Society of Laparoscopic & Robotic Surgeons | Chapter 16

Chapter 16

The Glory Days Part II
1930s

The danger in the use of instruments of this type is over-enthusiasm.
–Beling, 1939

Introduction
Despite the great pall that had fallen over Europe and America due to the great depression events, amazingly, innovation in endoscopy seemed barely affected. Indeed, judging by the list of innovations that came through in this era, one would think it was the season of the bulls. By this time too a number of textbooks on laparoscopy had already been published.

Operative Procedures More Sophisticated, Greater Quantities Achieved
This era also witnessed the great expansion of operative techniques. In the 1930’s, some of the first extensive reports of laparoscopic intervention for therapeutic purposes: lyses of abdominal adhesions, diagnostic biopsies under direct visualizations, and liver biopsies were some of the most commonly described laparoscopic procedures.

While these procedures actually were not exactly new– Kelling, Jacobaues, Nordie and others had performed them in the 1900s-1910s period- the difference during this time was that a greater amount of clinical successes had been reached, with some practitioners reporting upwards of 2000 procedures being performed.

Imaging and Radiology
Other technologies emerging (diagnostic imaging, hemotcrit) that begin to subtly compete with diagnostic lap with the original beginning of x-ray used for therapeutic procedures starting in 1897, by physician named Tuffier of Paris. Tuffier “managed to insert an x-ray opaque ureter catheter to the level of the kidneys and image the kidneys radiologically. By this 1930s time period, such procedures had been around for almost 30 years and were finally translating into significant improvements for diagnostics and minor surgical procedures, such as taking biopsies, which had been performed blindly. It was especially useful technology for stones and other conditions of the upper GI, as the precise location of tumors and calculus’ could be seen. The x-ray images could now be used to control the extraction of stones by the 1920s. Of course, many of these methods were eventually abandoned due to the danger of radiation. Substantial improvements in blood transfusions, anesthesia, and antibiotics were made within the first few decades of the 20th century as well, bringing to medicine almost a sense of inevitable infallibility.

Endoscopic Photography
There was a brief resurgence of interest in the lap after 1939, when color photographs introduced by Hoff and Neefl in 1938 taken laparoscopically provided visual evidence to the lap’s potential. The picture was produced using kodachrome film, and also utilized a mirror reflex camera invented by N. Henning.

Modern Medicine
By this time too, an amazing array of medical knowledge had been discovered, which directly improved the safety and possibilities in surgical procedures of all kinds, with antibiotics, better anesthesia, and blood transfusions being the most influential innovations for surgery. We have here in fact a continuation of that great transformation that began starting in the 1910s, with the famous successes of Jacobaeus, Bernheim, Ott, Kelling, and up to 20 others if our analysis of the literature is correct.

Despite all the momentum in the beginning of this 1930s decade, brace yourself for yet another change of sentiments by the day’s end. For, by the late 1930s, there is a cooling off period that is referred to in much of the American literature, lamenting why laparoscopy is still not that popular.

But before we burst that bubble, let’s continue where we left off, in the bucolic bustling of glory days, part II, where there lived outsized pioneers who were tirelessly working for the great humanitarian cause that is endoscopy.

Introduction to the Laparoscopic Pioneers of the 1930s
Admittedly, during the 1930s it seemed laparoscopy was experiencing an awkward stage of developmental delay, at least when compared to other disciplines, such endo-urology for instance. Of course, they say you shouldn’t compare yourself to others, but across the hall, our fellow endo-urologists were just about giddy with all the head-turning technologies teeming from their shores. For them, the 1930s seemed like the very incarnation of egalitarian endoscopy; there was an innovation for just about every man, woman, and child. Without assuming too much editorial leeway here, it was almost true that for laparoscopy, design techniques and other instrumentation remained relatively the same until the advent of the Hopkins lens and fiber optics. The exception to these overall lackluster realities came in the form of some of this era’s most preeminent laparoscopists of all time: Kalk, Ruddock, Fervers, Hope, and Benedict.

Recap of Optic Technology and Why Kalk’s Change was Significant
Part of the problem with this stall in progress related back to, as usual, that team of double troubles: poor lighting and inadequate optics. Prior to 1929, a puny field of view was still rather problematic for endoscopists, despite the best efforts of Nitze, Grunfeld, Jacoby, and Ringleb to solve this dilemma. Therefore, the fourth task of expanding the field of vision still loomed considerably over the heads of 20th century endoscopists.

To this task we turn now to one of the world’s most famous laparoscopists, one who is considered today as the father of modern laparoscopy.

Heinz Kalk
The German gastroenterologist, Heinz Kalk, is considered the founder of not only the German school of laparoscopy, but has over the years earned the broader title of “Father of Modern Laparoscopy.” His engineering genius led to a completely revamped laparoscope which Robert Fear called the “first high- quality instrument” ever devised at that time. Born in Frankfurt-Main in 1895, Kalk’s life has been described as “extraordinary.” Over the years, Kalk has become most known for his innovation of a lens system. However, like a true visionary, his contributions were in fact exceptional in multiple areas; in innovations of technique and technology, in research, and in his prolific publications. Perhaps of most significance, Kalk was one of laparoscopy’s first pioneers to routinely extend the scope into therapeutic procedures with verifiable success. This breakthrough alone launched what would become a century-long journey toward laparoscopy’s defining moment as the reigning champion of minimally invasive surgery.

1929 – Kalk’s Breakthrough Expansion of the Field of View
At the end of the 19th century, some of the best designed endoscope’s still only had a viewing angle between 80 degrees and 85 degrees, and a field of vision reportedly as small as 44.2 millimeters in diameter at a range of 2.5 centimeters. Though Nitze, Grunfeld, Ringleb, Jacoby, and so many others certainly gave it their best, at the end of the day their efforts amounted to only nominal changes. Therefore, the fourth task of expanding the field of vision still loomed over the heads of our early 20th century endoscopists. The world really needed a revolutionary change in order to rid our poor scope of its rinky-dink optics.

Enter Kalk:
In 1929, Heinz Kalk solved this field of vision problem, which had been one of the longest standing difficulties afflicting endoscopy. Though a forward-viewing instrument (135 degrees) had been introduced two years earlier by Kremer, Kalk was able to adapt this existing technology into a more practicable and successful instrument. With the introduction of his own modified foroblique lens system, Kalk was able to so effectively increase the field of vision that finally substantial progress could be made in both operative and diagnostic techniques.

