made possible video endoscopy. The point to be made is simply that endoscopists need to be alert to externally generated innovative ideas. Exciting new ideas can and do come from unexpected corners in our high tech world; computed tomography, after all, was brought to us by the same people that produced the music of the Beatles!210 New directions in gastrointestinal endoscopy may arise from similarly unlikely origins. 852

ACKNOWLEDGMENTS

Special thanks go to William Haubrich, Benjamin Sullivan, Bernard Schuman, Michael V. Sivak, Jr., and the A/S/G/E Archives Committee.

REFERENCES 1. Peter Rathert, Wolfgang Lutzmeyer, and Willard E. Goddwin, Philip Bozzini (1773-1809) and the Lichtleiter. Urology 3 (1974):113-18; Erna Lesky, Die Wiener Experimente mit dem Lichtleiter Bozzinis (1806/1807). Clio Medica 5 (1970):327-50; Gunter Mann, Der Frankfurter Lichtleiter: Neues uber Philipp Bozzini und ein Endoskop. Medizinhistorisches Journal 8 (1973):105-30; and Heinrich Schutte and John R. Herman, Philipp Bozzini (1773-1809). Investigative Urology 9 (1972):447-48. 2. One example of the lichtleiter may be seen at the International Museum of the Surgical Sciences, Chicago, Illinois. 3. The negative impact of Viennese medical politics is presented in Rathert et al. 4. In each instance it is difficult to determine if they were inspired by Bozzini's example, directly or indirectly, or simply embarked upon the path of simultaneous discovery. 5. Un moyen d'eclairer l'uretre et la vessie de maniere a voir dans l'interieur de ces organes, Revue medicale francaise et de l'etrangere (1827) 1:157-58. Segalas furnished no illustration with his description; for illustrations see Segalas' Traite des retentions d'urine (1828) and Ernest Desnos, L'histoire de l'urologie. In Leonard J. T. Murphy, The history of urology (Springfield, Illinois: Charles C Thomas, 1972), Fig. 7.51, p. 181. 6. Description of an instrument for inspecting the urethra and bladder. Lancet 2 (1826-27):604. 7. These included Heurteloup, Gabriel Guillon, and Nelaton. See Desnos, l'histoire de l'urologie, 180-81. 8. W. Channing, John D. Fisher. Boston Medical and Surgical Journal 42 (1850):117-21. Fisher, and not Bozzini, was credited with the idea of endoscopy by Richard Cruise in 1865. See The endoscope as an aid in the diagnosis and treatment of disease. Dublin Quarterly Journal of Medical Science 39 (1865):329-63. 9. I. H. [Isaac Hayes?], Instruments for illuminating dark cavities. Philadelphia Journal of the Medical and Physical Sciences 14 (1827):409. 10. Ibid., 409-10. 11. Ibid., 411. 12. De I'endoscope, instrument propre a eclairer certaines cavites intensely de l'economie, par. M. A.-S. [sic] Desormeaux, Comptes rendus de I'Academie des sciences 40 (1855):692-93. 13. A. J. Desormeaux. The endoscope, and its application to the diagnosis and treatment of urinary affections [trans. by R. P. Hunt]. Chicago Medical Journal 24 (1867):184. 14. An edited translation of De I'Endoscopie was published in the Chicago Medical Journal 24 (1867):177-208, 273-88, 378, 384400, 449-64, 545-56. 15. Robert Newman, The endoscope considered particularly in reference to diseases of the female bladder and urethra. Transactions of the Medical Society of the State of New York (1870):119-33. 16. Ibid., 119-20. 17. Trade catalogues illustrating Desormeaux endoscopes include J. H. Gemrig, Illustrated Catalogue of Surgical Instruments (Philadelphia, 1879), 77-79, pI.xxx and George Tiemann & Co., American Armamentarium Chirurgicum (New York, 1872), pI.xxxv, Fig. 14. With a purchase price of $150, the endoscope was the second most expensive item in the Tiemann line of products; most surgical instruments, while not cheap, cost far less. 18. Newman, 121. 19. L. Walk. The history of gastroscopy. Clio Medica 1 (1966):20922. Walk notes that Kussmaul's contribution to gastroscopy attracted scant contemporary notice and was generally acknowledged only after presentation by Killian. 20. Julius Friedenwald and Samuel Morrison. The history of the development of the stomach tube with some notes on the

