Chapter 2 - Society of Laparoscopic & Robotic Surgeons

Chapter 2

Ancient to Pre-Modern
~3000 BC through ~1000 AD

The history of modern endoscopy is relatively young, dating back no more than approximately 130 years ago. However, the roots of endoscopy actually stretch back much farther. Investigating the endoscope’s origins therefore naturally leads us far back in time, back beyond the reach of our clever radiocarbon- dating technologies no doubt.

To help us avoid getting lost entirely during our great leap backward in time, we propose for the reader four of endoscopy’s most fundamental obstacles which will be used as reference points throughout this historical review. As we shall see, the great race to discover the internal workings of the human body was characterized in part by the incremental process of trying to overcome these four main hindrances which plagued endoscopy’s pioneers well into even the twentieth century. In order for early endoscopy to truly achieve practical value, these obstacles had to be addressed:

Four Obstacles
1) Creating or expanding entrances to the interior body;
2) Safely delivering enough light into the interior space;
3) Transmitting a clear and magnified image back to the eye, and;
4) Expanding the field of vision1.

As we review endoscopy’s history then, it will be useful to keep in mind these four obstacles, for it allows us to keep perspective of the limitations the early pioneers were facing. And more than that, it is both entertaining as well as inspirational to marvel at the sheer tenacity and ingenuity involved in trying to outsmart this set of surprisingly persistent dilemmas.

Ancient Attempts to Overcome the Four Obstacles
Ancient Egypt
Indeed, some progress toward the first obstacle in particular was quite readily achieved by the ancients, proof of which has been provided by archaeologists, those dear individuals who, thankfully for humanity and history projects alike, are dedicated enough to sift softly through mounds of debris and decay, hoping to uncover vital clues to our human past. By this method, Egyptian history in particular has been meticulously reconstructed, allowing for remarkable discoveries in Egypt’s history of medicine. From a manuscript discovered by the late American Egyptologist, Edwin Smith, we are able to trace some rudimentary outlines of endoscopic-like practices and precursors as far back as circa 2640 B.C., during which time the great pyramids were built. Smith’s found manuscript, referred to as the Edwin Smith Papyrus2, is one of the oldest known medical treatises in the world, written in approximately 1700-1600 BC, but referring back to another older text from circa 2640 BC. From these findings we can see that Egyptian healing appeared to be an art form that was practiced on many levels, from embalming, to faith healing, to surgery. There are also clear indications that Egyptian physicians were treating some surgical conditions in ways remarkably modern in form. For example, a preference for non-intervention was described. Using an approach strikingly similar to modern- day triage, the ancient author divided medical conditions into three categories; treatable, treatable with difficulty; or “an ailment not to be treated,” a category roughly analogous to our modern concept of “inoperable.” Establishing such limitations reflects a philosophy of minimal intervention, for it must have been understood that further surgical trauma could exacerbate a patient’s condition and suffering.

And long before our modern preoccupation for managing pain through minimal intervention, the unknown ancient author of the Smith Papyrus was deliberating on this same issue over 3500 years ago, a staggering head start to our own era of patient advocacy. Demonstrating great consideration for pain management, the author wrote “As for measuring things with a grain measure … suffering is to be taken account of in the same way.” In other words, this ancient physician conceived of pain- even just a grain’s worth- as something to be viewed with great care and sensitivity. Other disciplines of medicine were similarly progressive. Supplementing the Smith Papyrus was another found manuscript, dating back to 1650-1553 BC, which described such urological procedures as evacuating a blocked bladder. Even a manuscript specific to gynecology, called the Kahun gynaecological papyrus, has been discovered.

Recent research has also demonstrated that ancient Egyptian’s knowledge of plants with medicinal properties was so sophisticated, that today the same plants are still used for curing common ills. Just one example is acacia, which was used to treat coughs and eye complaints in ancient times and is still used for those ailments to this day. And anti-spasmodics, such as hyoscymus, cumin and coriander were used to treat colic just as they are today.

Despite such sophisticated medical sensibilities, religious practices, such as preserving the body in preparation for a presumed afterlife, appear to have inhibited the ancient Egyptian’s inspection of internal anatomy. We can especially deduce this by noting that hieroglyphics for various organs usually resembled those of animals, not humans, indicating that autopsies must not have been common practice. Thusly, though some of the surgical knowledge for solving the first task had indeed been invented, we would have to wait much longer before inspecting the human internal body became a commonly accepted practice.

