Chapter 11 - Society of Laparoscopic & Robotic Surgeons

Chapter 11

The Era of Nitze

This era continued to be dominated by endo-urology. It was also an era which was first touched with the taming of electricity for illumination, first with cruder versions called galvanized wires, and later with the invention to end all inventions, Edison’s 1880 electric mignon light bulb. We left off at Part II with Bruck’s work in the galvanized wire department. In part III, this idea is extended not only as a source of illumination, but also as an early operative technique for coagulating tissue. The early pioneers in this era include Grunfeld, Trouve, Bottini, Kelly, Pawluk, Brenner, Billroth and von Dittel, in addition to the well-known father of modern endoscopy, Nitze. This was also one of the first eras in which we see significant contributions by American endoscopists. We also witness the continuation of endo-photography, first inaugurated in Part II by Czermack, and now blossoming into an exciting and established component of endoscopy, made especially practicable by the ingenious innovations of Stein.

Of most importance, this era is characterized by the establishment of operative procedures. Though crude by our own standards, these early forms of operative endoscopy, in the form of endo-urological electro-cautery, marked one of the most crucial milestones for endoscopy, for this was the moment when the scope first began to transform from a mere diagnostic tool to one with therapeutic value.

By the end of this section, cystoscopy has become a widespread diagnostic and operative procedure, with practitioners from all over the world working to improve and expand its applications.

We first review the work of Grunfeld and Trouve, who were described as the most important pioneers of this era, outside of Nitze. Their trailblazing work in technologies as well as operative procedures were said to have paved the way for Nitze’s innovations.

Grunfled Helps Pave the Way for Nitze
One of the era’s most significant achievements was the first documented case of therapeutic endoscopy, achieved in 1873 by the dermatologist-turned urethroscopist Joseph Grunfeld. Known commonly as one of the founders of modern urethroscopy, Grunfeld founded modern urethroscopy at the Clinic for Syphilitic Patients in Vienna.

He also developed a whole range of sophisticated instrumentation. Using his own specially designed cystoscopes made especially to remove tumors from the urethra and bladder, Grunfeld became the first documented to remove bladder stones and polyps with the endoscopic direct visualization. His polyp removal was one of the earliest versions of a punch instrument, which was a technique that was popular well into the early 20th century. Prior to this moment, all other instances of bladder stone or polyp removal had been essentially blind procedures. Therefore, Grunfeld is considered the founder of operative endo- urology and urologists today recognize his work as groundbreaking. His ingenious design made his method work better than others. It was considered the first workable punch instrument to remove polyps from the urethra. Grunfeld introduced other brilliant technological innovations and made especially well-known improvements to Nitze’s devices, including correcting for the inverted image problem. He was also able to expand the field of view even more than Nitze’s early efforts. Other novel auxiliary instrumentation include loop threaders, scissors, forceps and cutting knives. His scopes were the very symbol of the late industrial age fascination with mechanized components, with his scopes featuring automation buttons which controlled the movement of these auxiliary instruments.

Grunfeld also incorporated Coudee’s ingenious innovation to the catheter, which is commonly referred to as the Sonde Coudee, (which is the curve in the point). This allowed Grunfeld and others after him to keep urine back, thereby allowing for direct contact endoscopy with the bladder to be possible for the first time. Grunfeld also added the innovation of blackening the inner surface of the shaft in order to prevent scattered beams of light from occurring.

Grunfeld also contributed to the literature, publishing in 1881 the textbook called Die Endoscokie der Harnrohre und Harnbiase (Endoscopy of the Urethra and Bladder), edited by Billroth und Lucke, vol. 51, F. Enke, Stuttgart, which was one of the few textbooks specifically dedicated to endoscopy at the time.

Trouve Also Paving the Way
The Parisian engineer Trouve is considered by many scholars to be as crucial to the development of endoscopy as Nitze. Trouve in fact was the first- before Nitze- to found electro-endoscopy, with his distal placement of the galvanized platinum wire. Trouve founded electroendoscopy around 1873, adding illumination to the tips of endoscopes with glowing platinum light. He presented this idea in Vienna, using the name electrical polyscope. Trouve’s device also included newly designed and uniquely placed prisms, including the double prism system. These increased the field of vision to 90 degrees. Unlike Nitze’s device, Trouve’s scope did not require the awkward cooling system. Trouve designed several different types of scopes including a urthroscope, cystoscope, rectoscope, and gastroscope.