Indeed, Kalk was so many light years ahead of the curve with this idea that another thirty years passed before any further improvements to the optical system were made. Other refinements in technique promoted or modified by Kalk include standardizing the use of a separate pneumoperitoneum needle, as had been introduced earlier by Kelling and Korbsch, among others. Kalk is also considered the founder of the dual trocar approach. Though again he was not the first to invent this technique, he was one of the earliest to routinely apply it, as well as make certain refinements in technique which increased its safety.

What Drove Kalk to Innovate – Liver Biopsies Made Safe by Kalk
It is amazing to think that just a few years before Kalk, taking endoscopic biopsies of the liver (a rare procedure in those days to begin with) was fraught with a high risk of mortality because it could only be performed in a nearly blind state using still dangerously imperfect electro-cauterizing tools, all of which led to high incidence of uncontrollable bleeding and overlooking carcinomas to boot. Surgeons of the day believed – justifiably at the time- that only by thoroughly palpating the organ during a laparotomy could one come to discover the deeply-embedded nodules of cancer. This view was substantiated by many early reports on diagnostic larparoscopy which reported that the scope could not sufficiently illuminate certain areas of the liver and had therefore been unable to detect deeply-embedded nodules.

Kalk was deeply disturbed by the high fatality rates associated with these blind biopsies and especially wanted to help alleviate this devastating outcome for what was supposed to be a simple procedure. With his numerous refinements and inventions, Kalk became one of the first ever to introduce a safe and accurate method of endoscopic liver, gallbladder and kidney biopsies. Because Kalk was able to broaden the scope’s usefulness, the result was that the entire field was re-invigorated. As a result too, it moved surgeons that much closer to abandoning forever exploratory laparotomies.

One of First to Obtain Substantial Clinical Experience with the Endoscope
Kalk stood out not only for his visionary inventions, but for his world renowned expertise as a gastroenterologist in general. During his long career an entirely new category of virtuoso had to be defined to keep up with the pace of his clinical success. Patients from all over the world flocked to see him, turning the hospital in which he practiced – the Stadtkrankenhaus – into one of the most well regarded in all of Germany.

Combining his virtuoso clinical skill, along with his technical acumen, Kalk became one of the few who achieved substantial and consistent clinical success. By 1939, he published what was at the time one of the largest series of successful laparoscopic surgeries, reporting on 2000 laparoscopic procedures, all of which were performed under local anesthesia and apparently without a single mortality. This was in fact an astonishing achievement, since at the time others were experiencing mortality rates for taking biopsies in the range of 2- 5%. This fact alone establishes Kalk as one of laparoscopy’s true virtuosos. Besides biopsies, Kalk’s worked on some of the most advanced therapeutic laparoscopic interventions the world had seen at the time. By 1934, he had applied to laparoscopy the latest radiological technologies by attaching radiological cathodes to the endoscope to treat gall bladder and liver disease.

In the end, Kalk put routine, safe and accurate laparoscopic diagnosis of liver, kidney and gallbladder disease on the map as a finally safe and accessible modality that would help potentially millions to avoid the devastation of laparotomies. With his brilliant innovations and clinical precedence in place, laparoscopists finally were able to consistently and reliably perform a multitude of laparoscopic procedures, including finally those in the operative category.

Etiologies Uncovered – Kalk Helps Discover Virus as Cause of Hepatitis
Kalk’s work with laparoscopy helped improve the etiologic and differential diagnosis of disease states in another way too. With the new ability to gain access to biopsies in a much safer manner, physicians could now have a chance to conduct greater levels of research. In just this manner, Kalk helped discover through his numerous case studies of liver biopsies that hepatitis was caused by a viral infection. He therefore also goes down in history for his substantial contributions to hepatic research.

Some Areas of Contestation
There are essentially no negative reports about Kalk, which is certainly a refreshing change, given all the intense disputes we’ve covered so far. The slightest hint of doubt was expressed by Benedict, an American laparoscopist whom we will review shortly.

He alludes to Kalk’s description of laparoscopy’s safety record as being a matter that could stand for greater qualification. In one of Kalk’s first articles, he had made the claim that laparoscopy was essentially “without danger,” though not ignoring its potential for serious complications such bowel perforations and insufflation complications, Kalk had come to this conclusion after performing 100 examinations in which there had been “no damage.”

However, Benedict qualified this statement by pointing out that there were many contraindications that must be observed with great care. Of course, Benedict reports this in 1937, which naturally provided him with an unfair vantage point to Kalk’s 1929 preliminary report on the matter. Even so, these comments provide some important insight into the sorts of dialogues that were taking place in laparoscopy’s formative years. Just as is true today, not all practitioners brought to the table the same clinical or surgical skill. Perhaps in Kalk’s gifted hands, he achieved a level of success that may have been unattainable for others. There may also have been subtle differences in technique that developed between European and American laparoscopists.

The other issue causing for some degree of uncertainty relates to Kalk’s report of performing 2000 procedures without mortality. Due to issues of translation, we were not able to verify these reports with the level of precision we would have liked. While we definitely do not wish to cast doubt where none may be warranted, we do know that laparoscopy even in modern times has the potential to cause some degree of mortality. In addition, since laparoscopy at the time was still burdened by ineffective technologies in lighting and electro- cautery especially, it seems fair to say that this one particular area could stand to be researched more fully. Perhaps the next generation of historians will be able to gain a better understanding.

Conclusion Kalk
Without qualification, Kalk’s work was unprecedented for the times. Kalk is described as being the first to make laparoscopy a useful, practical and safe procedure. Indeed, Kalk became the singular force behind laparoscopy’s dramatic expansion and acceptance experienced throughout the world during the next several decades. Physicians from several different countries continued to cite his first 1929 article for years to come. It was Kalk more than anyone who became the decisive voice in steering Europeans away from the culdoscopic technique that had temporarily supplanted laparoscopy in America during the 1940s-1960s. For this reason, Europeans had a distinct lead in laparoscopic development until the 1960s.

