Society of Laparoscopic & Robotic Surgeons | Chapter 12

Chapter 12

Early 20th Century

Introduction
Formerly, when religion was strong and science weak, men mistook magic for medicine; now, when science is strong and religion weak, men mistake medicine for magic.
-Thomas Szasz, M.D.

Perhaps no one is more relieved to enter the 20th century than you the reader. Though it might have seemed unnecessarily cruel to have kept you in the 19th century for so long, the insufferable waiting indeed had a purpose, for we can now begin the story of truly modern endoscopy with a sound understanding of its scientific, social, and technical contexts in mind. The previous background information also helps us to appreciate more fully the extensive number obstacles that were overcome in order to make it to this 20th milestone, a process which actually required hundreds, if not thousands, of years of accumulated scientific knowledge to achieve, not to mention the tenacious work of innumerable pioneers.

As the introductory quote alludes, the 20th century was one marked by a true domination of the sciences, though sometimes not always for the best. Indeed, some have said that the modern era of science and technology was both a blessing and bane. On the positive side, thanks to modern medicine, the western world was gifted with a nearly doubled human lifespan relative to their 19th century counterparts. Yet, co-existing with these healthy, humanitarian applications of science were advances in war technologies that caused a level of destruction that broke every standing record of mass death in human history. More than any other century, the 20th saw more human lives lost due to advanced technologies of war.

In contrast, medical advances were, for the most part, deployed for the good of humanity. Surgical sciences especially experienced a unique renaissance and enjoyed growing prestige in the eyes of the public. By 1900, most open procedures, once deemed unthinkable just a few decades earlier, were now made possible through the advent of improved antiseptics and anesthesia. Yet here began a strange twist to the tale of endoscopy; for while these same medical advances were naturally beneficial for endoscopy’s continued development, they also worked paradoxically to forestall further progress toward more complicated, operative endoscopy. This occurred because open surgery trumped the still-developing endoscope when it came to the most crucial aspects: providing definitive diagnoses, finding and stopping internal hemorrhaging, and treating pathologies in the most complete way possible.

Without overcoming its shortcomings in these three areas in particular, endoscopy was in danger of remaining in the shadow of open surgery as a mere ancillary concern.

Re-Evaluating the Original Four Obstacles
If endoscopy was to overcome its diminished status relative to open methods, it was still imperative to make further progress toward solving more perfectly the original four obstacles. Even though these hindrances had actually all been resolved to some degree by the end of the 19th century, endoscopy still could not measure up to open methods, which remained the standard by which most other procedures- even those diagnostic in nature- were to be measured. Much of the literature on endoscopy during this early 20th century period made a point to remind the practitioner that no matter how advanced endoscopy had become (especially laparoscopy) it could never, would never replace open methods. Indeed, another 80 years or so would have to pass before a conceptual understanding of laparoscopy’s potential was achieved.

However, the scenery of surgery was about to change dramatically with the introduction of new 20th century technologies. In particular, the advent of electricity created a whole new dimension to surgery that thoroughly changed the landscape of endoscopy especially. In fact, this early period of 20th century medical history was often referred to as the electro-surgical age. Electricity improved the visualization of the inner body so substantially that an entirely new understanding of human physiology began to emerge as a result. Pathologies of living organs could now be visualized with unimaginable accuracy. Therefore, instead of being viewed from the imperfect perspective that biopsies or autopsies gave, organs could now be visualized in living color, just as they existed within the living body. With this newly enhanced understanding of the human body, the still fairly young field of human physiology was able to advance considerably.

In short, the electric bulb, appearing so simplistic to us today, gave endoscopy what it had been longing for all along: a bright yet soot-less, streaming beam of cold [1] and consistent light, which could be safely placed inside the body. As a result of the superior visual perspective obtained as a result, surgeons were now able to focus more keenly on perfecting highly specialized endoscopic techniques, rather than continuously troubling themselves with ineffective light sources or unsafe, over-heated galvanized wires. Patients and physicians alike were also relieved from the dangers associated with live, electrified wires going into their bodies and all the grave potential consequences of such a scenario that you can imagine. News of this new technology swept the world and by 1900, improved and miniaturized versions of Edison’s original bulb became widely available to all endoscopy medical device makers, alternately placed at either the distal or proximal end.

Limited Field of Vision Revisited
Of course, 20th century pioneers would still have to contend with one of the lingering, original problems; expanding the field of vision. Even though Nitze, Ringleb, and a handful of others had made some headway toward solving this problem in the 19th, the field of vision was still prohibitively small in the opening hours of the 20th century.

In fact, lens technologies (as applied to endoscopes) stayed relatively the same for almost 70 years after Nitze’s 1880s work. Even with Nitze’s innovation, only about a palm-sized area could be viewed, and both Otto Ringleb and Grunfeld only managed to expand the field ever so slightly. The average field of vision achieved amounted to no more than approximately 44.2 millimeters in diameter at a range of 2.5 centimeters. These diminutive dimensions naturally inhibited the ability to conduct more complex operative procedures.

