Chapter 6 - Society of Laparoscopic & Robotic Surgeons

Chapter 6

BOZZINI: The Beginning of Early Modern Endoscopy

One man with courage makes a majority.

Naming a specific moment when the modern endoscopic era began is an imprecise art, one that is also subject to biases in perspective. For urologists, the beginning may rightly be attributed to Desormeaux, while for laryngoscopists, Kussmaul’s incident with the sword-swallower could be cited. General surgeons of course, as the story goes, seem to mark 1987 as the year it all began! However, amongst various disciplines, it seems the Italian-German Philip Bozzini was the physician most believe achieved the first significant attempt to visualize the interior body in a novel way, earning him the title of the father of endoscopy.

How Bozzini Gave Endoscopy Its Groove
So one may rightly wonder; why all the fuss over Bozzini? After all, were there not others who developed similar instruments for similar purposes? Such issues may never be completely resolved to the full satisfaction of everyone. Part of the answer, however, predictably relates back to our constant companions, the formidable four obstacles. Bozzini’s essential achievement was that for the first time in history, three of the four central constraints hindering endoscopy’s development for thousands of years were finally all cured in a single moment in time by Bozzini’s singular instrument.

Some aspects of Bozzini’s invention cannot be considered innovations at all. For instance, reflecting light using mirrors was not at all a new concept. As previously mentioned, al-Qasim experimented with similar concepts nine hundred years earlier. Moreover, as was already noted, the technology required to make a functional endoscope had been available since at least 1710, if not earlier. This includes the lens system that Bozzini utilized, which had been derived from 17th century telescopes. Still, Bozzini’s creative genius went beyond the work of earlier innovators, for he was the first ever to efficiently solve endoscopy’s third flaw; reflecting images back to the eye.

Perhaps most crucially (though this part of the history is contested), Bozzini’s lichleiter was in fact somewhat successfully used1 in several diagnostic procedures on actual, living, breathing patients, making the device not just one languishing in theoretical hinterland, but one which indeed achieved immediate, practicable value. While such solutions may appear outrageously obvious to us today, in fact no one before Bozzini had been able to successfully combine the necessary technological elements into one unified, usable source. In short, it was a breathtaking coup, one that sets Bozzini apart as the indisputable founder of modern day endoscopy. As the saying goes, Bozzini was indeed “the right man, at the right time, with the right stuff.”

Despite Bozzini’s novel achievements, there are in fact disputed and somewhat disturbing aspects to this story. Therefore, to better understand the significance of this turning point in endoscopy’s history, let’s review not only details of the instrument’s best features, but some biographical aspects of the man behind the machine as well.

Technical Details
Throughout the history of endoscopy, many have denounced Bozzini’s device as rather simplistic in form, not the stuff turning points are made of. However, engineers at Mercedes Benz, who were recently commissioned to reconstruct the lichleiter using only Bozzini’s drawings, were in fact “very impressed” by the technical skill required to make the instrument.

Besides the complexities in the instrument’s design, being first counts as well. Bozzini was indeed the first to adopt existing lens technology in order to solve the third problem of reflecting images back to the eye (our modern understanding may not include Bozzini’s system of mirrors as an actual “lens system,” but it was for his time just about the latest that technology had to offer). He did this by devising a system of double aluminum tubes equipped with strategically angled mirrors (flat, concave and convex) that were positioned in such a way as to bring the image back to his eye while simultaneously conveying the distally-placed candlelight into the interior body. Though the double tubes ultimately proved unnecessary to reach this end (a singular tube is able to convey light in both directions at once), such knowledge of optical physics was not well known at the time, rendering this “mistake” a forgivable lapse in design. One could also interpret this differently and say instead that Bozzini was simply two hundred years ahead of his time on this point, for fiber optic technology in fact utilizes two “tubes” for conducting light and image separately.

Originally, the lichleiter was designed mostly with obstetric and gynecologic inspections in mind, since Bozzini’s initial training was in this field. And it appears that the most success with the lichleiter was in examining female patients. In this field, Bozzini became especially frustrated that only blind palpation was available as a means of examination. In fact, a common saying during his time was that “the eye of the obstetrician should be located in his fingertips.” Yet, this was a view Bozzini did not share in the least. Bozzini is quoted as stating that such inspections relied “merely on good luck and chance.“ He firmly believed that such games of chance could finally be ended by using his device.