Perhaps of most lasting value, his technical and clinical insights impacted the lives of potentially millions by offering to the world for the first time a safer way to perform diagnostic laparoscopies, a change which directly and dramatically reduced mortality rates for what were supposed to be routine diagnostic procedures. He was also a tireless researcher and prolific writer who wrote more than just about any other laparoscopists in his lifetime, publishing by the end of his career over one hundred articles. Kalk continued his clinical practice and research well into the 1950s, working ceaselessly to perfect various procedures. This was the case, even though he apparently almost “didn’t make it out alive [during] the Stalingrad invasion of Russia of 1943.”

In 1949 he was appointed chief of the Department of Internal Medicine of Kassel’s hospital called “Stadtkrankenhaus,” making it, as one German researcher pointed out “one of the most interesting places to be in for hepatologists and laparoscopically working internists.” During the 1950s Kalk was still innovating and began collaborating with Karl Storz to develop still more instruments. Later, Kalk eagerly tried out the latest technologies and was one of the earliest to use the Optical Esophagoscope Universal developed by Storz. The world lost a truly gifted physician, inventor, and visionary when Heinz Kalk died in 1973.

Veress Needle
In 1937, the Hungarian physician, Janos Veress developed a needle that was a major advance for laparoscopy. Indeed, today we still use that same Veress needle of 1937, virtually unchanged.

Its main purpose was to perform therapeutic pneumothorax to treat patients suffering from tuberculosis. However, laparoscopists quickly realized its potential as a safer method for creating pneumoperitoneum. The most striking safety feature was spring-loaded obturator that allowed safe insertion and insufflation of the peritoneal cavity. Amazingly, it had multiple talents and could be used for draining ascites and evacuating fluid and air from the chest as well. Veress eventually reported his use with it in over 2000 cases. He originally did not suggest that it be used for laparoscopy. Though Goertze and others invented similar needles almost twenty years earlier, the design improvements, added functionality and especially the enhanced safety make Veress’ contribution the innovation that changed everything for the better.

THE AMERICANS – 1930s

John Caroll Ruddock – 1891-1961
“Laparotomies for diagnostic should be condemned”
–John Ruddock

John Ruddock, an American internist from Los Angeles, was light years ahead of his time when he made this bold proclamation concerning exploratory laparotomies. The year was 1934, just when the popular 1910s fervor over laparoscopy as a new modality was beginning to visibly wane. Ruddock, with his outstanding and far-reaching contributions, was just the outsized catalyst that the 1930s needed to help revitalize the very life of laparoscopy. Today, Ruddock is considered by many to have been the principle driving force behind laparoscopy’s progress and acceptance in the United States during the 1930s and beyond.

Ruddock became the singular force responsible for advancing early operative laparoscopy in a time when American physicians still regarded it as fraught with unpredictable and unacceptable levels of complications. Indeed, one source explains the influence of Ruddock succinctly, stating “Before the Second World War there were two centers of laparoscopy in the world: Germany (Kalk) and the United States (Ruddock).”

With Ruddock’s meticulous attention to both the technical side of things, as well as matters of technique, he was able to work out many of the laparoscope’s main flaws. In this way, he became one of the first American pioneers to report on a significant amount of procedures, performing in his lifetime an incredible 5000 [1] laparoscopies, all with low levels of morbidity and mortality. He was also was one of the most vocal and influential advocates for laparoscopy, and continued to promote its use throughout his lifetime.

The timing was not exactly perfect for Ruddock to work with the laparoscope. You will recall that in 1925, Case came out with a most damning report, detailing laparoscopy’s most unbecoming features of insufflation embolism, bowel perforations, not to mention the hideous reality of its horrendous illumination.

Laparotomies Really Begin to Get Scrutinized
Like Kelling almost 30 years earlier, Ruddock also recognized that laparoscopy’s role as a diagnostic surgical technology was “many times superior to laparotomy.” He also understood that the problems of visualization stood as the most limiting factor. There were many technical reasons for this shortcoming, stemming from both the light source itself, as well as from the optical systems. The problem also related to the fact that there were no custom-made scopes specific to laparoscopy at this time. Rather, the instruments on the market were all essentially modified versions of cystoscopes, which had optics and other features designed with the contours of a urethra entry point and environment in mind. To this problem Ruddock set his energies and in 1934 he devised an optic system that has been described as one of the most sophisticated and crucial innovations of this pre-Hopkins era.

Ruddock was not afraid to seek out experts and learned a great deal from European endoscopists, particularly from “thoracoscopists” who had discovered better optics for viewing the chest cavity more clearly. At this time, the work of Kalk was widely known by American laparoscopists and so it is likely that Ruddock drew inspiration from his work. As well, he gained insight into electro- cautery from American urologists whose work in this area especially had been on the cutting edge. Drawing from all of these different elements and in collaboration with ACMI, Ruddock modified a McCarthy cystoscope and developed an optical system that allowed for a greater viewing area of the abdominal cavity to be captured. Referred to as a “foreblique visual system,” this innovation brilliantly solved a problem that turned out to be a matter of only a few degrees. Although Ruddock is not exactly the first to invent this type of optics system– Kremer and Kalk introduced their versions in 1927 and 1929 respectively– still Ruddock deserves credit for recognizing these disparate technologies and bringing them together into one smooth operating unit. Ruddock realized that a 45-degree indirect viewing angle was far superior for laparoscopes than the standard 90-degree angle found in the optics of cystoscopes. In 1937 Ruddock also attached an ACMI photographing unit to his laparoscope, becoming one of the earliest to experiment with laparoscopic photography.

From the Brink of Extinction: Bringing Operative Laparoscopy Back to Life
The other most important feature that Ruddock added was the built-in biopsy forceps which were capable of both cutting and coagulating. In other words, Ruddock offered for the laparoscopists an instrument capable of performing simple operations, albeit mostly with biopsies in mind. Some histories under- emphasize this point about Ruddock, portraying Ruddock as one who performed only diagnostics. This is definitely not the case, as he went on to perform what in those days were the most sophisticated- and just about only existing- operative procedures of the times: lyses of adhesions, draining of ovarian cysts, and taking biopsies.

The operating component of his system featured built-in biopsy forceps equipped with the newly available bipolar electro-cautery units, derived from the Stern-McCarthy cystoscope. While this detail alone may not seem impressive at first, recall that in later decades, many American laparoscopists actually forgot about the superior safety features relating to bipolar systems. The biopsy forceps were equipped with the telescopic unit, so that the biopsies could be taken under direct vision. Air could be introduced into the shaft of the scope at any time for air irrigation.

His procedures were performed using insufflation methods established by Kelling and improved with the Veress needle.