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duodenal tube, Bulletin of the History of Medicine 4 (1936):42554. 21. Gustav Killian. Zur Geschichte der Oesophago- und Gastroskopie. Deutsche Zeitschrift fur Chirurgie 59 (1900-1901):499512. 22. John Aylwin Bevan. Oesophagoscope. Lancet I (1868):470-71. 23. David M. Wallace. New lamps for old. Proceedings of the Royal Society of Medicine 66 (1973):455-58. 24. Julius Bruck. Das Uretroskop und das Stomatoskop zur Durchleuchtung des Blase und der Zahne und ihrer Nachbartheile curch galvanisches Gluhlicht (Breslau, 1867). 25. J. Baratoux. De I'Oesophagoscopie et de la Gastroscopie. Progres Medical 10 (1882):399-401. 26. Jacques Payen. La construction des instruments scientifiques en France au XIXe siecle. In P. R. de Clerq, ed., Nineteenth century scientific instruments [Papers presented at the Fourth Scientific Instrument Symposium, Amsterdam, 23-26 October 1984] (Amsterdam: Editions Rodopi B. V., 1985), 159-82. 27. Erna Lesky. The Vienna Medical School of the 19th century (Baltimore: Johns Hopkins University Press, 1968), 367. 28. Ibid. 29. Th. Hryntschak. Wiens annteil an der Erfindung des Kystoskopes. Festschrift sum 80. Geburtstag Max Neuburgers (Vienna: Wilhelm Maudrich, 1848), 239-45. 30. Walk,211. 31. Samuel J. and Jerome T. Pearlman. Johann von Mikulicz and the development of esophagoscopy. Quarterly Bulletin of Northwestern University Medical School 31 (1957):265-70. 32. Chevalier Jackson. Gastroscopy. Medical Record 71 (1907):550. 33. Otis K. Newell. The endoscopic instruments of Josepb Leiter of Vienna and the present development of endoscopy. Boston Medical and Surgical Journal 117 (1887):528-30. 34. Walk,213-16. 35. Jackson, 449-55. 36. Walk,212. 37. Theodor Rosenheim. Ueber Gastroskopie, Berliner klinische Wochenschrift (1896):275-78, 298-301, and 325-27. 38. Rudolf Schindler. Gastroscopy. The endoscopic study of gastric pathology, 2nd ed. (Chicago: University of Chicago Press, 1950), 8. Hans Elsner, Die Gastroskopie (Leipzig: Georg Thieme, 1911). 39. Schindler. Gastroscopy, 9. 40. Audrey Davis. Rudolf Schindler's role in the development of gastroscopy. Bulletin of the History of Medicine 46 (1972):153. 41. Walk,216. 42. Schindler. Gastroscopy, 10. 43. Jean Rachet. Practical gastroscopy (New York: William Wood and Company, 1927), 14. 44. Schindler. Gastroscopy, 11. 45. Rudolf Schindler. Georg Wolf. American Journal of Digestive Diseases 5 (1939):817-18. 46. Ibid., 818. 47. Rudolf Schindler. Diagnostic gastroscopy with special reference to the flexible gastroscope. Journal of the American Medical Association 105 (1935):352. 48. Davis, 156. 49. Schindler. Diagnostic gastroscopy, 352. 50. Ibid., 353. 51. Davis, 157. 52. Ibid., 159. 53. Edward B. Benedict. Examination of the stomach by means of a flexible gastroscope: a preliminary report. New England Journal of Medicine 210 (1934):669. 54. Edward B. Benedict. Endoscopy (Baltimore: Williams & Wilkins, 1951), 273. 55. Comments of Edward B. Benedict, first Schindler Award in 1954, as they appeared in Bulletin of the American Gastroscopic Society 3 (1954):4. 56. Ibid., 674. 57. William Haubrich noted that the diffusion of Schindler's gastroscope in the United States was affected by perceptions of who should properly conduct endoscopic examinations: "It should be mentioned that in certain prominent centers, such as the University of Pennsylvania and the Mayo Clinic, peroral endoscopy was considered in those early days to be solely in VOLUME 37, NO.2, 1991