New Inventions Lead to New Obstacles
Despite having just about finished off the first four obstacles, the pioneers of the early 20th century still had their work cut out for them. This was especially true since new technologies naturally bring along new and unexpected difficulties. For instance, the new methods established by Kelling, Ott, Jacobaeus and others, presented additional concerns specifically related to endoscopy, such as insufflation issues and intra-operative bleeding caused by trocar injuries. Another unforeseen issue centered on the need to better understand electricity so that it could be used safely and predictably in surgery. Naturally, the biophysics relating to the interactions between living tissue and electrical instrumentation was not well enough understood at this juncture, since the use of electricity in surgery had only been in practice for less than twenty years. As a result of this new wave of inexperience, endoscopy unfortunately underwent another difficult phase of trial and error. Many serious accidents involving electricity occurred, such as thermal tissue damage, electrocution, and other serious mishaps. Finding optimal electrical currents became a serious undertaking during the early days of the 20th century and remained a troublesome aspect for endoscopy for almost another hundred years.

As well, injuries caused by incorrect trocar placement or over-insufflation began to occur more frequently as endoscopy began to enter the mainstream. It was also necessary to further increase magnification levels if endoscopy was to truly evolve into a more useful form. By the 1930s, magnification capabilities (as applied to endoscopic devices) still only achieved 20-fold increases, as opposed to our current levels, which reach 80-fold magnification.

Endo-Photography
And finally, interest in advancing endo-photographic technologies kept the pioneers ever on the hunt for improved lighting. By 1900, endoscopes were being built with photographic powers. Called stereo-cystoscopes, these new scopes could split the light source, one beam for immediate viewing, and the other for photographic purposes. Jacoby and Ringleb were among the early 20th century’s most active innovators in this technology. Of course, with the splitting of the light source in this manner, this meant that even more powerful light sources were necessary.

Revised List of Obstacles
All of this leads us to a revised list of hindrances that emerged– or re-emerged- in the early 20th century:
1) improving magnification
2) increasing the field of vision still further
3) taming electricity inside the body
4) understanding insufflation issues
5) increasing light further (to be solved by the advent of fibre optics)
6) improving endo-photographic capabilities

This new set of encumbrances, along with the need to perfect even the old tasks, kept the minds of many pioneers preoccupied for another 100 years. Like the original obstacles from a hundred years prior, many of these problems were not sufficiently resolved until well into the 20th century.

The New Era of Endoscopy Made Treating Diseases Much More Feasible
Electricity at least helped solve the old dilemma of providing adequate light for use inside the human body. The now amplified illumination, combined with improved anesthetics and antiseptics, made diagnoses so reliable that a broader spectrum of conditions could readily be confirmed and treated endoscopically. In this way, in the eyes of internists, gynecologists, and urologists in particular, endoscopy began to emerge– ever so slowly at first- as the preferred diagnostic method over open procedures. With the vastly improved visibility brought on by electricity and fluoroscopic methods, along with the greater precision in electro-cautery, the endoscope now allowed for safer biopsies, a diagnostic procedure that previously ran the risk of causing fatal internal hemorrhaging. Performing risky blind biopsies of even the liver and other “bleeders” became significantly safer (though still racked with some lingering risks as we soon shall see).

By the turn of the century, endoscopy was also finally able to access areas that had been nearly impossible to visualize before electricity and other technological improvements.

Cystoscopic renal diagnosis (chromocystoscopy) was one of the most significant breakthroughs for 20th century endoscopists. With the use of dying agents, for the first time ever intricate details of the vessels were finally visualized.

Therapeutic (AKA Operative) Endoscopy Just Burgeoning
Despite these undeniable early successes, a greater body of convincing evidence supporting endoscopy’s efficacy had yet to be collected and confirmed. And here the story of this underdog of surgery really begins to unfold in all its true glory, for the evidence proving endoscopy’s tremendous value and potential finally became utterly irrefutable during this early 20th century time frame.

Proof to endoscopy’s growing indispensability as a therapeutic tool was evidenced by the great success found in removing pathologies of the bladder. By the 1880s you will recall, Nitze, Grunfeld, and a handful of others had made great progress in this domain with their respective successes in removing pathologies from the female bladder under direct visualization. Yet these were considered essentially rare feats, even in the late 19th century. However, by the early 20th century, removing bladder tumors endoscopically (via the urethra) had become a fairly routine procedure, as had the electrical cauterization of strictures, polyps, and other such conditions. Compare this relative operational ease to the year 1800, when the surgical removal of bladder stones had an associative mortality rate of 20-40%!

As for forays into therapeutic gynecologic endoscopy, we would have to wait just a couple of more decades, as it lagged somewhat behind the work of urologists and gastroenterologists.

Endoscopy and TB – Old Societal Scourge Meets New Technology
Curing an old nemesis of society was one way that endoscopy clearly gained a decisive victory in proving its unmistakable potential. One of the most notable advances during this time frame was the endoscopic treatment of tuberculosis, a disease that was still a dreaded scourge throughout the first half of the 20th century. So fearful were people of TB that many turned to dangerous, ‘alternative’ therapies, even at one point inhaling chlorine gas vapors for supposed relief. Until antibiotics and other treatment methods for TB were perfected in the late 1940s, endoscopic approaches proved to be among the most effective therapeutic measures that physicians could offer. Patients infected with TB often succumbed to internal hemorrhaging caused by TB- induced lesions afflicting the lungs and sometimes the peritoneum. Before endoscopy, diagnosing and treating such internal bleeding could only be achieved via laparotomy.

Georg Kelling – Brilliantly Synthesizing Existing Technologies
TB however, was about to meet its match with a persistent pioneer who believed endoscopy could help treat such diseases in a much safer way than laparotomy.