Of particular note, Trouve was able to dispense with the complicated water- cooling system (around since Bruck’s time). He did this by making the wires really flat and thin (referred to as “thin platinum filaments”) by hammering them down to measure about 1/14th to 1/6th mm thick. Modified in this way, the wires, while sufficient to conduct the current, produced such little heat that Trouve said “every examination…is possible.” Although this particular claim of Trouve’s was apparently “intensely debated” by Nitze and Leiter, ultimately it was proved true that Trouve’s design innovation did what he said it would; reduce heat so it could be safely brought inside the body.

Other innovative technical improvements include a built-in eyepiece which was based on magnifying glass as introduced by Galilei, which was able to magnify by 2.5 times. As well, he constructed a rheostat which helped to regulate the strength of the source of the current. After Leiter presented his Nitze endoscope (with the so called “new” distal source of light) in 1880, Trouve took a very strong stance to protect his priority, writing in to the main journal. Eventually Trouve received his rightful recognition for primacy on this innovation. Some of the most credible sources assert that modern endoscopy “was founded by Trouve, and perfected by Nitze.”

NITZE – 1877
Preface to Nitze

One important point to make at this point is that, even with all these ingenious innovations to date, at the end of the day it was still only possible to observe fields of view no larger than the size of the lenses. For almost seventy years, since the time of Bozzini, the optical field’s development had been conspicuously arrested; it did not budge outside of the size of the aperture of the scope itself.

Maximilian Carl-Friedrich Nitze
1848 – 1906

The life of Nitze was probably the most difficult to reconstruct for this history. At turns described as “irascible,” other times as “shy,” this was a man who unquestionably was touched with genius, years ahead of his time. Perhaps this was why he seemed to live a life of exquisite intellectual torture, trapped in a state of implacable visionary reverie for technological advances which could only remain ever elusive. One source summed up Nitze as being “a shy and often irascible loner who reportedly did not care much for society or politics, yet he was pegged as brilliant at a young age.”

Nitze was born on September of 1848 in Berlin, Germany. He studied medicine in Heidelberg, Würzburg and Leipzig. Nitze obtained his medical degree in 1874. Aside from these few biographical details, not much else is known about his private life. Speculation about the man himself will go on forever, but the confirmed truth is that Nitze is one of the most important fathers of endoscopy, whose brilliant discoveries ushered in the modern era of endoscopy. Urologists today also claim Nitze as their own father of modern urology for his imponderably vast contributions to the field. No other pioneer of his time came close to achieving such a sweeping revolution of change for endoscopy. He is most known for being the first to make routine operative endoscopy safe and reliable, to bring distal light to life as a practical reality, to apply the latest microscope optics to the endoscope which ultimately expanded the field of vision (so that he could achieve those routine operations), and to be the first (along with V. Dittel) to introduce a miniaturized version of Edison’s electric light bulb to the endoscope (although Newman was the first actually). The scope of his accomplishments is almost too great for this short survey. Yet we begin with his 1877 debut of an endoscope of his own design that marked the beginning of modern endoscopy.

1877 – Nitze and the Adaptation of Microscopy Optics Technology to the Endoscope
Every endoscope with a telescopic feature in fact is said to be the legacy of Nitze. Indeed, his series of innovations forever changed how urologists inspected the urinary tract. In collaboration with Josef Leiter, Nitze developed the first rigid endoscopic instrument with a built-in light source– often referred to as first direct-vision scopes. This instrument was primarily used for urologic procedures, but was also later adapted for the upper gastrointestinal tract, and indeed, was the same instrument design that was applied for the first series of laparoscopies in the 20th century. The lens system was actually three lenses in one, described in detail by one source as (paraphrased) “essentially a mini microscope that included a wide angle lens which was fully immersible in the watery environment of bladder. The second lens produced the combined objective, and the objective reflected the image onto the middle lens with as little light loss as possible at that time, which then magnified the image even more (though it darkened it considerably).” Despite all this technical brilliance, the image was in fact upside down (Ringleb would correct for this problem a bit later). Of note, Nitze apparently did offer a solution via an auxiliary part to be added to the eyepiece, but for reasons that are a bit unclear, this solution was never accepted.