Bozzini was especially hopeful that his lichleiter would render exact diagnoses of pathological lesions of the uterine orifice. True to his vision, he did construct a metal catheter for the female urethra, with lateral slits on the sides through which instruments for “swabbing painting and cauterization” could be introduced. Specific therapies for cervical carcinoma were also described as early as 1805.

One of the contested aspects of Bozzini’s history concerns whether or not his device was used on living patients. Based on the latest research by Dr. Peter Figdor, a German physician, documents were uncovered which indisputably confirm that the lichleiter was successfully used on living female patients. These test trials were conducted at the private maternity ward of the Institute of Professor Ludwig Friedwich von Froriep, in June of 1806. One specific report, referred to as the “ninth experiment,” described a case in which the lichleiter was used to visualize a high fistula within the rectum, a condition that was later operated on.

The next report, named the “tenth experiment,” described using the lichleiter on living, female patients, in which an exact diagnosis of pathological lesions of the uterine orifice was obtained. Specifically, the lichleiter was used to examine the vaginal canal of a woman who was believed to have a tumor, which had been palpable upon digital examination. Using the light conductor, the physician was able to definitively confirm the presence of a polyp. As a result of this observation, the patient subsequently underwent an operation and was healed seven weeks later. The positive report of these results stated that ‘This preoperative colposcopy conducted by Dr. Beinl is the first published clinically indicated endoscopy.’

It is also of great importance to mention that Bozzini did in fact understand the significance of the endoscope’s operative potential. He described his hopes in the following passage:

“Surgery will gain not only from the new operations that could not easily be performed until now, but also all other uncertain operations, which depended on mere luck and chance, will now be relieved of uncertainty by the influence of sight…But extirpation of carcinoma of the uterus, many of the unfortunate women who otherwise could not escape certain death will be returned to the enjoyment of life and health. Deformations of the uterine orifice, the vagina, polyps and ulcera of the same, and of the rectum and the bladder stone can be operated by sight” – Bozzini, 1805

Indeed, such designs truly establish the lichleiter as one of the most significant precursors to operative endoscopy, a vision Bozzini embarked upon almost one hundred years before others would even attempt to extend the endoscope into such realms.

What is also striking about Bozzini’s work is the wide range of use he had envisioned. Possessing a naturally expansive imagination, Bozzini declared that his device would be applicable for “practically all cavities.” Since it was an accepted custom for physicians to work in multiple disciplines during this time period, Bozzini did indeed conduct research in many fields. The attachments he designed for his lichleiter were intended for inspections of the vagina, urethra, the female bladder, the rectum, and the upper air passages. Other auxiliary attachments were constructed which could be used for parts of the body inaccessible to direct viewing, such as was necessary for the esophagus, larynx, and posterior nasal and throat cavities. Called a “winkelleitung,” or angle conductor, these specially designed lenses enabled him to achieve some visualization to these areas for the first time in documented history. Many laryngoscopists in fact credit Bozzini as being the first to conceive of the laryngoscope. An early pioneer of laryngoscopy by the name of Morell Mackenzie (1837- 1892) referenced Bozzini in an 1867 publication, noting that the lichleiter was the first laryngoscope to have achieved success in clinical uses.

In the field of urology, the record is unclear concerning the lichleiter’s success. Bozzini had crafted a smaller tube specifically for urethroscopy which allowed for ulcers in the male urethra to be visualized. However, the record is not clear as to whether bladder stones were in fact removed from living patients. Research on this topic was conducted by one of endoscopy’s later pioneers, Professor of Urology, Otto Ringleb. After extensive investigations, Ringleb concluded that he didn’t believe Bozzini was actually able to access bladder stones in living patients. Instead, Ringleb found that Bozzini’s reports were more consistent with experiments using cadavers, in which case such access could easily be achieved. Nonetheless, Bozzini does appear to have had some success with the female urinary tract.