the province of what was called broncho-esophagology." William S. Haubrich, History of endoscopy. In Michael V. Sivak, Jr., ed. Gastrointestinal endoscopy (Philadelphia: WB Saunders Co., 1987), 6. 58. John Tilden Howard. The gospel of gastroscopy in the United States. Gastrointestinal Endoscopy 17 (1970):19-22. 59. James L. Borland. The present status of flexible tube gastroscopy. Southern Medical Journal 30 (1937):310. 60. Examples of this omission are found in Walk, History of gastroscopy, and Joseph B. Kirsner, The significant impact of gastrointestinal endoscopy. The development of American gastroenterology (New York: Raven Press, 1989), 275-99. 61. Schindler. Gastroscopy, 1. 62. Rudolf Schindler. An American built gastroscope. American Journal of Digestive Diseases 7 (1940):256-57. 63. Ibid., 257. 64. A. Ray Hufford. A new light weight, extra flexible gastroscope. Review of Gastroenterology 13 (1946):381. 65. Edward B. Benedict. Cameron omniangle flexible gastroscope. Bulletin of the American Gastroscopic Club 1 (1943),15. 66. Haubrich, History of endoscopy, 7. 67. Louis Streifeneder claimed to have conceived the idea for the omniangle gastroscope design, only to have it appropriated by William J. Cameron. The omniangle design was later patented by Eder and his associate Leo L. Hardt. See U.S. patent number 2,376,249, May 15, 1945. Personal communication, Benjamin Sullivan, July 1990. 68. Hufford. A new light weight, extra flexible gastroscope 381-83. 69. Hermon Taylor. A new gastroscope with controllable flexibility. Lancet 2 (1941):276-77. 70. Rudolf Schindler. The Taylor gastroscope. Bulletin of the American Gastroscopic Club 1 (1943):7; and Edward B. Benedict, Hermon Taylor flexible gastroscope. Bulletin of the American Gastroscopic Club I (1944):21-22; A critical review of gastroscopy. Bulletin of the New York Academy of Medicine 20 (1944):179-80; and The Hermon Taylor flexible gastroscope. Bulletin of the American Gastroscopic Club 2 (1946):3. 71. Donald T. Chamberlin. Description of a new gastroscope. Gastroenterology 12 (1949):209-11. 72. Rudolf Schindler. Metro-Tee flexible gastroscope. Bulletin of the American Gastroscopic Club I (1944):29. 73. Roy L. Sexton. Notes from the instrument makers and advertisement for Cameron Surgical Instruments Co., Bulletin of Gastroscopy and Esophagoscopy 6 (1959):9-10. 74. American Cystoscope Makers, Inc., A.C.M.I. Cystoscopic, urologic and allied diagnostic instruments and high frequency apparatus (New York: ACMI, Inc., 1952),3. 75. Ibid., 7, and William K. Otis, Concerning the new electrocystoscope. New York Medical Journal 81 (1905):625-28. 76. ACMI, Cystoscopic instruments, 266-67. 77. Gastroscopic instruments. Bulletin of the American Gastroscopic Society 2 (1949):4. 78. Edwin Boros. Flexible tube esophagoscopy. Bulletin of Gastroscopy and Esophagoscopy 6 (1960):11-12. 79. See Edwin Boros, Esophagoscopy by means of a flexible instrument. A new esophago-gastroscope. Gastroenterology 8 (1947):724-28. Boros provides photographs to illustrate the instrument. 80. Edwin Boros. The use of the flexible tube in the diagnosis and treatment of disorders of the esophagus. Bulletin of the American Gastroscopic Society 2 (1949):2-3. 81. Boros. Esophagoscopy by means of a flexible instrument, 724. 82. Edwin Boros. Flexible tube esophagoscopy. Gastroenterology 11 (1948):880. 83. In 1957 Rudolf Schindler reported that "the manufacturers inform me that they consider this instrument now obsolete by their standards, but that design modifications are under way." See Rudolf Schindler, Diagnostic esophagoscopes for palpatory introduction. Surgical Clinics of North America 37 (1957):1200. 84. See Schindler. Diagnostic esophagoscopes, 1197-1206. 85. Schindler. Diagnostic esophagoscopes, 1201. 86. Rudolf Schindler. Construction and use of a safe diagnostic optical esophagoscope. Gastroenterology 12 (1949):356. 87. Rudolf Schindler. A safe diagnostic esophagoscope. Journal of the American Medical Association 138 (1948):855-87. 853