Ancient China
China’s history of medicine is one of the most unique and extensive in all of world history, and, like Egyptian medical practices, it too can be said to reflect a long-standing preference for minimal intervention. An exquisite synthesis of philosophy and science, stretching back beyond 4500 years ago, much of ancient Chinese medicine has indeed stood the test of time. Today it enthralls modern medical experts with much of its clinical efficacy, despite having been development in pre-modern eras without the benefit of (supposedly superior) modern medical knowledge. As well, western patients themselves have embraced the growing trend of so-called alternative medicine, a field deeply influenced by Chinese holistic and minimalist principles, such as maintaining harmony with nature, and more existential notions concerning our unity within the universal order of things. Like the ancient Egyptians, the ancient Chinese as well achieved an extraordinarily sophisticated understanding of medicinal plants, knowledge that is still relied on today. Some sources also cite Hua Tuo, the famous Chinese physician of the Three Kingdoms era, as one of the first documented physicians to have performed surgery with the use of anesthesia, achieved some 1600 years before western counterparts.

Precursors to technologies associated with endoscopy can be found in both broad and nuanced forms. Important Chinese contributions include early versions of catheters and understanding of the camera obscura phenomenon, knowledge of which would later of course influence the development of integral components of endoscopy. As for the catheter, it has a rich history at least 2000 years old as an integral part of medical practices throughout numerous ancient societies. China’s version of a catheter was described as consisting of hollow leaves, referred to in Latin as allium fistulosum.

References to camera obscura principles have also been found in the literature of many societies throughout the ages, though Chinese discoveries in this field were among the earliest. Almost 2500 years ago, one of China’s most famous philosopher’s, Mo-tzu (470-391 BC) described what may have been the first accounts of camera obscura principles, which he termed “the locked treasure room” (also “the collecting place”). The ancient Chinese also contributed extensively to medical literature and compiled voluminous compendiums of knowledge. One such work, the Nei-ching, is considered one of the most important and extensive medical canon of all time and was said to have been written by one of China’s most renowned philosopher-physicians, Huang-Ti3, the third of the first five emperors viewed as China’s Father of Medicine. Without question, the Nei-ching (Huang-ti Nei-Ching su wen) is China’s single most influential work passed down from antiquity. Cited as written in approximately 2674 BC, the Nei-ching has stood throughout the ages as the primary foundation for traditional Chinese medicine, even as it is practiced today. Roughly translated as The Yellow Emperor’s Classic of Internal Medicine (also The Inner Classic of the Yellow Emperor), this canonical masterpiece demonstrates an unprecedented degree of knowledge concerning physiology, pathology, surgery, and other disciplines4. For example, it outlines one of the earliest known references to the correct understanding of blood circulation, a discovery proposed over 4000 years before the famed British physician William Harvey’s discovery of a similar kind.

Ancient India
Other civilizations as well were achieving progress toward overcoming the four obstacles that thwarted early efforts to visualize living viscera without harm. Rooted in such remarkable religio-philosophical works as the Rig Veda (circa 2000 BC), ancient Indians contributed to the world some of the most outstanding medical, mathematical and scientific discoveries. For example, one of the earliest known surgical and medical compendiums, with some parts compiled as early as circa 600 BC5, was discovered in the present day city of Benares in northern India. Referred to as the ‘Shushruta-Samahita6 these extensive volumes were compiled in part by the famed practitioner named Shushruta, known today as one of the “fathers of surgery” for his exceptional skill and knowledge. Like the Egyptian Smith’s Papyrus and the Chinese Nei-Ching, this Indian treatise also referred back to medical knowledge established as early as 2800 BC. These texts indicate that ancient Indian physicians were especially advanced in surgery, specifically in the areas of plastic surgery, removal of prostate gland, extraction of cataracts, crushing of bladder stones, and even dental surgery. In fact, some of the surgical methods Sushruta in particular advocated, such as his method of forehead flap reconstructive rhinoplasty, have been passed down almost unchanged today. And as for specific precursors to endoscopic-like methods, some of the first known descriptions of a tube speculum used for internal ear examinations are also found in these works; in other words, what we might today call otoscopy.

Ancient Greek and Roman Physicians- Hippocrates, Erasistratus, Celsus
As to diseases, make a habit of two things– to help, or at least to do no harm . -Hippocrates, in Epidemics, 1:11

It is to 5th century BC ancient Alexandria, Greece that many attribute as the era ushering in medical practices rooted more firmly in modern western concepts of the scientific method. Hippocrates (460?-377 BC) in particular must be given substantial credit for establishing an entirely new way of practicing medicine, one that emphasized close clinical observation and investigation into lifestyle and other environmental factors as contributors of disease. As well, Hippocrates insisted on finding a natural, rather than supernatural, understanding of disease. With his great skill in observation and analysis, Hippocrates was able to achieve an understanding of disease pathologies that were often previously attributed to supernatural inflictions. Most notably too, Hippocrates was one of the greatest advocates for minimally invasive medicine. Recognizing the value of a minimalist approach, he stressed that physicians, instead of trying to interfere with the body’s own healing powers, should instead seek to restore harmony by prescribing diet, rest, exercise and even music as therapy.