The Complicated Cooling System of His First 1877 Cystoscope
Nitze’s illumination system (prior to his use of the electric bulb) was actually the main design drawback of Nitze’s scope. The electrified platinum wire (the only technology available to create light which could be used inside the body) required the use of a complicated and elaborate water-cooling system, a system which was a modification of the Bruck’s from the 1860s. Nitze introduced his “kystoskop” and “Urethroskop” in Berlin on October 2, 1877, demonstrating first on cadavers. Two years later, in 1879, he began full clinical trials.

The Second and Third Nitze Cystoscope With Edison Electric Light Bulb
A crucial breakthrough for Nitze came by way of Edison’s invention of the electric bulb, officially introduced to the world in 1880. This technological coup helped to change Nitze’s earlier complicated system into what most sources cite as being the first “practical operating cystoscope” which was a safe, simplified, inexpensive, and readily usable instrument. In 1888, Nitze adapted a miniaturized bulb (as developed by Koch and Preston) for use with his second generation cystoscope. This new and improved cystoscope made bladder stones easily located and removed, something which had long been inaccessible by most endoscopic methods, except for by the few virtuosos in the field. Using this new scope, Nitze became the first to coagulate a bladder papilloma using hot, galvanized wire loops. This breakthrough led ultimately to the systematic treatment of bladder diseases in this manner, with Nitze eventually reporting 150 cases of bladder tumors removed cystoscopically with only one death and 20 recurrences.

Other Innovations
Nitze worked on dozens of other inventions and modifications of the scope. His forceps equipped with electro-cautery devices at its tip, introduced in approximately 1886, were especially successful and gave rise to his ability to make simple operative procedures on bladder tumors a fairly routine and reliable procedure for the first time.

Indeed, this invention was similar in concept to the 20th technique of TURP, although without the benefit of modern electro-current technologies of course. Nitze is also credited with designing the first ureter balloon catheter in 1905, as well as the earliest practical irrigating cystoscopes (although Leiter and Berkeley-Hill are also cited as the first to introduce these). As well, Nitze (along with Fenwick) was the founder of trocar cystoscopy, a newer method for removing bladder stones which involved the use of a guiding trocar in the suprapubic region.

He continued to develop the irrigation cystoscope, as well as a photocystoscope (derived from Stern’s) and additional version of his operating cystoscope in collaboration with the instrument makers Hartwig, Loewenstein, Hirschmann and Heyneman. He also contributed to the literature substantially by publishing the first atlas on cystoscopy in 1894.

Even Nitze Faced Criticism
It is amazing to think that even the master Nitze’s ideas were rejected by officials of his day. In one instance, when applying for recognition of his invention in 1880, a court counselor dismissed his device with the following: “the devices are interesting in themselves, but appear to have no future,” (letter from Dr. S. Th. Stein, published June 19, 1880). As for the specific of the lens system, the field of view was 70 degrees, and “there was considerable perspective distortion inside the bladder because the distances in the bladder are no more than 8 cm.”

Also, Nitze’s scope was apparently difficult to manipulate, and galvanic cautery using the wire loop proved to be an unreliable treatment for bladder tumors.

When other technologies came along in the early 20th century, specifically diathermy currents and also instruments with the Albarran lever system from the United States, Nitze’s methods of electro-coagulation were made obsolete. Finally, his system was considered prohibitively expensive.

Of course, the final drawback of Nitze may have been Nitze himself! Apparently prone to pugnatiousness, he was involved in several highly publicized heated altercations between his one-time collaborator Leiter, and later too with Stein, who lodged a lawsuit against him on behalf of Trouve, whose idea for the distal placement of light was essentially borrowed from Nitze without giving full recognition to Trouve. HH Young from America personally reported almost getting into a “ knock down, drag-out fight” with Nitze because of some less than flattering remarks that he apparently made to Young concerning his work.