Georg Kelling, a gastroentologist from Dresden, Germany, ingeniously combined already existing endoscopic technologies with a previously invented insufflation method, performing for one of the first times a successful endoscopic procedure within the abdominal cavity of a living dog. Using a Nitze cystoscope designed for children and insufflating the abdomen with filtered air from a device he constructed himself, Kelling successfully inserted the scope through a small incision in the abdominal wall, thus allowing for the endoscopic examination of the dog’s peritoneal cavity. Through a second trocar insertion, he then established pneumoperitoneum in order to visualize the interior body to avoid, as he described it, “damaging any of the internal organs.” This occurred live at the 73rd Congress of the Naturalist Scientist’s Medical Conference on September 23rd, 1901, in Hamburg Germany.

There is a great deal of confusion in the historical record on Kelling, matters we will address shortly. However, it is important to point out early on that, contrary to what other histories report, Kelling did in fact eventually go on to perform many endoscopic procedures on living human patients in his private clinic, apparently achieved between the years 1901-1923. He published an account of his extended clinical experience in a 1923 article that recapped his 22 years of experience using endoscopic methods. Kelling mentioned that his increased usage of the scope’s diagnostic capabilities was partly influenced by the poor economic situation of Germany after the First World War, which made the cost of laparotomies, which required hospital stay and anesthesia, prohibitively expensive.

As for the disputes over primacy between Kelling and Jacobaeus, we perhaps can never know for sure at this point. However, based on Kelling’s own insistent testimony in the matter, it does appear that Kelling did successfully perform laparoscopies on two human patients sometime between 1901 and 1910, thereby making him– and not Jacobaeus– the first to perform a laparoscopy on a living human patient. Kelling’s own testimony on the subject is our source in this case. After Jacobaues claimed to be the first to perform a laparoscopy in 1911, Kelling defended his primacy with a written response which was published in the same journal two months later, which stated that he had in fact successfully performed his laparoscopies on several human patients between 1901 and 1910. The exact total of these procedures in this timeframe vary in the literature, but the most reliable source states that Kelling reported a total of just two human cases at this point in time. By the time he published his last article in 1923, Kelling claimed to have achieved even greater clinical success in human patients, but our research was not able to uncover the precise details on this matter. From these cases, he described the appearance of the liver, tumors, and tuberculosis.

In any case, though his first published clinical trials up to the year 1901 never reached beyond a few dogs, Kelling nevertheless deserves recognition for boldly developing an entirely new field of endoscopy. Specifically, Kelling was the first to establish laparoscopy as a field by using the novel combination of three methods most closely related to today’s procedure; the abdominal approach, artificial insufflation, and reliance on scopes with full optical equipment (as opposed to simple tubes without optics).

Artificial Insufflation
Kelling’s technique of insufflation was actually a brilliantly new and improved solution to one of our ancient obstacles; expanding the body cavity. He adopted the technique of expanding the abdomen with air with two main purposes in mind: First, he realized it was useful for improving the safety of endoscopic procedures since it helped surgeons avoid hitting organs, a problem which had earlier limited the ability of the endoscope to safely enter the abdomen: Second, as was commonly believed during this time period, the use of injected air into the lungs had been shown to sometimes act as a curative for TB. Artificial pneumothorax therapy, as it was then called, was a somewhat crude surgical procedure that had been known since the time of Hippocrates. However, it often resulted in infection and death from emphysema, especially prior to the use of antiseptics.

To adapt this technology in a safer manner, Kelling mainly referred back to the principles established by the Italian physician Carlo Forlanini, whose substantial innovations in insufflation in the late 1880s helped provide inspiration for many of Kelling’s own techniques.

Even before Forlanini, insufflation of the abdomen was not an entirely new concept. Many others had made important contributions related to this field. Reports about its use as a therapeutic measure were published as early as 1870 by Robert Simons of Bonn, Germany (among others). The earliest known creation of peritoneum in a person was achieved by Albert von Mosetig-Moorhof of Vienna, who in 1882 cured a 4-year old boy infected with TB using this method. Other early contributors who helped advance understanding of the physiology of pneumoperitoneum include John Murphy, a surgeon from Chicago, Willem Nolen of Leiden, Netherlands, and Wegner of Germany. Kelling also worked in tandem with the Czech surgeon Vitezslav Chlumsky. As for early endoscopists, many urologists had been practicing the use of using natural insufflation methods which entailed positioning female patients in the deep Trendelenberg to allow for air to come into the pelvic regions (called air- cystoscopy).

Kelling however, was ultimately the first to take these existing technologies and combine them in a uniquely practicable fashion. He also used a two-trocar site entry (although he had apparently returned to a one-punch site according to Nadeau), a method that was fairly new at the time, and one that most modern laparoscopists of today have ultimately chosen as the best way. And since Kelling lived during an era in which TB was killing some 2 million people around the world each year, he had great incentive to find a safe solution fast.

Kelling also promoted his technique as an efficient way to investigate intra- abdominal bleeding, another common condition which often proved fatal for patients in those days. Kelling not only believed that endoscopic diagnosis could achieve a safe and precise understanding of the origin of internal hemorrhaging, but went further to hypothesize that adding air pressure to the abdominal cavity might even stop the bleeding entirely. Though this particular hypothesis turned out to be wrong, such attempts nevertheless demonstrate that Kelling was well ahead of the curve in attempting to address difficult to treat conditions endoscopically.