The pre-op with the patient was remarkably reminiscent of modern methods. The patient was prepared as if for laparotomy, including fasting stomach, empty bladder, and preliminary sedation with barbiturates and morphine. The same midline just below the umbilicus was the site of the trocar puncture. The most astonishing difference is that only local anesthesia was used (novocaine injected into the abdominal area), something difficult to contemplate today. Regular atmospheric air was used to provide the insufflation. During this time, patients were carefully selected. Just like today, those having pulmonary or cardiac disease were cited as not good candidates.

Like Jacobaeus, Ruddock’s operative procedures were modest in scale, at least as viewed from our modern perspective. His main operative accomplishments were in the taking of biopsies. Yet, this was no small matter in those days. As you will recall, prior to the perfection of electro-cautery technologies, biopsies had actually been a procedure burdened with great risk of mortality due to hemorrhaging. “Bleeders” such as the liver, kidney, stomach, and pancreas were essentially off limits due to the added difficulties associated with inadequate illumination. For this reason, surgeons were especially reluctant to switch from their tried and true diagnostic laparotomies, with its known risks, to the unknowable territory of a new, unproven technique. Ruddock himself ultimately advised against doing kidney and pancreatic biopsies since he described these regions as nearly impossible to visualize adequately. This is somewhat different than the experience of Kalk, who did end up pushing the scope into this region. Yet, this may simply speak to the difference in comfort levels that they had for risk, with Ruddock apparently the more conservative of the two.

Ruddock named his device the peritoneoscope and went on to describe his success with its use in his first series of 200 patients in 1934.

Later in 1937, he was able to report initially on over 500 cases, which dealt with biopsies, as well as a broad range of conditions such as bladder diseases, draining of ascites, lysis of adhesions, and other lesions of the abdomen such as neoplasms of the stomach and colon. Ultimately Ruddock reported on a grand total of 500 cases by the end of his career, a publication which became widely disseminated and influential in the United States.

It is even more impressive to look back on Ruddock, situated as he was in the 1930s, before fiber optics, before Hopkins, and realize just how much risk he assumed in re-investigating and establishing even more operative procedures. In retrospect we can see that his work in this respect marked a crucial turning point for laparoscopy in America, for not even diagnostic laparoscopy had gained enough credibility to hold sway to any significant degree. As for operative laparoscopy, for all intents and purposes, in the United States it essentially remained a procedure practiced by precious few. Only a few clinics scattered throughout the world had begun experimenting with operative laparoscopy.

This was the reality, despite all the achievements in operative laparoscopy so famously achieved by the American pioneers Orndoff and Bernheim from just the previous decade. For this reason Ruddock stands out as one of the most important pioneers in the American history of endoscopy especially, for having the vision and courage to push the laparoscope’s usage closer toward operative procedures- in both the upper and lower abdomen- in an era when not even diagnostic laparoscopy had been entirely welcomed.

Re-Establishing the Scope’s Superiority in Diagnostics
Ruddock also provided even more evidence of the scope’s superior diagnostic capabilities (compared to other non-invasive ways). He became one of the first to take careful measurements to show just how much the laparoscope improved diagnostic accuracy.

He found this particularly true in diagnosing stomach carcinomas, a fact which turned out to be a critical turning point for laparoscopy. Using the laparoscope to make diagnoses of the stomach region had actually been achieved by very few. Other prominent pioneers had found difficulty to access, including Jacobaeaus, Kalk, Beling, and many others. In this instance especially, Ruddock was definitely well ahead of his time.

Ruddock’s statistics on stomach diagnostics in particular are simply breathtaking for the times. Aided by the laparoscope, he reported a diagnostic accuracy rate of 91.7%, compared to just 63.9% achieved without its use (in other words, using other methods that internists generally relied upon, including clinical observations).

At that time metastasis of stomach cancer was considered completely inoperable. Exploratory laparotomy that found metastasis was always seen as a wasted and unnecessary procedure after the fact, one which unnecessarily precipitated death, or at the least, diminished the quality of the patient’s precious remaining life. Ruddock’s statistics revealed a 6% mortality rate after laparotomy for those patients with stomach cancer, with only a 25% chance that it would prove to be operable. Therefore, being able to determine metastasis beforehand was an essential tool to help avoid unnecessary laparotomies. That way, the patient at least had a chance to convalesce rather than be plunged into more pain and suffering without even a curative aspect to it. We feel retrospective sadness in knowing that these life-saving results were never fully recognized in Ruddock’s era, or indeed for many years thereafter.

Ruddock differed from Kalk on the usefulness of laparoscopy in stomach cancer. Kalk believed its diagnostic value was quite limited, since (in 1929) not much could be seen.

Ruddock also raised an interesting point when he mentioned the diagnostic x- ray, which his experience revealed to have an impressive 95% accuracy rate when it came to diagnosing stomach carcinomas in particular. Yet it was that 5% that he was after, as well as what he referred to as that “extra level” of confidence which visual confirmation provided which made the scope such an indispensable tool. By providing such superb statistics and careful clinical analysis, Ruddock became one of the first to gain the necessary clinical evidence which ultimately helped drive diagnostic laparotomies into long overdue obsolescence.

As for diagnosing carcinomas of the liver, Ruddock found his laparoscopic technique achieved up to a 90% degree of accuracy. For all diagnostic procedures combined, Ruddock determined the clinical accuracy of laparoscopy to be 93.6% overall.

Ruddock Proceeds with Caution
It seems Ruddock was fully aware that new technologies could attract suspicion and scorn. To this element, Ruddock offered reassurance, stating in 1937 that the “peritoscope will not and cannot replace a laparotomy.” Still, he mentioned that this method was better than laparotomies, which had the prolonged hospitalization and discomfort and costs.

Some Shortcomings
Criticisms aobut Ruddock were certainly difficult to come by; where were the full scale academic brawls of the Nitze-Leiter lore? Don’t worry; we’ve got plenty reserved for the 1990s. Yet, for this era, it seems there was indeed a kinder, gentler nation of endoscopists. All the same, the excellent research of Litniski found a most telling comment by Ruddock that keenly exposes his great misunderstanding concerning insufflation. In his 1934 article, Ruddock stated that “it is not easy to measure the quantity of air used, as the abdominal cavity is not sensitive to inflammation.” This state of oblivion with respect to insufflation was not the sole province of Ruddock or his contemporaries. Indeed the physiological understandings of insufflation would not be fully worked out until many decades later.