88. Ibid., 888. 89. N. Henning. Uber ein neues Oesophagoskop fur den Gebrauch der inneren Klinik. Klinische Wochenschrift 11 (1932):1673. One needed to sheath the end of this instrument in a rubber condom to protect it from coming in contact with the esophageal mucosa. Once inside the esophagus, the condom would be inflated and the esophageal mucosa viewed through the condom. This instrument is illustrated and described in Schindler, Diagnostic endoscopes for palpatory introduction, 1199-1200. 90. The telescope system was not introduced before 1952. See ACMI, Cystoscopic instruments, 268-69. 91. During this same period Hufford was investigating flexible gastroscope design and use. See A. Ray Hufford, A new lightweight, extra flexible gastroscope. Review of Gastroenterology 13 (1946):381-83. 92. A. Ray Hufford. Flexi-rigid, optical esophagoscope. Gastroenterology 12 (1949):779-81. 93. A. Ray Hufford. The Eder-Hufford flexirigid optical esophagoscope. Bulletin of Gastroscopy and Esophagoscopy 6 (1960): 1O. 94. Precisely when Hufford made the shift to the telescope is not entirely clear; in 1953 he still mentions a "lens obturator" for viewing both the esophagus and the upper segment of the stomach. See A. Ray Hufford, Integral use of gastroscopes. Bulletin of the American Gastroscopic Society 3 (1953):3. 95. Changes in the title of the A/S/G/E's journal reflect this development. In 1959 the American Gastroscopic Society Bulletin became the Bulletin of Gastroscopy and Esophagoscopy. 96. Eddy D. Palmer. Clinical benefits of routine combined esophagogastroscopy with the help of the two transesophagoscopic gastroscopes. Bulletin of the American Gastroscopic Society 4 (1956):7-8. 97. A. Ray Hufford. Integrative esophagogastroscopy. American Journal of Gastroenterology 22 (1954):116-25. 98. Ibid., 121. 99. J. Tomenius. An instrument for gastrobiopsies. Gastroenterology 15 (1950):498; and I. J. Wood, R. K. Doig, R. Motteram, and A. Hughes, Gastric biopsy, report of fifty five biopsies using the new flexible gastric biopsy tube. Lancet 1 (1949):18. 100. Charles Debrey and Pierre Housset. A new direct vision biopsy gastroscope. Bulletin of Gastroscopy and Esophagoscopy 8 (1962):10-12. Debrey and Housset observed that "the instrument most largely used in the United States of America and in the majority of European countries to obtain these delicate mucosal specimens is the Benedict operating gastroscope." p. 10. 101. Bruce Kenamore. A biopsy forceps for the flexible gastroscope. American Journal of Digestive Diseases 7 (1940):539. 102. C. Wilbur Wirts, Joseph L. Carroll, and Donald Wald. Experience with the operating gastroscope. Gastroenterology 19 (1951):786. The authors also recommended removal of the rubber finger tip and its replacement by a smooth metal bullettype tip. 103. Discussion of symposium on gastroscopy. Gastroenterology 16 (1950):356. 104. Edward B. Benedict. The differential diagnosis of benign and malignant lesions of the stomach by means of the flexible operating gastroscope. Bulletin of the American Gastroscopic Society 2 (1949):1, 3. 105. P. L. Shallenberger, C. H. De Wen, C. B. Weed, and J. C. Reganis. Biopsy through the flexible operating gastroscope. Gastroenterology 16 U950):327. 106. Edward B. Benedict. Gastroscopic biopsy. Gastroenterology 37 (1959):447-48. 107. Edward B. Benedict. Positive stomach diagnosis by gastroscopic biopsy. Surgical Clinics of North America 37 (1957):1239. 108. Rudolf Schindler. On the comparison between gastric suction biopsies and gastroscopy. American Journal of Digestive Diseases 22 (1955):336-37. 109. Opinionscope [Responses to the question: In your opinion, of what practical clinical importance is peroral gastric mucosal biopsy these days?). Bulletin of Gastrointestinal Endoscopy 11 (1965):27-28. 110. David Y. Graham, Harlan J. Spjut, and Rolando G. Estrada. Directed cytology of the esophagus and stomach: a comparison of 3 rapid collection methods. Gastrointestinal Endoscopy 24