The history concerning the origins of endoscopic precursors will always remain somewhat contested. In this case, Greek history is no exception. Though the other ancient surgical practices predating Hippocrates were thought to have informed Greek practitioners tremendously, generally Hippocrates is given credit as the first to have described an endoscopic technique applied to living patients. The passage describing Hippocrates’ endoscopic applications can be found in his great work The Art of Medicine, circa 400 BC. In excellent clinical detail, a clear method for examining the rectum using a speculum was found in On Hemorrhoids, Section 5, and is described as:

“But if the condyloma be higher up, you must examine it with the speculum, and you should take care not to be deceived by the speculum; for when expanded, it renders the condyloma level with the surrounding parts, but when contracted, it shows the tumor right again.”

So while rudimentary endoscopic techniques had already existed, the more advanced nature of technologies found from this era do indicate that a shift toward incorporating internal inspections as part of normative medical practices was beginning to occur. One way to track this shift is through observing changes in instrumentation. Substantial improvements to the catheter for instance can be found during approximately the same time period as Hippocrates. The first known catheters with the correct anatomical curvature were described by Erasistratus (ca. 330-255 B.C.), a renowned ancient Greek physician and surgeon considered to be the first physiologist. Also of this era was the invention of the indwelling catheter, attributed to another well-known Grecian physician named Oreibasios, (b. circa 325 BC) who was also credited as an early contributor to endoscopic-like methods for examining inside the throat.

Antiquity with an Attitude
The scientific theory I like best is that the rings of Saturn are composed entirely of lost airline luggage.
-Mark Russell

In case you have nodded off as a result of this onslaught of historical anthologies, we would like to nudge you back into consciousness with a rather surprising fact: cutting or puncturing the peripheuneum on living patients is not in the least a new concept. Quasi-surgical techniques referenced by the Roman physician and author, Aulus Celsus (25 BC – 50 C.E.), have proved to be some of the earliest attempts to access the abdominal cavity, laying the groundwork for important understandings of the living anatomy. In addition to being the customary territory of lithotomists at the time, such medical innovations were likely influenced by the medico-philosophical doctrines promulgated throughout the Greco-Roman region, which emphasized maintaining balanced production and excretion of bodily waste, since imbalances were thought to trigger disease states. Therefore, preferred therapies aimed to restore normal balance through purgatives and cathartics. Alternatively, balance was said to be restored through a quasi-surgical technique (possibly similar in technique to acupuncture), by inserting a trocar-like instrument into the abdominal cavity in order to drain the disease-causing, bad humors. Of course, we have to issue a broad disclaimer here, for further clinical details have been difficult to procure. As such, just how common this method was, or to what depth the cuts were made is not at all clear. Indeed, the incisions made may only have been superficial and more ritualistic in nature. Nevertheless, these early attempts to access the lower abdomen were important preliminary steps. Evidence to such procedures is given by Celsus whose written works left us with the following exquisitely detailed passage concerning this technique:

“Some perform it below the navel at the distance of about four digits to the left; some perforate the navel itself; some cauterize the integument and make their opening into the abdomen by incision…”

The instrument used was described as:

“A leaden or copper cannula with its lips curved outwards, or one that has a circular rim at its middle to prevent its slipping into the cavity, is then introduced through the aperture. When the latter is used, that part of the instrument that is introduced should be no longer than that which remains external to the aperture, in order that it may proceed beyond the peritoneum.”

Even before Celsus, Erasistratus too had earned acclaim in Greece as a preeminent surgeon who performed abdominal surgeries rarely attempted (or successfully completed) by others in his day. Based on these records, along with discovered remnants of ancient trocar-like instruments and speculums, we can marvel in knowing that the history of endoscopy is a story which has been flowering and unfolding throughout the centuries, a fact which connects us therefore to a rich heritage filled with brilliant scholars and indomitable spirits.

Near and Middle East- Al-Qasim, Al-Haytham, Ibn Sina
Medical practitioners from the near and middle east were some of the first to come closest to solving the first two obstacles in one fell swoop, by using your everyday, run-of-the-mill mirrors, oil, candles, and sunlight.