As for the number of procedures, based on Ruddock’s original article from 1951, we confirm that he was at that time working on a large series of patients that had reached a total of 5000 by that time.

As for uncovering morbidity and mortality rates from over eighty years ago, it is probably safe to say that we will never be able to assert anything at this point with much confidence. In general, medical articles of this era are a bit notorious for their lack of clarity when it comes to mortality rates. For endoscopy, this was no exception. Therefore, we proceed with caution in this area. What we do know for certain is that Ruddock did experience one mortality in his first series of 500 patients, stemming from taking a biopsy of a carcinomatous nodule in the liver. He reflected that he believes this could have been avoided if he had more thoroughly coagulated the biopsy site. We also know he reported eight puncture wounds of the bowel, also from his first 500 cases.

Another way to gain insight into issues concerning complications rates is by reviewing what others reported about laparoscopic mortality rates in general for the time. One of the best articles for shedding light into this subject was written by Beling in 1939, who plainly admits that mortalities were occurring, stemming from in particular that notorious nemesis of laparoscopy; bowel perforations. Mention of complications arising from insufflation and electro- cautery was nearly non-existent at this time since such technologies were still too new to be have been understood fully in the first place.

Conclusion Ruddock
Ruddock’s careful studies that revealed laparoscopy’s superior diagnostic value resulted in a resurgence of trust and popularity for the discipline, a fact that certainly had a direct impact on the lives of many patients. Yet more than that, Ruddock’s early work in pushing the scope into the operative domain turned out to be that one crucial factor absolutely necessary to lift operative endoscopy off the ground. Indeed, later reports from 1939 for example, speak of the era’s recent flurry of activity in laparoscopic methods, which was partially attributed to Ruddock’s success.

Perhaps just as significantly, Ruddock worked tirelessly to advocate for the laparoscope and was described by one source as the most “vocal proponent of laparoscopy in North America.” However, the reason for his fervor always centered around improving the lives of his patients, whom he wished to protect from the trauma of exploratory laparotomies. With this in mind, Ruddock made a plea to internists and surgeons to work more cooperatively toward this ultimate goal of bringing minimally invasive care to patients.

Though Ruddock’s career was temporarily suspended with the events of World War II in 1941 because of his recruitment as an army medical surgeon, after the war he continued to work on advancing laparoscopy. In fact, he published one of his most excellent works on the subject after the war, in 1951, with his widely acclaimed article entitled “Peritoneoscopy: A critical Clinical Review.”

Carl Fervers – The First Operative Gynecological Laparoscopy
Many credible sources including Kurt Semm’s articles on the subject, name Carl Fervers, an American gynecologist and general surgeon, as the first to perform an actual, truly operative laparoscopic procedure, with his successful laparoscopic lysis of adhesions. The groundbreaking work of taking biopsies, while requiring some operative elements, ultimately was not as close to an operative procedure as was the lysis of adhesions.

The procedure was made possible by the recent improvements made to electro- cauterizing endoscopes, most notably the Stern-McCarthy bipolar system introduced in 1926 by Max Stern. Fervers quickly understood the potential that this improved electro-cautery had for gynecologic laparoscopy. Using a modified-cystoscope equipped at the distal end with the electro-cautery component, Fervers became the first ever to cut and divide intra-abdominal adhesions by applying the coagulating tip of the scope to the adhesions.

Though mentioned less often, in that same year Fervers also is the earliest Americans to report on performing a liver biopsy laparoscopically, just before Ruddock. In his article Fervers expressed concern about the “audible explosions and flashes of light” caused by the combination of the electro-cautery equipment with the atmospheric air (oxygen) which the abdominal cavity had been filled with. This is a great snapshot of just what sorts of troubles had to be endured to get laparoscopy off the ground! With the adverse affect, Fervers was quick to look for a solution and suggested using CO2 instead.

It wasn’t long before others heard of his work and attempted their own experiments with the new modality. From approximately this point on in fact, the application of electro-cautery in laparoscopy became a mainstay of the 20th century.

Conclusion Fervers
Fervers’ work was absolutely groundbreaking. Prior to this time, operative endoscopy had been essentially the exclusive domain of endo-urologists. In this way, Ferver’s recognized that the time was ripe to move forward and like a true pioneer, despite the lack of precedents, he leaped forward and took that tenuous but extraordinary first step which finally startled gynecological laparoscopy out of its great slumber and toward its phase of awakening evolution. Though there is an unfortunate paltry supply of information about Fervers in the literature, his work nevertheless deserves a prominent place in laparoscopy’s great halls of fame.

Early 20th Century Gynecologic Laparoscopists – 1930s
It is said that the early 1930s saw the first round of activity from gynecologic laparoscopists. This was the first decade in which the American Board of OB- Gyn’s came into existence, established since 1930.

In Benedict’s own review of the literature of this time period, he found that the laparoscope had been so far used in the following conditions: liver diseases, including cancers, ascites, neoplasms of the stomach and colon, and female pelvic diseases including uterine tumors, ovarian tumors ectopic pregnancies. Benedict noted that this surge in interest had been influenced by Ruddock.

By the 1930s there were some sophisticated operations performed using hysteroscopy as well. R. Segund in 1934 developed a hysteroscope to overcome the issue of over distending the uterus by using a smaller caliber input device than for the output.

Moving away from the last few overviews concerning the work of internists, we now highlight the progress achieved by our early brethren practicing some of the earliest documented instances of gynecologic laparoscopy performed in the modern abdominal entry with insufflation.

Robert Hope
Another working in early gynecologic laparoscopy was Robert Hope, who was one of the first Americans to apply the laparoscope to gynecology and was one of the most influential in the field. In 1936, he published what was apparently the first gynecologic report on the use of the laparoscope to secure a definitive diagnosis of an ectopic pregnancy, reporting that his method had a high rate of accuracy.

As for the current day’s drawbacks, Hope added a great deal of insight into what was frustrating his efforts. He mentioned that bleeding caused several problems for the laparoscopists, including the fact that one couldn’t be sure where it was coming from, but also because the blood diminished the view that one could obtain from the scope. For these reasons, Hope reported that if the abdomen bled, the procedure must be converted immediately to a laparotomy. At the time too, a ruptured cyst required laparotomy.