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(1978):277-80. 111. Harry L. Segal. The history of gastroscopic color photography. Bulletin of Gastroscopy and Esophagoscopy 7 (1960):7. 112. Harry L. Segal and James S. Watson. Color photography through the flexible gastroscope. Gastroenterology 10 (1948):575-85. 113. John Tilden Howard. The President's Column. Bulletin of the American Gastroscopic Society 4 (1957):1. 114. B. I. Hirschowitz, L. E. Curtiss, and H. M. Pollard. Demonstration of the new gastroscope, the 'fiberscope'. Gastroenterology 35 (1958):50-53.9. 115. Ibid., 52, and Basil Hirschowitz. A personal history of the fiberscope. Gastroenterology 76 (1979):864-69. 116. H. H. Hopkins and N. S. Kapany. A flexible fiberscope using static scanning. Nature 173 (1954):39-41. In his reminiscences on these developments Hirschowitz also cites A. C. S. Van Heel, A new method of transporting optical images without abberations. Nature 173 (1954):39. 117. Basil I Hirschowitz, Endoscopic examination of the stomach and duodenal cap with the fiberscope. Lancet 1 (1961):107478. 118. Ibid., 1077. 119. Robert S. Nelson. Endoscopy in diagnosis of peptic ulcer. American Journal of Digestive Diseases (new series) 4 (1959):890. 120. H. M. Pollard. Discussion of foregoing papers. American Journal of Digestive Diseases (new series) 4 (1959):902. 121. John Hett. The design of gastroscopes. American Gastroscopic Society Bulletin 5 (1958):8. 122. Robert S. Fontana. An evaluation of the fibergastroscope. Bulletin of Gastrointestinal Endoscopy 9 (1963):11. See also Paul L. Shallenberger, Report of International Congress of Gastroenterology. Bulletin of Gastrointestinal Endoscopy 9 (1962):6-7; Arthur M. Olsen, A report on the symposium on fibergastroscopy. Bulletin of Gastrointestinal Endoscopy 9 (1962):4-6; and Benjamin B. Weisinger, Alfred B. Cramer, and Lawrence C. Zacharis, Comparative accuracy of the fiberscope and standard gastroscope in the diagnosis of gastric lesions: preliminary report. Gastroenterology 44 (1963):858. 123. Moses Paulson. Gastroenterologic medicine (Philadelphia: Lea & Febiger, 1969). See esp. Tabulation of the comparative benefits and disadvantages of the conventional or standard (semi-flexible) and glass fiber optic (flexible) gastroscopes, 234-35. 124. A. M. Olsen. Memorandum to the governing board, A/S/G/E Archives. 125. Fiber optic gastroscope [Eder Instrument Company advertisement). Bulletin of Gastrointestinal Endoscopy 10 (1963):19. 126. William Burnett. An evaluation of the gastroduodenal fibrescope. Gut 3 (1962):364. 127. Norman N. Cohen, Rollin W. Hughes, and Hector E. Manfredo. Experience with 1000 fibergastroscopic examinations of the stomach. American Journal of Digestive Diseases (new series) 11 (1966):949. 128. N. N. Cohen. An unusual complication of the fiberscope. Bulletin of Gastrointestinal Endoscopy 11 (1964):19, and R. E. Braucher and J. B. Kirsner, Case report: impacted fiberscope. Gastrointestinal Endoscopy 12 (1965):20. 129. Robert Kemp. A note on the fiberscope. Lancet 1 (1962):88. 130. Ibid., 89. 131. Fontana, An evaluation, 13. 132. John F. Morrissey. Progress in gastroenterology: gastrointestinal endoscopy. Gastroenterology 62 (1972):1242. 133. Philip A. LoPresti and Abram M. Hilmi. Clinical experience with a new foroblique fiber optic esophagoscope. American Journal of Digestive Diseases 9 (1964):690-97. 134. Morrissey, Progress, 1242; and Gastrointestinal endoscopy: 20 years of progress. Gastrointestinal Endoscopy 29 (1983):55. 135. Haubrich, in Michael V. Sivak, Jr., ed., Gastrointestinal Endoscopy,13. 136. Morrissey, 20 years of progress, 56. 137. John F. Morrissey. Gastrointestinal endoscopy-20 years of progress. Gastrointestinal Endoscopy 29 (1983):54. 138. Ibid., 54. 139. See, for example, J. F. Morrissey. The use of the gastrocamera

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140. 141. 142. 143. 144. 145. 146.

147. 148. 149. 150. 151. 152.

153.

154. 155. 156. 157. 158. 159.

160. 161. 162. 163. 164.

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