Even today, identifying and treating internal hemorrhaging continues to be one of the most formidable problems plaguing surgery. During Kelling’s time, its causes not only stemmed from TB-induced lesions, but also were the result of a wide range of medical conditions, from ectopic pregnancies to ulcers and pancreatitis.

Therefore, Kelling’s pioneering work provided insight into solving a broad swath of very serious conditions which had stopped short the lives of millions. In recognizing how endoscopy could help treat such devastating medical conditions, Kelling’s work proved to be visionary in establishing and defining laparoscopy as an indispensable new field of surgery.

One of the First to Recognize Laparoscopy as a Safe Alternative to Laparotomies
An under-recognized achievement of Kelling’s is his early insight into laparoscopy’s potential role to make diagnostic laparotomies obsolete. Kelling was in fact one of the first in the literature to mention the desire to avoid exploratory laparotomies.

However, during this time period, endoscopic methods could only play an occasional role in providing what really was only a tenuous diagnosis at best. Ultimately however, a laparotomy was the only way, in most cases, to definitively diagnose conditions affecting the abdominal region. Kelling noted however that the patient’s condition often worsened after such aggressive surgery. He therefore introduced his new endoscopic technique as a way to save patients from the dreaded laparotomy. Specifically, Kelling stated that his inventive drive was influenced by a desire to treat patients afflicted by the growing TB epidemic without having to resort to laparotomy, which he knew to be painful and traumatic for the patient.

Kelling was therefore one of the first to recognize and advocate endoscopy as an alternative to laparotomy. By 1898, he had already published two articles on endoscopic methods. In one publication entitled “Endoscopy for Esophagus and Stomach,” [2,3] Kelling wrote: “The endoscopic method finds more usage than has been the case until now, considering the fact that it is truly more useful than the method of laparotomy…”

This foresight was quite unique for his time, for many surgeons still relegated endoscopy to the backwaters of surgery, as it continued to suffer from unpredictable outcomes and seemingly insurmountable technical difficulties.

To help make his new technique more predictable, Kelling also focused on the tiniest details. In fact, Kelling gave some of the most precise instructions concerning the preparation of the patient, some of which were just as rigorous as today’s standards. For instance, he was one of the few laparoscopists then (and even up until very recently) who recognized the importance of purging the patient before the surgery as a preventative measure in case bowel perforation occurred at the time of the trocar entry. This is evidence to astonishingly keen foresight, for even as late as the 21st century, we find that some laparoscopists still have not incorporated this simple preventative measure as standard procedure! Kelling was also cautious enough to recognize important contraindications (relevant to his time period), with the presence of abdominal adhesions being one of the most important. As well, he had experimented with various placement methods for the trocar, finding the preferable angle to be 45 degree, an angle remarkably similar to today’s standards.

Kelling’s Early Days: 1897-1898
Even before his seminal 1901 debut of laparoscopy, Kelling was actually beginning his pioneering discoveries several years earlier. Kelling’s training as a gastroenterologist first led him to explore the possibility of treating ailments affecting the esophagus, lungs, and stomach. In fact, Kelling’s writings emphasized that his methods were (initially) intended for examining the esophagus and stomach and not obstetrical or gynecological related procedures. And the endoscopic world was small back then. To bring us back to previous chapters, it turned out that Kelling learned from and worked closely with Mikulicz of the laryngoscope sword-swallower fame.

For gastroendoscopists, one of the most difficult obstacles was the difficulty in viewing the multiple blind spots of the stomach. After some initial trials, Kelling developed a brilliantly conceived flexible esophagoscope/gastroscope in 1897, inspired by Mikulicz and Stoerk’s “sectional” instruments, respectively. One of the first of its kind, it was designed with the human finger in mind, constructed of vertebrated segments of hollow tubes covered with India rubber, the tip of which could be angulated or pulled straight with what one source referred to as an “ingenious” system of wires which were controlled proximally. It was then illuminated by Leiter’s panelelectroscope or a Kasper hand-held lamp. All the same, this particular instrument of Kelling’s failed to find wide favor.

There is no consensus in the historical record concerning this early work of Kelling’s. One source referred to his flexible gastroscope as “clumsy,” and emphasized its lack of commercial success. However, other recent and credible sources describe it as “a masterpiece of optics and mechanics.” Nevertheless, Kelling apparently wasn’t racked with doubt on this matter. He was so supremely confident of this creation that he decreed “no essential improvements remain to be made.” He did, however, admit that “for long esoph-scopes, the illumination is sometimes not altogether sufficient if one is looking for small objects which are not easily visible.” Kelling also honored his mentors and gave credit to Mikulitz (of 19th century fame) with being the first to recognize the need to look straight into the esophagus as contrasted with various indirect reflective methods using mirror methods (As it turns out, Kussmaul is actually generally cited as the first to recognize the principle of straight endoscopes and of successfully using them in living human beings).

One point can certainly be agreed upon; Kelling was well ahead of the curve in introducing a flexible gastroscope, since flexible esophagoscopes are today the preferred instrumentation for esophagoscopy (made possible only after the invention of fiber optics technologies).