Hope was also attempting to advance operative gynecologic laparoscopy, attempting especially to achieve the laparoscopic sterilization. His work in this area over the years has been overshadowed by others who were able to achieve laparoscopic tubal ligations before he did. However, Hope’s contributions for American laparoscopy were still influential and were important for its continued acceptance and development.

Edward Benedict
In the late 1930s, Edward Benedict of Boston was considered one of the leading endoscopists in the United States. Like many other exceptionally talented physician-inventors, he contributed substantially to a number of endoscopic disciplines, including gynecologic laparoscopy and esophagoscopy.

Benedict’s First Endoscopic Work – Gastroscopy, Esophagoscopy
Benedict became so enamored with the scope that he actually quit working in general surgery to dedicate himself entirely to endoscopy. At this time, German endoscopists had been much more accepting and active in gastroscopy and esophagoscopy. However, there was a small group of American pioneers whose dedication to the discipline led to important innovations early on, of whom Benedict became the most renowned. In 1933, at the Massachusetts General Hospital, Benedict, working with the lead endoscopists, Chester Jones, conducted what were described as the first American trials using the Wolf- Schindler gastroscope (developed in Germany). Using this instrument, Benedict and Jones performed a gastroscopy for the first time on April 6, 1933. Apparently with just this first experience, Benedict was hooked. He gave up general surgery and dedicated himself to all types of endoscopy, including laparoscopy. After achieving over 75 patient trials, he ultimately found the gastroscope (with the assistance of x-ray technologies too) to be most useful with diagnosing stomach tumors, gastritis, and gastric ulcers.

Turning Point for Gastroscopy – Benedict’s 1948 Operating Gastroscope
Prior to the late 1940s, gastroenterologists relied mostly surgical means to obtain biopsies. Others had attempted to incorporate a biopsy component to the early scopes, with the efforts of Bruce Kenamore in 1940 as one of the most notable attempts. It was Benedict though who was able to get all the components to work smoothly together. In 1948 he introduced his operating gastroscope, which included biopsy forceps and a suction tube. Benedict tried to overcome the shortcomings of Kenamore’s device, but found the only way to do so was to increase the diameter of the instrument, which ultimately was the downfall of his device. Widening the size to 14 mm, it was substantially wider than the 11 mm scopes that Schindler had deemed to be the maximum size for comfort. For this reason, the patients were less able to tolerate the device, which often triggered the choking response. Nevertheless, Benedict really believed that internists had to do more than just peer into the stomach. He fervently believed that obtaining biopsies was the only way physicians could obtain a definitive diagnosis and argued that the advantage of obtaining a more definitive diagnosis far outweighed its technical shortcomings.

In fact, during the early 1950s, Benedict’s opinions on this matter of biopsies set off an intense debate amongst gastroenterologists, with the new Benedict school of thought saying that it would be completely irresponsible not to take biopsies in every patient. Prior to his work, gastric biopsies were reserved predominantly to differentiate between diffuse carcinomas and lymphomas. In general though, biopsies were not taken for every presenting patient. With Benedict’s influence though, slowly others began to see the importance of taking biopsies as a routine part of their practice. Benedict’s device was one of the few on the market to offer the operating feature and, of this group; his was the instrument of choice into the 1960s. Ultimately though, it was not widely used due to the intolerance by patients and misgivings of physicians. Eventually time would prove Benedict’s theoretical arguments about the need to take biopsies in every patient to be absolutely correct. However, he wasn’t able to push the idea further until the advent of fiber optics made smaller, flexible scopes possible.

Gynecologic Laparoscopy
By at least 1937, Benedict had also applied the scope to other disciplines, working in both the upper and lower abdominal regions. Like so many others of the era, Benedict had been inspired in part by the work of Kalk. In 1937, Benedict published one of the most detailed reports on laparoscopy to be found in the literature. In this article, he (or his group) had already performed a total of 48 laparoscopies [2]. One of his most successful cases in this series involved one of the earliest instances of operative gynecologic laparoscopy, in which he was able to aspirate a large ovarian cyst of an 85 year-old woman.

His general techniques were similar to those prevailing at the time, such as the use of two trocar sites, atmospheric air to insufflate the abdomen, and relying only on local anesthesia in conjunction with sedative drugs.

Benedict Establishes Contraindications for Laparoscopy
Benedict did suffer the loss of one of his patients, which was described as stemming from insufflation complications, along with the inability of this particular patient (with terminal lung cancer) to tolerate the use of sedative drugs administered pre-operatively. It seems with this early experience of adversity, Benedict became especially insistent on determining contraindications more carefully. This sentiment can be discerned when he gently calls into question the remarks by Kalk, who had reported laparoscopy as being essentially “without danger.” Perhaps he was unfamiliar with other articles by Kalk, which came out later giving more detailed indications. In any case, Benedict became one of the first American laparoscopists to give exquisitely defined information about what he believed to be the contraindications of laparoscopy. Benedict mentions many that are no doubt familiar to us today, including the presence of abdominal adhesions and patients with pulmonary or cardiac concerns. In those days before antibiotic use, an inflamed pelvis was also described by Benedict as being a contraindication.

Benedict was careful to explain instances in which the laparoscope failed to diagnose accurately. He gave excellent detail about the difficulties of properly diagnosing carcinomas of the liver, reporting that in case a cancerous liver was overlooked because its surface appeared normal, but that upon palpation nodules were discovered. Later with laparotomy it was discovered that there was a very subtle bulging of the liver as well.

Conclusion Benedict
Benedict was among America’s small group of trailblazing endoscopists whose numerous contributions were crucial for getting the field out of the shadows and into a real practicable form. Benedict also performed some of the earliest work in operative gynecologic laparoscopy in America. As well, Benedict’s clinical work was light years ahead of his time, especially with respect to the care in which he noted contraindications. He was also one of the first Americans to begin experimenting with gastroscopy, which he recognized early on held tremendous value for the field of gastroenterology. Benedict’s advocacy of laparoscopy and gastroscopy was crucial for getting the field off the ground at this early stage. Few were willing to take on a new modality so misunderstood as endoscopy, especially when exploratory laparotomies had by this time become a wide-spread accepted practice. In fact, many in the late 1930s were beginning to grow suspicious of laparoscopy and by the 1940s, Americans had switched almost exclusively to culdoscopy. For these reasons alone, Benedict must be considered one of endoscopy’s irrefutable pioneers, in similar league as Orndoff, Bernheim and other American endoscopists of the early 20th century.

