Chapter 3 - Society of Laparoscopic & Robotic Surgeons

Chapter 3

Renaissance, Scientific Revolution, Age of Enlightenment
1500s CE –1700s CE

There is a single light of science, and to brighten it anywhere is to brighten it everywhere.
-Isaac Asimov

Clearly, the prohibitions concerning inspecting the human body were finally dissipating, allowing for a new era of discovery to steadily unfold. This turning point was crucial for another reason as well, for it was here that endoscopy was pushed toward the threshold of a new beginning, one characterized by a long, tedious battle to achieve a source of immaculate illumination– aka, the second obstacle. Leaving off from the 11th century, the story of endoscopy at this juncture centers on the journey toward solving the second problem of bringing sufficient light inside the body, a process that would take another 900 years of accumulated scientific knowledge to resolve. In fact, this second obstacle actually defied true decryption well into the 20th century, for it was not really adequately resolved until the introduction of electric technology and later, through fiber optics. However, during this pre-Edison era, the attempts were nevertheless clearly becoming more sophisticated. Innovators began experimenting with new sources of light, such as electrified platinum. Though these devices often proved impractical, such attempts to piece together the puzzle of illumination must be considered great acts of ingenuity for an age before Edison.

The European Scientific Revolution – 1500s–1700s
Leaving the 11th century, we make a fairly large leap forward, beginning with the year 1500, a year commonly cited as the starting point for the modern era of history. Despite our circumvention of a few centuries, it is important to remember that many minds contributed to the development of endoscopy, including those from the intervening years before 1500. For our purposes however, we turn now to the 16th century, an era when a brilliant rebirth of interest in the arts and sciences poured forth from the Eurasian continent in particular. Progress seemed to take shape especially after the world received perhaps one of this era’s greatest contributions: the Guttenberg printing, perfected for use by 1440. While other rudimentary forms of mass print production had been in existence much earlier (most notably from 11th century China) the Guttenberg press stood out for its greater mechanical sophistication and for its ability to achieve production on a much larger scale. This breakthrough in technology was instrumental in launching a new era in communications, which naturally enhanced scientific understandings. Similar to the effects of today’s Internet, access to knowledge soon became possible for a wider audience, not just for those within elite society. No doubt too, the Guttenberg press helped further expand the scientific progress of this time period.

Until this point in time, the technologies associated with endoscopy had not developed much beyond their ancient forms conceived a thousand years before. But this seemingly plodding pace of progress was about to change with the onset of what is commonly referred to as Europe’s Scientific Revolution1. With the great progression of scientific knowledge that ensued, countless medical traditions were boldly called into question; a great many physicians were knee-deep in this unfolding plot to overthrow all established but untenable theories held so dearly by their classical counterparts. Of course, even with the era’s strident efforts to obtain more knowledge, a great many aspects of human biology remained woefully misunderstood. Misconceptions about female anatomy in particular were still circulating well beyond this 16th century time frame. Even the famed anatomist Vesalius (circa 1538) missed the mark considerably when he failed entirely to identify the ovaries in his classical works on anatomy published during this time frame.

A 2nd Turning Point- Capturing and Reflecting Artificial Light
Despite such lingering confusion over anatomy, a great many innovations during this era would prove crucial for endoscopy, particularly those relating to light and lenses. In the opening hours of this modern era, one of the first documented attempts to harness artificial light was achieved by the famed though somewhat controversial Italian mathematician-physician named Gerolamo Cardano (1501-1576)2, whose life work exemplified the Renaissance era of rambunctious intellectualism. The ingénue behind many inventions and discoveries– and author of a notorious treatise on the secrets of successful gambling- Cardano clearly broke the mold for endoscopy at this time with his invention of a mechanical lamp for examining interior body cavities. Unfortunately, historical records reveal far too little about this particular innovation of Cardano’s to hazard further interpretation. It is tempting however to view Cardano’s work as a 270-year old ancestor to Bozzini’s lichleiter.
Another Italian named Giulio Cesare Aranzio (1530-1589), a celebrated Venetian physician and anatomist in his day, is commonly cited as an important 16th century figure contributing to endoscopic-like techniques, though the bulk of his work related mostly to brilliant anatomical discoveries. However, he did devise a clever method for harnessing reflected light by utilizing the known principles of camera obscura to reflect natural sunlight off a glass balloon flask filled with water, which was then placed in front of the shutters of a darkened room and then directed into the nasal cavity of his patient.