Kelling Conclusion
Kelling’s innovations, particularly the introduction of laparoscopy with insufflation, were truly some of the most spectacular and novel developments to have kicked off the new century. What is most impressive overall is the fact that, more than any other physician of his era; Kelling’s methods are strikingly similar to modern laparoscopy, even down to the most minute detail. Nadeau in his 1925 article summed it up best when he said that Kelling’s work “becomes all the more remarkable when we consider that the technique which he applied and describe almost 25 years ago is with little modification the technique used today.” Indeed, Kelling came closer than any other practitioner of his day to achieving progress in the three areas in which laparatomies were then dominating: providing definitive diagnoses, finding and stopping internal hemorrhaging, and treating pathologies in the most complete way possible. Though ultimately Kelling’s work did not overcome these three objectives entirely, his work did provide some of the most crucial and groundbreaking insight towards understanding how such goals might be attained endoscopically.

Concerning both our original and new set of obstacles respectively, Kelling made some progress on several fronts. Finding a novel solution to the original problem of expanding inner cavities was a particularly unequivocal success. However, Kelling did fall somewhat short in obtaining an accurate understanding of the complicated physiological effects of insufflation. However, given the nature of his era’s medical understanding of such matters, such a shortcoming is understandable.

However, because of his (initial) limited clinical trials and lack of further publications about laparoscopy, Kelling has been somewhat marginalized over the years. For instance, only the address to the audience from his September 23rd, 1901 presentation at the medical congress was published in January of 1902; his work that day was never followed up with a full clinical account or subsequent publications until almost twenty years later. Being late to publish on these results proved to be a mistake of great consequence, for Kelling’s work ultimately became overshadowed by that of Hans Christian Jacobaeus, who achieved greater clinical success, expanded the field of laparoscopy considerably, and made sure to publish his results (publish or perish!).

However, this hasty judgment seems to be rather unjust, for his inventive energies were quite impressive, even by our modern standards. His ingenuity took him across a broad spectrum of endoscopic experiments, ranging from esophagoscopy to gastroscopy to, of course, laparoscopy. By 1923, he was one of the few in the world who could claim twenty-two years of clinical experience using laparoscopy.

As well, Kelling engaged in extensive research in other issues relating to laparoscopy, such as attempting to understand the precise physiological outcomes associated with insufflation. In this area, some of Kelling’s ideas did prove to be a bit off the mark. For instance, he did not realize that too much insufflation could have fatal consequences. However, this failure again must be understood in the context of a time when naturally the medical knowledge of insufflation issues was quite limited.

Even so, many have revisited Kelling’s contributions and have concluded that much of his technical expertise was even more sophisticated than previously thought. Kelling’s innovations were cutting edge technologies of his day, and many of his design principles are still in use. In particular, his idea of a flexible esophagoscope, though ultimately ineffective in his own day, was in fact adopted late in the 20th century after fiber optics made such a design concept possible. In retrospect, though much of his work was not fully developed, his unique design principles and innovative thinking about endoscopy have stood the test of time and changed the field of surgery forever.

Kelling’s legacy has been difficult to reconstruct for another reason, though one far more tragic. During the final days of WWII allied forces destroyed the German city of Dresden in February of 1945 with 650,000 firebombs, killing thousands of its residents in the process. The actual death toll remains unknown to this day, but unfortunately the record is clear that he and his wife perished in this attack. With their entire home charred to the ground, few of Kelling’s own memoirs and other biographical records could be recovered. This is one of the greatest tragedies not only within medical history, but for the history of humankind, for the world lost a great humanitarian on that day.

Dmitry Ott [4] For the 20th century, we finally begin to branch out of Europe and attend more fully to the rest of the world’s endoscopic pioneers, whose earlier works may have been marginalized somewhat through the process of inadvertent historical inaccuracies. We turn to the historic city of Petrograd (now St. Petersburg), to revisit Dmitry Ott, the first surgeon in the history of endoscopy (before Kelling by a few months) to successfully view the pelvic organs in a living human patient using endoscopic principles. For this and his other outstanding contributions, Ott is remembered as one of the Russia’s greatest surgeons and pioneers of gynecologic endoscopy. A professor of gynecology and obstetrics, Ott also headed the Princess Helene Midwife School.

Though some unresolved discrepancies remain within the records, it does appear that Ott did in fact peer inside a living human abdomen a few months before Kelling’s work with a dog by using a modified colpotomy approach, assisted with laparoscope-like techniques. Despite Ott’s primacy over Kelling, over the years Kelling’s work has overshadowed his mainly due to Kelling’s innovation of the modern-styled abdominal approach. In fact, some critics didn’t even consider Ott’s vaginal approach as an endoscopic procedure at all. However, putting aside these contested details surrounding issues of priority and definitions, it stands without question that Ott indeed was the founder of modern gynecologic endoscopy in Russia. In addition, he was one of the first to demonstrate the feasibility of pelvic endoscopy by the vaginal route, establishing an important alternative modality for laparoscopy.

His work was based on the principles of a posterior colpotomy, a well-known (but essentially blind) procedure used by gynecologic surgeons for many years, though the exact originator of the method appears to be unknown. Its primary use was for the removal of cysts, ovaries and fibromas. As well, prior to the perfection of modern-day operative laparoscopic techniques, it had served as the only way to extract the appendix and gallbladder during a laparoscopy. However, Ott’s modified version of this standard colpotomy made the procedure one that for the first time allowed for the direct visualization of the lower abdominal cavity, utilizing endoscopic methods. Naturally, by enhancing visualization, this was the safer choice over blind methods. Ott’s technique (which he named ventroscopy) was an innovation conceived independently of Kelling. His approach was showcased on April 19, 1901 [5], in St. Petersburg’s Meeting for the Gynecology and Obstetrical Society, and was subsequently published in an article entitled Illumination of the Abdomen (Ventroscopia).