C. Abbot Beling, Newark, New Jersey, Newark City Hospital
“Miracles were wrongly hoped for in situations where the use of the peritoneoscope was not indicated”

The American internist, C. Abbot Beling of Newark, New Jersey, proved himself to be one of the most accomplished pioneers of his day, achieving for laparoscopy some of the most crucial milestones. On par with such famous pioneers as Kalk, Ruddock, and the French pioneers already reviewed, Beling also achieved tremendous success in the area of liver biopsies. In one of the most exciting firsts of laparoscopy, Beling was among the earliest to successfully remove a small section of the liver laparoscopically.

We have derived most of the information on Beling directly from his two articles on the subject of laparoscopy, published back to back in the years 1938 and 1939, respectively. In both articles, Beling provides exquisite detail of what he believes to be the benefits of laparoscopy, giving highlights of his case studies to support his views. He viewed the laparoscope to be most effective in making definitive diagnoses of tuberculosis peritonitis and in taking biopsies. Most crucially, Beling wrote his articles specifically as a comparative piece, giving us a rare, side-by-side comparison between diagnostic laparoscopy and diagnostic laparotomy, one of the first series of articles of their kind. He also compares laparoscopy to the traditional non-invasive diagnostic techniques that internists generally fell back upon before calling in “the surgeons.” For instance, Beling notes that before laparoscopy making a definitive diagnosis of tuberculosis peritonitis could only be determined laparotomically.

As far as traditional clinical diagnoses went, Beling found that the clinical accuracy in diagnosing ascites was “low” (lower than in laparoscopy) in the old method using paracentesis. Specifically he stated that the laparoscope got out more liquid and supposed the discomfort level of the patient to be about the same. He noted as well that the views obtained by the scope had presented “unexpected discoveries” which had not been readily apparent clinically, concluding that the laparoscope’s efficacy as a clinical tool was simply “incontrovertible.”

Liver Biopsies
We hold special affection for any pioneer in these early years that recognized the importance of abolishing forever the disconcerting practice of exploratory laparotomies. Beling made a special effort to address this issue, noting that his research indicated that up to firstly that one third of patients with pre-existing cancers would die as a result of exploratory laparotomies. For these patients especially, Beling advocated for the use of the laparoscope, so that terminal patients would not be subjected to unnecessary pain and suffering caused by pointless laparotomies. The early confirmation of these conditions, although inoperable at the time, at least allowed the patients to experience more comforting and less invasive palliative care. He found that the laparoscope excelled most in the diagnosis of inoperable liver carcinomas, but that the pancreas and parts of the stomach were still inaccessible.

Contraindications
Perhaps the best article for the history of endoscopy at this time came from Beling, who gave one of the most exhaustive lists of contraindications for the lap found, even above and beyond what Benedict had published in his 1937 article.

Like Benedict and Orndoff from just a few years before, Beling was also one of the earliest to report extensively on the important contraindications to laparoscopic use, giving an even longer list than Benedict had. Beling listed a total of nine main contraindications, including “the presence of acute inflammatory disease of the abdominal cavity, pneumonia, pulmonary abscess, disease of the thorax, intestinal obstruction of the small or large intestine, acute perforation, heart failure, and extensive adhesions.” One of the most striking aspects of his 1939 list was that extensive adhesions and operative scars were actually contraindicated. This is interesting to take notice of, since there were early accounts of the laparoscope being used to cut adhesions, including even in Jacobaues’ time. This qualification therefore is useful in order to understand more clearly the outer limits that the early pioneers were facing when it came to operative procedures. Operative scars and adhesions were in fact contraindicated. He even mentioned bullet and stab wounds as not being good candidates.

Why the Laparoscope Was Not Fully Accepted in Beling’s Time
Beling’s two articles, published as they were back to back, provide for a medical historian a dream come true: they reflect an abrupt change of attitude- within the same physician- concerning the newly adopted laparoscope.

In his first 1938 article Beling expressed excitement about the excellent diagnostic results afforded by the laparoscope, and even lamented on the lack of interest in the procedure. For instance, he used the word “astonishment” to express his incredulity that paracentesis continued to be performed more than laparoscopies. On this point he writes, “this cannot be defended as a necessary procedure because peritoneoscopy (laparoscopy) accomplishes the same purpose with as much ease and with more information.” From this article we see that Beling was a strong advocate of laparoscopy who didn’t mince words when he urged all physicians to take note of its diagnostic and therapeutic advantages (i.e., the draining of ascites and tuberculosis fluid).

Apparently this reticence in 1938 had been caused by what Beling characterized as misconceptions surrounding our once loveable lap. Beling believed at that time (and later too) that this circumspection most likely stemmed from misunderstandings about its contraindications. Beling attempted to address this issue by reiterating all the known contraindications for its use.

In the next article however, there is a completely different tone. Something strange has happened which caused Beling to reflect on a number of new yet contradictory concerns, ranging from, on the one hand, over-enthusiasm and injudicious use of the scope, then by turns another lamentation about why the scope was not fully accepted, then back again with warnings not to rely too much on laparoscopy just because it gave such excellent visuals, and finally returning again to laparoscopy’s serious limitations. It was quite tricky to understand just precisely what he meant and the contexts of all these paradoxical strands of thought; here is our best effort to sort out the confusion.

Beling’s Second Article – 1939
The second article overall focused on what the laparoscope “could and could not accomplish,” a direct response to address what had apparently been “miracle” stories circulating during this time. In 1938 Benedict had also referred to a “recent revival” of interest in laparoscopy, which he attributed partially to the influence of Ruddock. Another physician comments on this phenomenon sweeping the times, stating that “Miracles were wrongly hoped for in situations where the use of the peritoneoscope was not indicated. This led to the condemnation of the peritoneoscope, rather than the faulty judgment of the doctor-operator.” Indeed, it seemed the laparoscope’s reputation had actually exceeded itself in this case!

Something spectacular must have occurred to have made such a dramatic shift in Beling’s perspective. From our search, we found the most likely sources of this renewed sense of enthusiasm for the lap- and the attendant calls for temperance- came possibly from news of Hoff and Neefl, the German team who in 1938 presented the world’s first color photographs made during an endoscopic procedure.