Concerning other fields, there is again some dispute concerning the lichleiter’s efficacy, particularly for the esophagus. Historical records also do not make clear whether the investigations of the upper G.I. were successful in living patients.

Bozzini conceived of other uses that remained only in his imagination. For instance, he had intended to eventually modify the lichleiter to make it capable of inspecting the abdomen; in other words, laparoscopy. Of course, prior to the advent of asepsis and antisepsis, such operations would most likely have been lethal. Nevertheless, these historical notes attest to Bozzini’s genius, for his visions were truly far ahead of his time. Through the originality of his work, the stage was set for subsequent trailblazers who would come to acknowledge and rely on many of his foundational principles.

Some Setbacks
Despite these great strides, Bozzini nevertheless came up against a great many difficulties. This next section explores the hindrances affecting Bozzini and the acceptance of his Light Conductor.

In reviewing the history, it seems Bozzini faced at least three main types of obstacles: 1) technical difficulties, 2) time constraints, and 3) resistance and rivalry from colleagues.

As for the technical side, the light source of candlelight has been cited as the weakest aspect of Bozzini’s invention. Of course this is a consequence stemming from the limited range of light sources available during his time. In fact, the problem of inadequate illumination would not truly be solved until almost 200 years later, with the advent of fiber optics. We certainly cannot bother Bozzini too much then, on this point. It does seem that Bozzini made the best of what was available. His meager little candle in fact was not so measly, for he devised a way to stabilize it with a system of springs so that it remained securely in place in order to deliver a consistent ray of light as reflected off the concave mirror placed adjacent to the wick. Another technical concern was the small field of vision, which was limited to the circumference of the scope itself. In fact, this drawback was the main one cited by Bozzini’s most vigorous critic: Dr. Andreas Josef von Stifft, head of the opposing Viennese medical center and also personal physician to the Kaiser himself. Despite his prestigious ranking, Stifft was hardly a visionary; he dismissed the lichleiter, claiming that even if improvements in the optics were made, “the judgment of a reasonable doctor and the finger of an experienced examiner will still remain, as in the past, the sole means from which the patient …can expect…fitting treatment.” Within just a few short decades of course, Stifft did stand corrected.

In any case, again, one cannot really fault Bozzini’s inability to overcome the field of vision aspect, for this obstacle remained insurmountable for quite some time and was not actually solved satisfactorily until Nitze’s innovations, some 70 years later. More importantly, Bozzini had the ability to use his powers of imagination to see past such nominal constraints, a talent which set him apart from everyone else of his day.

The other immediately observable setback relates to the untimely and unfortunate demise of Bozzini himself, who succumbed to typhoid fever on April 4, 1809, just about a month shy of his 36th birthday. This fact underscores that Bozzini actually achieved a great deal within his short life. Within only three short years from its first round of testing at the Josephinian academy in 1806, and until his passing in 1809, Bozzini’s lichleiter was able to garner the attention of some of the most important medical centers of the world. To put this in proper context, consider that even in the 20th century, the remarkable discover of penicillin by Alexander Fleming actually took over ten years to be recognized as valuable by the scientist community.

Other issues related to the resistance and rivalries of fellow colleagues, a persistent problem that has affected quite a few pioneers within endoscopy’s history. Some of Bozzini’s contemporaries reacted with resistance for having to undergo special training (a similar problem to that encountered hundreds of years later when videolaparoscopy emerged). Because the lichleiter was new and had so many sets of attachments, carefully reading the instructions was mandatory. Bozzini believed that those physicians who rejected his devise had done so prematurely as a result of failing to follow his precise instructions. To be fair, Bozzini’s invention was not exactly “user-friendly,” with its perhaps unruly array of attachments and such. In other words, just like today, the lack of training, technical inexpertise and ‘user-error’ (or lack of user-friendliness) figured into some of the reported failures. To the end, Bozzini made many special efforts to point out these errors and attempted somewhat in vain to rectify the situation.