Ott was able to achieve visualization of the abdominal cavity by using a combination of instruments, including his own custom-designed vaginal retractor, along with a “tube” to facilitate the actual exposure of the abdomen. An important distinction must be made at this juncture concerning the various types of endoscopes available during these early days. Broadly speaking, there were two types of endoscopes; those with optical equipment and those without. Ott had used the type without optical lenses, which often was referred to as an “open” scopes, or more colloquially, simply a “tube.” Kelling on the other hand used the more sophisticated Nitze scope, which came with lens systems similar in concept to telescopic systems.

For illumination Ott attached to the end of his retractor a “peanut-sized lamp and a spoon-shaped shield to protect the patient from burn,” which was reflected into the cavity using metallic mirrors and a headlamp. This instrumentation was inserted vaginally through an incision made in the Douglas cul-de-sac (posterior fornix). A cotton filter was placed in the vagina, with the patient in deep Trendelenburg position, head downward, pelvis upward. In this way, the abdomen vacuumed the filtered air into the abdominal cavity, creating a natural condition of insufflation. Though other historical accounts credit Nordentoft as the first to adopt the Trendelenburg position for endoscopic procedures, it was in fact Ott who became the first to do so. Ott did not apparently rely on any method of artificial insufflation.

With the ureter catheterized, Ott was also able to inspect the bladder, uterus, and other parts of the pelvic region. During Ott’s era, his method briefly gained some popularity within Europe and was in fact nearly identical to the culdoscopic method so favored by European endoscopists in the early 1920- 1930s, and later by Americans throughout the 1940s-1960s.

By introducing a new method of pelvic endoscopic by the vaginal route, Ott created a niche surgery that served a population of patients who may have otherwise been contraindicated for other methods, particularly laparotomy. It is also important to bear in mind that laparoscopy had not yet been officially invented during this time period. Nor were the endoscopic technologies of the day adequately evolved to handle the types of cases we routinely treat today. Therefore, given the means available during his time, Ott does deserve recognition for adapting existing technologies in combination with his own technical innovations, to come up with a novel solution that enjoyed successful clinical outcomes.

As for Ott’s technical innovations, several stand out. Firstly, he designed special retractors which had light bulbs affixed to the tip which were used for both diagnosis as well as surgeries within the lower abdominal area, bladder, bowel, and uterine cavity. He also modified the operative table and equipped it with stirrups and shoulder-holders, which enhanced his ability to perform procedures in the steep Trendelenburg position.

Other Achievements
Though Ott’s work remains less well known relative to other endoscopic pioneers, this does not diminish the reality of his work, which was characterized by great ingenuity and insight into the problems of endoscopy in its formative years. Ott’s contributions also went beyond his 1901 debut of ventroscopy. He also advocated another version of minimally invasive surgery with a minilaparotomy, and published the results of this new method in 1909.

As well, in 1914, Ott, along with co-author Paul Kapolsky, published a textbook, entitled Operative Gynecology (Operativnaia ginekologiia), which, though not exclusively on endoscopy, nevertheless helped to broaden knowledge about the field considerably for future Russian endoscopists. Because of his numerous works, Ott eventually was appointed head of one of Russia’s most prestigious research institutes in St. Petersburg, which was renamed the Ott Institute of Obstetrics and Gynecology as a tribute to his outstanding contributions.

Discrepancies
Some sources have refused to categorize Ott’s work as laparoscopic or even endoscopic, claiming instead that it was, as one source claimed, simply ”a disguised laparotomy.” To be sure, an incision into Douglas cul-de-sac is not necessarily a minimally invasive procedure. Yet at the same time, it is not equivalent to a full-blown laparotomy that calls for incisions 10-12 cm long. In all fairness, it may be best to leave such essentially insoluble contestations to future historians to sort out. What we do know for sure is that Ott successfully introduced an alternative to open laparotomy using endoscopic principles. At the time, few others had the visionary mind to think so far ahead.

Ott Conclusion
Ott was described as an “outstanding surgeon,” whose repertoire of inventive outpourings ranged from creating specialized endoscopic instruments, to recognizing a need avoid laparotomies. Establishing a new way to safely access the lower abdomen was Ott’s main contribution toward overcoming endoscopy’s main obstacles. However, Ott’s work transcends the list of obstacles in a way, for he helped establish an entirely new conceptual understanding of just what endoscopy might achieve, and made the possibility of finding an alternative to laparotomy a reality.

Ott’s main contributions were fairly substantial. Yet, he worked on the minutiae details as well, including improvements to the operating table, such as shoulder straps to help patients maintain proper positioning, to inventing a completely revamped operating bed for further enhancement of his specialized
procedures.

Though ultimately the preferred laparoscopic approach has come to resemble Kelling’s design principles more closely, Ott’s vision for the field nevertheless provided crucial impetus and momentum toward expanding the burgeoning field of laparoscopy.