Conclusion Nitze
Despite the tales of altercations, Nitze was ultimately recognized for his brilliant contributions. His work was especially lauded in America and when the AUA was founded in 1902, Nitze was bestowed as an honorary member. More on Nitze is yet to come, for his inventive genius continued on into the 20th century.

After the friendship with Nitze dissolved in disagreement, Joseph Leiter continued to work with other physicians to improve upon Nitze’s designs. He was said to have introduced before Nitze one of the earliest irrigating cystoscopes in 1887. Leiter also introduced a photographic camera which could be attached to his gastroscope, though most sources describe it as essentially useless.

1874 – Theodor Stein
Still, although Czermak’s work had priority and was significant, it was nevertheless Theordor Sigmund Stein of Frankfurt who has been credited with establishing scientific photography in 1874, bringing unique improvements to the field that were clearly ahead of his time. After Czermak, Stein was the first to construct an automatic endocamera, or photoendoscpe. This very clever system, which he referred to as a heliopiktor, has been described by many as a forerunner to Polaroid technology. Stein also improved upon Czermak’s system by utilizing an even brighter source of light called gas magnesium light. Unfortunately, there is a somewhat messy history that coincides with these innovations. His various systems included photoendoscope, magnesium lights, heliopiktor, photo-ophthalmoscope, photo-otoscope, photo-laryngoscope, photo-urethroscope.

It appears that Stein’s system was not well received by some of the top endoscopists of the day. Nitze for instance, apparently tested Stein’s invention without much success, while Grunfeld did the same and reported similarly negative results. In 1881, perhaps in response to all of the negative feedback, Stein initiated a lawsuit against Nitze and Leiter for patent infringement. Despite all of these unpleasantries between the pioneers of the day, Stein and Czermak’s technical breakthroughs in photographic documentation systems were truly wonderful innovations for endoscopy. A plethora of scientific possibilities was created by this newfound ability to investigate human organs and other tissue pathologies.

Others after Stein to make contributions to this field include von Dittel’s modifications in 1888, Olbermann’s idea of a gastrocamera in 1890, Robert Kutner’s photos of the stomach in 1891, and even forays by the famous director Fritz Lange, along with his colleague DA Meltzung, who experimented with gastrophotography in 1898. Trocar photography was also introduced by the end of the century.

Karel Pawlik
The gynecologist Karel Pawlik of Prague was one of the first to probe the female ureter under direct visualization in an air-filled bladder. He apparently achieved this by approximately 1886, but didn’t publish on it until 1894. Pawlik used a urethroscope custom made for the female anatomy, and which was modified according to Grunfeld, using a distally placed platinum glowing light. This helped launch endoscopy into procedures for female patients. Before this, catheterizing the two ureters was apparently very difficult.

Howard A. Kelly
Though often erroneously credited as the inventor of air-cystoscopy, (that credit goes to Pawlik, Grunfeld, and Otis), Howard A. Kelley’s “tremendous experience and prestige” with the method catalyzed its introduction and wide acceptance in America. Kelly was a professor of gynecology and obstetrics at The Johns Hopkins University. His modified aero-urethroscope, advanced in 1893, and had shafts as small as 5-20 mm in diameters. Air cystoscopy is partially related to the positioning of the female patient, which when placed in the knee-elbow position, allows the bladder to fill with air. Initially Kelly failed to get air cystoscopy to work in men. But later in 1896, Kelly was able to solve this problem (with Otis also being one of the first to do so in 1887). In addition to his ob-gyn work, Kelly was also one of the earliest pioneers to apply the endoscope for use in diagnostics of the colon. Kelly introduced in 1894 “the first long 30 cm rigid rectosigmoidoscope which subsequently became known as “Kelly tubes” by his colleagues. Kelly published the description of his work in the Annals of Surgery in 1895. Through the use of several amplification systems (including a forehead lamp), Kelly was able to increase illumination significantly, which was described as being as bright as approximately twenty candles.

