Chapter 14

Recap of Where Endoscopy Stood
1920s

And die the death, the long and painful death, which lies between the old self and the new.
–DH Lawrence, The Ship of Death

Introduction
As usual, we must contain ourselves here and reign in our own exuberance, for there were still rather substantial limitations hounding our poor fledgling scope, despite the great transformations taking place. This generation’s pioneers were still contending with many of the same outstanding technical difficulties that had thwarted the minds of the late 19th century. These still- lurking limitations would become especially apparent now that greater quantities of endoscopic procedures were being performed, but without the attendant application of additional training and proper instrumentation needed to insure safety. Rising death rates caused by endoscopic mishaps were now an inextricable part of the medical landscape and had to be immediately attended to. Ironically, the same conditions that give rise to complications for today’s surgeons were affecting our early 20th century counterparts too: lack of adequate training or equipment, inexperience, and improper technique or instrumentation. As well, problems with limited visualization, inability to detect or stop intra-operative hemorrhaging, deaths caused by unpredictable insufflation complications, burns caused by electro-cautery, bowel perforations, and injuries to major blood vessels still served to scare off would-be practitioners from attempting endoscopic techniques in the first place or investing in its further development.

Yet, like generations prior, the inventiveness of this era’s endoscopic pioneers would soon devise ways around these barriers. These challenges were met head-on by a new breed of pioneers, who now had increased understanding of human physiology, especially with respect to electricity, as well as greater transportation and communicative resources to help spread knowledge at their disposal. This period was also characterized by wider sharing of scientific knowledge. There were far more textbooks, whose exportation sped along scientific finds and medical discoveries to other continents.

Continuation of Technical Obstacles
The next decade was one marked by a continuing and clear evolution and striving toward more therapeutic uses. The next set of pioneers began pushing for ways to help extricate endoscopy out of its diagnostic days toward its true operative potential. However, the laparoscopists of this 1920s decade were still struggling with the existing technical limitations that had plagued all endoscopists since the 1900s. Even though many new devices and improvements were made throughout the early 20th century, problems with limited visualization, inability to detect or stop intra-operative hemorrhaging, deaths caused by unpredictable insufflation complications, burns caused by electro- cautery, bowel perforations, and injuries to major blood vessels still served to limit further development of laparoscopy.

Technical Innovations of the 1920s
Many technical developments which increased safety and efficacy were introduced during this formative stage that helped laparoscopy to become a more accepted procedure. These were just a few:

– the first needle for introduction of a pneumoperitoneum by Korbsch in 1921
– invention of the insufflator by Goetze also in 1921
– a new optics system in 1923 by Unverricht who was instrumental in designing a lens system with a widened viewing angle through the lap
– Orndoff’s improved trocar in 1920
– Zollikofer’s introduction of CO2 as a means for insufflation in 1924

LAPAROSCOPY IN THE 1920s
Complications Beginning to Be Reported More
Another reason is that, as the rise in popularity of endoscopic procedures occurred, so too did the attendant complication rates. For instance there were many more deaths being reported from laparoscopic surgeries in particular, including the still somewhat blind biopsies, as well as problems related to anesthesia, insufflation, and possibly electrical current mishaps (though the literature only states that insufflation and internal hemorrhaging from blind biopsies were the main mortality risks).

American Pioneers
In America, a few milestones had been reached by the 1920s. Bernheim’s well- respected and amply published successes helped to catalyze a new frontier in surgery. Other sources cite Stewart and Stein have having introduced laparoscopy into the US in 1919. Yet earlier than this period were several other American pioneers.

B. H. Orndoff – 1920s
BH Orndoff, an internist hailing from Chicago, was just the exemplary pioneer that the times needed, for he paid particular attention to defining and articulating the precise contraindications for laparoscopy, definitions which had never really been categorized thoroughly at this time. In other words, he recognized laparoscopy potential, but also recognized the need for more training and information on the subject.

In this way in particular, Orndoff took endoscopy by the horns and gave it just the push into modernity that it needed with his meticulous emphasis on proper recording of statistical outcomes and detailed clinical reporting. Orndoff was also was the one who coined the term peritoneoscopy.

Using many of Kelling’s techniques, especially as related to insufflation, Orndoff was able to successfully diagnose ectopic pregnancies, TB of the peritoneum, ovarian cysts, and other pathologies of the reproductive tract. Of special note, Orndoff switched from looking into the scope and then back to an x-ray screen to guide his actions, a method which comes quite close to the concept of operating off the monitor! In addition to his incredible clinical success, Orndoff is also well known for his 19201 report on 42 (48 is also a number reported) peritoneoscopies, which was one of the first large published series of its kind.
In this seminal article, he meticulously tracked the precise presenting conditions, outcomes, contraindication and complications associated with these 42 peritoneoscopies.