Hans Christian Jacobaeus
Hans Christian Jacobaeus, a professor of internal medicine at the Karolinska Institute in Stockholm is credited as one of the founding fathers of endoscopy, not only for becoming one of few to successfully perform laparoscopies using abdominal entry on human patients, but also for performing the world’s first thoracoscopic therapeutic procedure in a living human patient in 1910. Jacobaeus stands out from all other pioneers of his generation mostly for his achieving a greater quantity of clinical success in laparoscopy in human subjects and for boldly envisioning and extending endoscopy into operative use in the thoracic cavity. Jacobeaus was a prolific publisher of articles, with at least ten that we were able to find. Jacobaeus published his last article in 1922, in which herecapped his lifetime of experience with both laparoscopy and thoracoscopy.

Laparoscopy – The Moniker is Born
Jacobaeus was the first to coin the term laparoscopy (originally “laparothorakoskopie”) with his 1911 publication on both laparoscopy and thoracoscopy in humans in the journal Münchener Medizinische Wochenschrift. Jacabaeus reported what he believed to be the world’s first laparascopic case, performed June 10th, 1910 on an electrical worker suffering from hepatic cirrhosis. During this first series in his career, Jacobaeus treated a subsequent 19 patients laparoscopically. Concerning the final total of successful laparoscopies, there are conflicting numbers in the record. What seems mostly agreed to is that his first article of 1910 covered a total of 19 laparoscopies and 2 thoracoscopies. As for Jacobaeus’ seminal 1912 publication, which was by far the most detailed and substantial article, the most credible source cites a total of 97 laparoscopies (with no further thoracoscopies). Others sources report the number to range from 109 to 115. The confusion may stem from subtracting those cases which were not done in humans, but rather in living dogs during demonstrations.

This 1912 report described cases in which Jacobaeus diagnosed patients with various forms of liver disease, including cirrhosis, Pick’s disease, syphilis, liver blockage, as well as other abdominal pathologies such as tuberculosis peritonitis and ascites. Despite all of this phenomenal success with laparoscopy, sometime around 1913, Jacobaeus reportedly switched his attention back to predominantly thoracic concerns related to TB, possibly under the influence of his great advocate Brauer. Despite this shift away from specifically laparoscopic research, Jacobaues’ work nevertheless remained the foundation and gold standard, for thoracoscopy especially, for at least the next 15 years before other technologies, diagnostics, and pharmacologics displaced much of the work. It was to this work that Kalk, Ruddock, and other great early pioneers looked to for much inspiration.

Some of Jacobaeus’ techniques were quite different than Kelling’s. For instance, Jacobaeus did not inflate the abdomen with air as had Kelling. Instead he relied on different positioning techniques that enhanced the visibility of the internal viscera.

For this reason, Jacobaeus generally was only able to perform laparoscopy when stomach-enlarging (bloating) ascites were present in the patient, who mimicked the effects of insufflation. In his career, it appears he only examined eight patients without ascites laparoscopically. His reports on the outcomes of these procedures were overall quite optimistic. His description of laparoscopy’s future was however somewhat muted, stating that the implications for its use would lead someday to the full visualization of both the front and upper parts of the liver, but that he had been unable to obtain any views of value in the stomach region.

Another Small Dispute in Endoscopy’s History
Jacobaeus’ claim to priority concerning the first laparoscopy in humans instigated a strong response from Kelling, whose written retort on the issue appeared two months later in the same journal. Kelling claimed that he had in fact successfully used celioscopy in two humans between 1901-1910, though for reasons left unstated, never published on this until much later in 1923.

Thoracoscopy
In 1910, Jacobaeus had achieved what no one else had been able to at the time [6]: he performed the first ever thoracoscopic procedure on a living patient. A Nitze cystoscope was inserted into the pleural space of patients with pleural diseases so that a visual inspection of the pathology could be established. Jacobaeus pushed beyond these initial diagnostic measures, eventually performing what must be considered some of the early examples of operative endoscopy. Using one cystoscope to achieve direct visualization, he made a second incision, which was used to insert a galvanocautery instrument into the pleural space to cauterize adhesions between the lung and chest wall. Like Kelling, Jacobaeus’ initial innovations were made to treat patients suffering from TB. This particular thoracoscopic technique was designed to establish therapeutic pneumothorax for patients with pulmonary tuberculosis. Jacobaeus’ first article outlining his thoracoscopic methods, entitled “Concerning the possibility of applying cystoscopy in the examination of serous cavities,” was published in October of 1910. In this article, Jacobaeus, like Kelling, paid tribute to Forlanini whose work, as he stated, proved “that one can enter the pleura without injury to the lungs.” Of course, with legends like Kelling and Jacobaeus both citing Forlanini, this brings to light an important realization about Forlanini’s work, which might need to be reevaluated and given more recognition in the history of endoscopy.

Jacobaeus achieved an important milestone in his career during the 1912 2nd International Congress on TB. Many of the greatest pioneers working to combat TB were there, including Forlanini. They were quite interested in hearing about Jacobaeus’ artificial pneumothorax method. Professor Rudolph Brauer, one of the world experts on TB at the time, as well as editor of an important medical journal took particular note. With Brauer’s influence Jacobaeus’ work gained the attention it deserved. With his respect for Jacobaeus, Brauer’s influence may have helped ensure that Jacobaeus’ work was not overlooked. Overall, this conference was one of the most important for Jacobaeus’ legacy, for his work in the field of TB treatment using artificial pneumothorax did gain worldwide recognition after these presentations. In fact, Jacobeus’ methods, along with advances made by Kelling in this area, were the cornerstones of TB treatment until the discovery of streptomycin in 1944 .