Other Pioneers
In 1883, David Newman of Glasgow developed the first urethroscope- before Nitze- with Edison’s light bulb attached at the distal end; the mignon lamp is the novel feature of this adaptation (though other sources say that this innovation of Newman’s was for the minielectric bulb that he used). This is important because it was the first light system which no longer required a complicated cooling system. Double-channeled irrigating cystoscopes were available since 1889, with Brenner apparently the first to introduce these multi- tasking scopes, followed by Nitze, Boisseau de Rocher, James Brown of New York, and eventually many others; Felix Guyon of Paris (Civiale’s successor) around 1888, among others, reported bladder tumor operations using alternative methods ; Leopold von dittel of Vienna also advanced the same; Bottini’s work marked the beginning of electro-surgery of the bladder and prostate, even earlier than Nitze and in approximately the same time frame as Trouve. In particular, Bottini’s introduction of an endoscopic approach to treatment of prostate disease with the use of galvanized wires (electro- cautery), introduced as early as 1874 was especially significant. His work was said to have gained “considerable success.” James Brown of Johns Hopkins University invented a new catheter system in 1893 that made it easier to insert in male ureters (using the Brenner cystoscope). In 1899, Boisseau du Rocher introduced a dual channel scope which had the ocular part separated from the rest of the sheath. This enabled the surgeon to add different telescopes through the sheath without having to take the scope out and reconfigure it. Felix Martin Oberlander (1849-1915), a colleague of Nitze, is cited as being the one to make Nitze’s device usable “for the first time” in 1888. Oberlander improved urethroscopy and developed endoscopic treatments of the urethra. Moreover, with the discovery of the anesthetic properties of cocaine, he was able to stretch the urethra further than most and insert wider caliber shafts.

Cold Light
Other significant milestones of this era include the introduction of cold light technologies which helped obviate the need for an elaborate and cumbersome cooling system. Some of the earliest work into cold light advances was both Preston or Valentine in approximately 1895 and Koch in 1899. His innovation, the koch urethroscope, was the first endoscope equipped with the Preston cold lamp (a cold mignon bulb possibly derived from Valentine), which replaced the ultra hot and therefore difficult system of electrified platinum wires. This light bulb was described as “pea sized.”

Koch’s advertisement in one of the earliest catalogues of endoscopy gives a quite fascinating glimpse into the era, over 100 years ago:

“In this instrument, devised by Dr.Koch, we offer to the profession an endoscopic urethral tube in which the entire lumen (inside the tube) is clear and unobstructed, thus giving ample room for the manipulation of applicators, etc. Along the side of the tube proper is our small auxiliary tube for the light carrier and lamp. Through a fenestra at the distal end the light is thrown directly upon the surface to be examined or treated, thereby giving a clearly lighted field and permitting the application of medicaments without the possibility of cotton catching on the lamp when the applicator is withdrawn” – As researched by Reuter.

S. Duplay and S. Clado, in 1898, two Frenchmen who wrote the first completed book on hysteroscopy. Their hysteroscope was an open tube with a battery- powered light source. Also, RT Morris in 1893 added an interior obdurator, which could be withdrawn once the instrument had been introduced into the uterine cavity.

Continuing where we left off with the great innovations that made open surgeries on bladder stones a dead art, we now turn to a great breakthrough by Henry J. Bigelow of Boston who developed a lithotripter which also included an efficient catheters system and also aspiration balloons, introduced in 1876. Apparently Bigelow adapted this idea of a rubber balloon attached to a glass container by Clover of London who introduced it a few years earlier in 1874.

CONCLUSION PART III – Summary of the Late 19th Century
In summary, by the end of the 19th century, endoscopes had been well established as a means of evaluating the urinary tract, anorectum, larynx, esophagus and stomach. Although the chest and abdomen were not yet accessible, the methodologies had been developed for this possibility.

Despite all this progress, cystoscopy was still plagued by great disadvantages. By the late 1880s, it was still considered a procedure which was not reliable and which could cause grave injuries, including cases of life-threatening, uncontrollable hemorrhaging. To these problems, we look to the 20th century pioneers to work out novel solutions.