A Turning Point– Abu-Qasim Establishes World’s Earliest Endoscopic Techniques
Hailing from Cordova, Spain and known as one of the world’s fathers of surgery, Abu-al-Qasim7 was one of the greatest surgeons and philosopher-scientists of the pre-modern era, (936-1013 C.E.), whose innovations in surgery especially served as foundational principles throughout Europe and Eurasia for over 500 hundred years. Al-Qasim’s contributions to medical literature were also substantive, with his thirty-volume medical encyclopedia Al-Tasrif (The Method) among the most renowned. Most incredibly for the history of endoscopy, the descriptions of surgical practices found in the chapters dedicated to surgery demonstrate that al-Qasim was performing some of the earliest known procedures involving basic tenets of endoscopy. For these works alone, Al-Qasim is considered as one of the most important pre-modern founders of endoscopy. His pioneering spirit also led to a lengthy list of inventions as well. He is credited for inventing several of the surgical-cum- endoscopic instruments, including a device for internal examination of the ear, one for the internal inspection of the urethra, and a separate instrument for removing foreign bodies from the throat. Another instrument was described as an “exploring needle with a groove,” which had an attached handle, indication for a trocar or cannula-like instrument. While the records are unclear about the use of external light sources or the extent to which true visualization was achieved, these surgeries nevertheless demonstrate that early endoscopic techniques and instruments were in the process of being developed, even if only as a continuation of such well-established ancient practices as lithotomies.
Another Turning Point – Harnessing Reflected Light

In approximately the same time frame, the Persian physician-philosopher, Ibn Sînâv8 from Buchara, commonly known to westerners as Avicenna (980-1037), stood as one of the greatest thinkers of his era. It is not surprising then to find that it was he who has been credited for one of the most crucial turning points in endoscopy’s history; the use of reflected light. Avicenna’s endoscopic techniques are generally considered to be the first documented instances of using reflected sunlight and polished glass mirrors to examine internal cavities. This method for examining the vulva and cervix consisted of laying a mirror in front of the affected vulva, expanded with a speculum, at which point the physician could then position himself standing behind the woman in order to view the reflected image. By these methods, Avicenna achieved a moderate degree of success in overcoming (at least partially) two of the four obstacles hindering endoscopic inspections. Other innovations introduced by Avicenna include a flexible catheter and a technique that suggested introducing a pipe into the larynx of a suffocating patient (an idea which also had been presented earlier by Hippocrates). Avicenna also reported on the use of diamond-tipped metal probes that were used to destroy bladder stones (something early Greeks wrote about too).

Innovations within other scientific fields proved crucial to endoscope’s later development. In approximately 1000 AD, a mathematician and astrologer from Basra (now part of Iraq) named al-Hasan ibn al-Haytham9, contributed substantially to the field of optics when he resolved the mystery of vision through experimentation, simple empirical observations and geometrical proofs. Al-Haytham determined that light originated from outside the eye and reflected back in, rather than the other way around as had been commonly believed. Through these observations, al-Haytham was able to overturn the prevailing classical theories proposed by Ptolemy and Euclid and discovered for his own era new insight into camera obscura. In fact, some in the field of optics today have referred to Al-Haytham as one of the fathers of modern optics.

Summary of Ancient Periods
How did our ancient friends do in resolving the four dilemmas? Struggles with operating within limited space still persist even today, but this initial task was one of the earliest hurdles that our ancient colleagues had to face before really being able to move on to the next levels. Such innovations as the trocar, sheath, speculum with screws, and the like, reflect the variety of methods used in trying to solve the first dilemma of creating or expanding bodily cavities. As to the other tasks however– with the exception of Avicenna’s modest efforts with reflected sunlight- we would have to wait until deep into the 19th century before these could be sufficiently addressed.

1. The author of Highlights in the History of Endoscopy, Litynski, suggested the first three tasks. We propose the addition of the fourth.
2. Not to be confused with a second medical manuscript known as the Ebers Papyrus.
3. There is some contestation about the true date in which the Nei-ching was written, and about whether Huang-ti actually wrote the text himself or even if he existed.
4. The Huang-ti Nei-ching is considered the original text, whose authorship is ascribed to Huang-ti himself. A similarly named text called the Nan-ching is a rendition written circa 150 CE.
5. 800 B.C. has also been cited.
6. Also called Charaka-Samahita
7. Full name Abu al-Qasim Khalaf ibn Abbas al-Zahrawi. Sometimes also referred to as al-Zahrawi. Known in the west by the Latin translation Abulcasis. 8. Full name is Abu Ali Al Husein Ibn Abdallah Ibn Sina.
9. Latinized as Alhacen or Alhazen.