Despite the acclaim afforded him for establishing the field, the success of Jacobaeus’ use of thoracoscopic methods seems somewhat debatable. In one of Jacobaeus’ initial findings, he reported that nothing at all could be seen within the pleural cavity with his procedure. His limited clinical data in thoracoscopy seems to corroborate this view, since he apparently only initially reported on two successful cases in 1910, with the next reports on thorascopscy not arriving until 1922. There are records indicating that Jacobaeus continued to perform still more thoracoscopic operative procedures (lysis of adhesions) beginning again in 1913, using galvanocautery techniques. The full report on these procedures is apparently detailed in his 1922 final article entitled “The practical importance of thoracoscopy in surgery of the chest,” published in the journal Surgical Gynecology and Obstetrics. It is not clear however, whether or not his procedures after 1913 were actually fully endoscopic; some may have been open with only thoracoscopic diagnosis without operation, or thoracoscopic-assisted open procedures, rather than full-blown endoscopic operations. Even with these additional cases after the initial two, it seems clear that he achieved success with laparoscopy in a greater quantity of patients, eventually achieving at least 97. Despite these clinical set backs in thoracoscopy, Jacobaues actually reported in his 1911 article that he viewed it as the procedure with greater promise than laparoscopy.

Interesting Detail
One of the most striking peripheral aspects revealed in Jacobaeus’ papers relates to an apparent on-going debate Jacobaeus’ and his colleagues were having in the 1912 era, about whether or not to use exploratory laparotomy or laparoscopy to diagnose patients. Jacobaeus stated that he had heard “very different opinions” on this matter, and that some surgeons indeed approved laparoscopy in some types of cases.

This is an obscure, but all the same amazing allusion if there ever was one, for it demonstrates that laparoscopy was taking place in Germany, at least to some limited degree by unknown early pioneers. There is brief mention of another internist named Hegler, who apparently had investigated for himself Jacobaeus’ endoscopic techniques. Without more details, we certainly cannot speculate further on the matter at this point. However, it would be a good research query for the next generation of medical historians to pursue!

Conclusion
For the early era of the 1910s, nobody came close to achieving the degree of success that Jacobaeus did just in terms of the sheer number of successful laparoscopic surgeries. This is especially impressive when we look back and see just how limited the lighting and optical technologies were at that time. More than that though, it was Jacobaeus great vision concerning endoscopy’s potential that demonstrated his true visionary gifts. He boldly pushed for operative thoracascopy when it had not been proven feasible and predicted that laparoscopy held especially tremendous value for diagnosing tuberculosis, cirrhosis, cancer, and syphilis in humans. Jacaobaues was also quick to adapt the latest technologies for endoscopy and was already using x-ray technology by 1912 in order to diagnose stomach and other gastro-intestinal diseases. Jacobaeus continued to travel throughout Europe demonstrating his techniques and remained throughout his life a prominent and vocal proponent of both and remained throughout his life a prominent and vocal proponent of both laparoscopy and thoracoscopy. His work seemed to have catalyzed an entire generation of laparoscopists in Europe especially, since soon after Jacobaeus’ debut a great flurry of reports on laparoscopy cropped up throughout Europe, and North and South America. Ironically, it was new medical technology that displaced much of Jacobaeus’ work. His therapeutic thoracoscopic method for TB eventually fell out of favor when other treatment options became available, such as improved methods of chemotherapy. It took almost another 100 years for Jacobaeus’ techniques to be rediscovered as important contributions to the field of thoracic surgery. Since lung collapse therapy was no longer needed after cures were found for TB, his work for a time was overlooked. Today, however, thoracoscopic surgeons rightly honor Jacobaeus as the founder of their field. As for laparoscopy, Jacobaeus is universally recognized as one of its most important founding fathers.

Other Important Early Pioneers
Apparently catalyzed by Jacobaeus’ work, many other reports on laparoscopy came out. From the reference list of Nadeau and Kampmeir’s influential 1925 article, from the period between 1901-1925, there are a total of 23 different names listed, 13 of which we have not covered in this review, including work from F. Tedesko (also Todesco) of Austria; WE Stone from Kansas, who reported in 1924 on his experiments which had extended to dogs only at the time; Stewart and Stein of USA, with their 1919 article, Louis Renon of France in 1913, G. Rosenthal, also of France, with a 1913 article, EJ Stolkind of Russia in 1912, A. Johnsson of Finland, 1916, Janssen of Denmark, JL Tierney 1920, Unvericht’s article from 1922 (also the inventor of a new optics system in 1923), Andrea Roccavilla of Itlay with his 1920 publication, Schmidt of Germany, Meirelles of Brazil with a 1913 publication entitled “A laparoscopia” from the journal Tribuna Med of Rio de Janeiro, LR Sante’s 1921 publication, and finally Bernheim of the United States whom we are about to cover. Nordentoft, the next pioneer to come onto the scene, may also have been influenced by Jacobaeus’ work.

Notes
1. The minituarized mignon lamp, which gave off less heat and was therefore considered “cold,” was invented a few years after Edison’s original bulb.
2. Later he revised this publication, changing the procedure name to “coelioskopie.”
3. The article was originally named “On viewing the esophagus and stomach by means of flexible instruments.”
4. Also Van Ott.
5. One source has mistakenly cited the debut of his work as having been in 1903. However, our extensive research uncovered the original manuscript concerning Ott’s work, which was indeed dated 1901.
6. An exception is made for the early work of Forlanini, who apparently did enter the pleural.