Finally, it was the myopic views of a handful of Bozzini’s contemporaries that stood as one of the most difficult setbacks of all. Many could not see past the lichleiter’s technical flaws. Bozzini was so far ahead of the curve that he envisioned his instrument as an operative force almost 200 years before advanced operative laparoendoscopy made it to the mainstream. Yet, invariably it seems, being too far ahead of the curve has its consequences, making pioneers susceptible to reactionary criticism.

Latest Research on Bozzini
Despite such a long list of hindrances, Bozzini did gain the respect of the majority of his colleagues, contrary to today’s commonly held beliefs about the matter. Helping us set the record straight again is the research by Dr. Figdor, whose keen eye has been responsible for clearing up a great many inconsistencies in Bozzini’s story. Dr. Figdor’s extensive research uncovered for the first time documents archived in Frankfurt and Vienna. Among the best of Figdor’s new findings was that Bozzini’s lichtleiter was not so thoroughly rejected as has been commonly claimed. Other reports also erroneously describe Bozzini as a man whose “reputation was ruined” and whose career was destroyed after receiving widespread criticism. Fidgor’s research however, uncovers a substantially different picture. Though Bozzini had his critics, he also had his staunch supporters and friends in very high places, including the Kaiser Wilhelm’s brother, the Archduke. Bozzini also could not have been chosen as the Frankfurt city doctor– an appointed position– without having the support of the elected officials of Frankfurt. And though there eventually was an official Imperial Resolution that forced use of the lichtleiter to cease, Figdor points out that, off the books, unofficial clinical use continued. In fact, a modified version of the lichleiter, called the Viennese-model, enjoyed fairly wide usage, even by Bozzini’s archrival, Dr. Stifft himself! As well, Bozzini’s invention remained the subject of lively discussion and marvel throughout the world’s most important medical centers at that time.

Based on Figdor’s analysis, this Imperial Resolution is also somewhat misleading because it was apparently influenced by Bozzini’s most powerful critic and rival, Dr. Stifft, who again we should be reminded was the Kaiser’s (i.e., the signator of that very Imperial Resolution) personal physician. So, influence may have had more to do with this decree than the actual shortcomings of the device.

Summary of Bozzini
It is always wise to look ahead, but difficult to look further than you can see.
-Winston Churchill

It has been said that Bozzini “stood at an historical turning-point between old and new medicine.” By wishing to avoid needless patient injuries and to gain knowledge about disease pathologies, Bozzini evolved beyond the ways of old medicine, which had relied on blind palpation and diagnosis through deduction. By so fearlessly forging ahead, Bozzini helped to herald in the new medicine, rooted in what we know today as the scientific method.

The combination of all of Bozzini’s strength of vision and character signaled a significant advance for the endoscope’s development, one that captured the interest of the world’s most established medical centers of the time. It is equally important to note that, like a good pioneer, Bozzini recognized the value of his discovery and spent significant energy trying to bring to the world’s attention the implications of his innovation. By solving the endoscope’s first three shortcomings with one instrument, with clinically useful applicability on living patients, Bozzini presented a conceptual breakthrough. His invention allowed for an entirely new way to diagnose and treat diseases that had been otherwise difficult to learn about since the interior body could not be systematically and conveniently explored.

Though all of this may seem effortless to us now, such concepts had in fact defied the best and brightest for centuries before Bozzini. Later, the likes of such world-renowned pioneers as Desormeaux, Segalas, and Cruise, all would follow the principles of Bozzini’s light conductor. Perhaps if Bozzini had not succumbed to typhoid at such an early age of 35, he most certainly would have remained a tireless advocate for not only endoscopy, but for the many other innovations that were tumbling around in his head, such as flying machines, aeronautical studies, mathematics, and art as well.

While no consensus has ever been reached as to whether Bozzini’s work was truly abandoned by the medical establishment, it seems quite apparent that overall Bozzini’s contemporaries fell short of understanding the potential value of his invention, and ultimately it was not fully recognized until many years later. Therefore, as Churchill’s quote expressed, the tradition-bound medical community found it difficult to look further than they could see.

1. From our modern perspective, claiming that the lichleiter achieved clinical success may seem a stretch. However, for the times, obtaining that tiny, blurred speck of visualization of living internal organs was an achievement that had never been achieved before.