However, it wasn’t just Orndoff’s clinical reporting that set him apart. He also made several technical innovations, including a sharp pyramidal trocar point that allowed for greater ease for the initial trocar puncturing. This was especially crucial since, like today, many complications arose from damage caused by initial trocar entries.

Orndoff also experimented with other details of peritoneoscopy and treatment options. For instance, he changed from using regular atmospheric air to the more pure (but less stable) element of oxygen.

Deaths
The switch to oxygen may have been prompted by Orndoff’s experience with losing a few patients due to air embolism associated with carbon dioxide insufflation. Orndoff did apparently have a few deaths from air embolism using carbon dioxide. In 1921 he reported on these adverse outcomes.

Though it doesn’t appear that Orndoff went further than diagnostics, as had Stewart and Stein, he did innovate in the area of radiological treatments via laparoscopy, which certainly can be considered a precursor to operative procedures. He worked early with radiological treatment for lesions and tumors, using a radiological device called a fluroescope.

Nadeau
Nadeau and Kampmeirer did one of the best reviews of the literature that could be found from the 1920s. In 1925, they compiled a meticulous meta analysis of the entire peritoneoscopy literature. These two authors, from University of Illinois College of Medicine, Chicago, focused on the fact that they found it strange that something so useful as abdominoscopy would be so rarely used. They acknowledged in particular Kelling’s and Jacobeaus’ crucial introductions to the modality. Their review of the literature was the most complete for the times and listed over twenty three early pioneers working to develop laparoscopy. Explicitly focused on its diagnostic value for surgeons, who then can make more informed decisions? They acknowledged the conservatism in the medical profession, stating “there is an enforced cautiousness since they are dealing with human life at stake. In the end, the method was said to be one which “…has hardly met with a clinical mishap which could serve as a hindrance to its acceptance.”

Aside from their excellent clinical research, Nadeau and Kampmyer also devised a flexible cannula and trocar for use in peritoneoscopy. This would have been fairly significant, considering that most literature claims that flexible instruments only began with fiber optics. We could not uncover just what materials were used to make the instrument flexible, but probably a type of India rubber, commonly available in those days, could certainly have been used.

Rendle Short – England – 1925: First Guidebook on Laparoscopy in English
Short is best known for being the first to provide a comprehensive textbook- format guide about laparoscopy in the English language, although there is some discrepancy in the records on this point. However, more than that, Short was one of the earliest that understood things from the patient’s perspective. Like a true visionary he understood just how much potential the laparoscope had. He wanted to steer away from laparotomies for the sake of his patients. This is demonstrated with his statement from his publication of 1925: “An exploratory laparotomy, often referred to as though it were a mere trifle, may be from the patient’s point of view a very formidable affair” (Short,“The Uses of Coelioscopy,” 1925).

Korbsch – First Textbook on Laparoscopy 1927
In Germany, a physician named R. Korbsch published one of the first books on laparoscopy in 1927. As well, in 1921 Korbsch– before Veress but around the same time as Goetze- introduced improved instruments and techniques, including the “utilizing a separate pneumoperitoneum needle,” which he described in his 1921 article entitled “Die Laparoskopie nach Jakobaeus.”

Laparoscopic-Assisted Sterilization – First Round of Interest
Reproductive medicine could be said to have a history 2000 years old, with such compounds as queen anne’s lace (wild carrot), silphum, the calendar plan, pomegranate skin, and other natural compounds used as natural abortants.

As for tubal ligations, that history dates back to as early as the 1820s, when James Blundell published a report suggesting this. However, the first confirmed tubal sterilization surgery (open method) was in 1880 by Lundgren of Ohio. Although some sources refer to attempts as early as 1919, the first documented example of tubal sterilization endoscopically was introduced to the US by Bosch in 1936, a development seen by many to be the start of operative gynecologic laparoscopy. Work by Hope, the US pioneer in the related field of diagnosing ectopic pregnancies, was also independently advanced during this same time period. Later in 1941, Power and Barnes reported success in tubal sterilization by coagulating the isthmic portions of the fall. Another American gynecologist, Anderson, also reported on his use and appreciation of laparoscopy for diagnosing gynecologic disorders. His 1937 article on the subject mentioned a wide variety of operative procedures that he believed the laparoscope would one day be useful for treating. He suggested laparoscopic tubal fulguration as a method that might be successful for tubal sterilization but provided no other detail on the matter. One point of confusion in the literature surrounds this particular subject, for some reports suggest that Anderson actually performed one of the earliest tubal ligations. However, after careful review of the documents, it seems that Anderson only alluded to it as a possibility, but provided no further clinical data on the subject. Even so, his recognition and advocacy of laparoscopy as a potentially important part of gynecological surgery was a bold first step for our discipline.

Note
1. Other sources state 1919 as the year of this publication. However, this may have referred to a lecture presented in 1919, several months in advance of the 1920 publication.