In order to qualify these so-called miracle stories, Beling warned physicians that they should not do laparoscopies routinely or in the place of other thorough clinical examinations. To this point he stated that just because the laparoscope was so accurate in diagnosis, there was “no excuse for incomplete investigation,” (which apparently meant other clinical investigations, not necessarily exploratory laparotomies). Notice the paradox to this statement, which on the one hand speaks to the laparoscope’s uncanny diagnostic abilities, yet which belies the nervousness so many physicians feel when technologies begin to supplant traditional methods. Beling went on to report that he believed the scope was being “injudiciously used” due to poor understanding of its contraindications. For the second article, a substantially broadened list of contraindications was reported.

This new, expanded list mentioned that laparoscopy was not safe or useful for the following procedures:

“The amount of posterior fixations of the stomach can not be determined with the peritoneoscope. Except under unusual circumstances the peritoneoscope is not indicated for neoplasm of the colon or rectum. Furthermore, the peritoneoscope does not lend itself to the diagnosis of pancreas disease and removal of ovarian cysts.”

The indications for using the laparoscope were cited as:

“Tuberculosis peritonitis, ectopic pregnancy, non-inflammatory disease of any of the organs within the greater sac of the peritoneal cavity, excluding however the contents and borders of the lesser sac, and excluding the pancreas, the kidney and other retroperitoneal structures, with still further exceptions; masses of the peritoneum, suspected neoplasm or anomaly of pelvic organs, including endometriosis, ascites of non-cardiac origin, splenomegaly or hepatomegaly.”

Beling did acknowledge that the overall safety of laparoscopy specifically had been well established by that time, mentioning several large studies on the matter, such as Ruddock’s report on 500 cases. Beling wanted to add an additional layer of safety on the matter, since there were also apparently reports of mishaps and mortalities with the procedure as well. Beling did his best to form a clinical opinion based on clinical rather than mythical data. In the process, he provided one of the most balanced reports of the times.

Conclusion Beling
Beling’s brilliant clinical work, exceptionally thorough research, and dedication to accurate reporting were simply breathtaking examples of a truly gifted physician, setting him in a league of his own during this experimental phase of laparoscopy. Of most importance, he did his best to convince physicians everywhere to abandon the practice of exploratory laparotomies.

Beling demonstrated his great vision as well when he spoke of the day where he hoped ultimately the successful marriage of diagnostic and operative surgery could be realized, so that operations like the removal of ovarian cysts could be diagnosed and then removed, all in one sitting with the laparoscope. Amazingly too, Beling recognized a problem that afflicted our modern times too; issues of re-training. Beling pointed out that “the need for doctors to essentially retrain themselves” was one of the most daunting impediments standing in the way of the laparoscope’s further acceptance. Overall, Beling wins our trust as one of the most meticulous and forthright of practitioners, whose many balanced but astute insights into laparoscopic matters proved to be years ahead of his time.

Beling and the other newly converted laparoscopists of this era did just about everything they could to take the scope this far, to the outer edges of simple operative procedures. In the end though, there wasn’t a pioneer around in 1939– or 1949 for that matter- who could squeeze any more progress out of our exhausted laparoscope at this time, for the underlying limitations still were rooted in those same damning duo of dilemmas we’ve been kvetching about since page one: poor lighting and inadequate optics.

Gastroscopy, Esophagoscopy, Laryngoscopy 1930s
Despite the impressive progress in endoscopy in general, for gastroscopy in particular, there was the added difficulty of working with the extreme angles and reflections necessary to get the light source to make it all the way down to the nether regions of the stomach. The diagnostic and especially surgical limitations of working on a mirror image were constraining. However, in 1932 the desperately needed turning point was finally achieved by Rudolf Schindler, one of endoscopy’s most gifted and significant pioneers of the 20t century. His introduction of a semi-flexible instrument- which actually worked- had been an idea in progress since the time of Nitze and Leiter from the 1880s. This semi- flexible gastroscope, manufactured by the Wolf Company, originally featured a phenomenal 48 lenses, which was the secret behind its ability to overcome for the most part the difficulty of transmitting the illumination down to the nether regions of the stomach. This feature significantly decreased the risk of perforations. As well, the stomach’s distal area could now be viewed in up to 80% of patients, a substantial improvement over the rigid scopes which had only a rate of 30%. Schindler’s contributions are significant in other areas as well, with dozens of other inventions to his name. He was also a prolific writer, producing over 170 manuscripts and five books. With such an outstanding record of innovation and contribution to endoscopy, Schindler has been called “The Father of Gastroscopy.”

Conclusion Part IV – 1939
By the end of the 1930s, many operative laparoscopic procedures had finally been achieved in numerous and repeated clinical settings, as opposed to isolated times such as had been the case just 30 years earlier when Kelling was starting off. In the following years, laparoscopy became a somewhat accepted diagnostic procedure.

However problems started to arise as more adopted its use. Rising death rates caused by endoscopy-gone-wrong were now an inextricable part of the scenery and had to be immediately attended to. The same conditions that give rise to high complications were affecting our early 20th century counterparts: lack of adequate training inexperience, and improper technique or instrumentation.

New endoscopic technologies were also fairly limited during this time, with difficulties with light sources and 19th century lens technologies still the only technologies being used, despite the fact that microscopy technology had been improving significantly. In fact, the work of the German electrical engineer Ernst Ruska, who invented the electron microscope, was introduced in this decade, in 1931. For the first time, viruses could be viewed at up to 1 million times larger than prior light microscopes. However, this level of magnification technology wouldn’t trickle down to the laparoscope for a while, but this invention did at least facilitate the accuracy of biopsies and gave more reason to do laparoscopies, knowing that the biopsies obtained could now really be understood more fully.

Modlin sums up this year of 1939 quite well when he states: “Despite the fact that laparotomy was a dangerous procedure, its use as a diagnostic tool was widespread, and there was little impetus for surgeons to develop an alternative. Thus, regardless of the unique clinical possibilities that could have evolved from the development of laparoscopy, its widespread use was not embraced by the medical community.”

Notes
1. There are many discrepancies in the record concerning the exact total, with values ranging from as low as 500, to a high of 5000. The most credible sources cite 2500 as the overall figure.
2. From Benedict’s own description of these cases, it is not clear whether he performed these 48 procedures himself, or whether he was referring to the number of cases that the group from his hospital in aggregate had performed.