Around the same time, important improvements to the simple specula were made by a French physician named Pierre Franco (1500-1560). A renowned lithotomist from Provence, Franco made substantial contributions on many levels, including the construction of an improved speculum to examine the female urethra, which ultimately helped to achieve some of the first instances of extractions of urinary calculus in the female patient. With many other innovations, Franco is therefore credited by many with setting the foundation for urethroscopy.

Bombastic Blowing of Bellows– Paracelsus and Insufflation’s Early History
Who does not know that most doctors today make terrible mistakes, greatly to the harm of their patients? Who does not know that this is because they cling too anxiously to the teachings of Hippocrates, Galen, Avicenna and others?…. In experiments, theories or arguments do not count. Therefore, we pray you not to oppose the method of experiment but to follow it without prejudice. -Paracelsus, circa 1530

Experiments with an inseparable adjunct to today’s laparoscopy– insufflation– were also just beginning to appear in the literature of this time, though early work in this area has also been attributed to Hippocrates. Born in Einsiedeln and later practicing in Basel, Switzerland, Theophrastus Philippus Aureolus Bombastus von Hohenheim– self-renamed Paracelsus (1493-1541)- was a physician credited with distending the lungs of his suffocating patient by devising a clever system using bellows to blow air into a tube that was placed in the mouth. Paracelsus also contributed to surgical literature with his well- regarded work entitled Die grosse Wundartzney (The Great Surgery Book). Despite these and other contributions, Paracelsus’ unconventional methods were unfortunately not well received, attributable in part to his apparently arrogant demeanor (cited as the perhaps apocryphal origin of the word bombastic). He certainly made few friends when he tried to overturn many of the established medical tenets of the day, which in part still relied on Galen’s grossly incorrect theories of the four humors. Or perhaps it was his uncanny talent for upsetting people with either his drinking or temper; he was reputed to have drunk “miners and teamsters under the table” and as well carried with him at all times a “huge sword.” Dabbling too in other misunderstood and therefore controversial medical practices for the time, Paracelsus was taunted as “the Luther of medicine” and was forced by the mainstream medical establishment to leave his city altogether. As we shall see, this is just one of many figures in endoscopy’s history who would be publicly disparaged for unorthodox innovations.

From Guttenberg to Newton- Late 16th through Early 18th Century
Nature and Nature’s laws lay hid in Night. Then God said: “Let Newton be,” and all was Light.
-Alexander Pope, giving praise to Newton

In short, the timing couldn’t have been more perfect for the endoscope to take off at this stage in time. Divination had long since past as a popular means for treating illnesses. Fundamental changes in understanding about the physical world were unfolding, elegantly illuminated by such brilliant minds as Newton. And though remnants of erroneous Aristotlian-based medicine, with its central belief in bodily humors, were still part of commonly held convictions, these views were indeed crumbling before an ever-widening audience of educated thinkers ready to scientifically challenge unverified assertions. Perhaps most importantly for surgery, the long-standing unease about inspecting the interior human body- living or otherwise– had finally abated to the point where research actually could be conducted for the most part in full view of academic bystanders. In short, it seemed at last the world was now ready- socially and religiously- for great and profound leaps forward in science and medicine.

Electricity Unleashed- The Second Obstacle Begins to See Its Slow Demise
Within this vibrant era of scientific discovery, crucial new research about electricity was being conducted, which naturally directly catalyzed great advancements in medicine. Of course, theoretical knowledge of electricity’s existence was known since ancient times. The word electra was a Greek word for amber, a mineral rock found to be capable of lifting light materials after being rubbed. This era however was characterized by efforts to actually capture this mysterious electrical energy, as well as to understand its effects on animal tissue. Physicians were especially influential in this critical new field and were some of the first to find ways to harness the powers of electricity for the benefit of humankind. One such pioneer was William Gilbert, the personal physician to Queen Elizabeth I and founder of the so-called ‘magnetic philosophy.’ In 1600, Gilbert introduced the term ‘electrica’ and described what would later be known as ‘static electricity,’ a term used to distinguish his discovery from earlier terms associated with the prevailing but erroneous Aristotlean views on matter that had for centuries misguided scientists concerning the physics of electricity. Without question, these innovations proved to be crucial for the transformation of endoscopic technologies, though another 200 years or so of tinkering would be required before these discoveries could yield an endoscope of practical use.

Peripheral Developments – Lens Technology
Great strides were being made in other fields during this period of rapid scientific transformation. In particular, progress in lens technology was advancing quite nicely. Many of the necessary components for modern endoscopy were being conjured up right here. Credit is given to the Frenchman Pierre Borel of Castres (1620-1689), the personal physician to King Louis XIV, for inventing the concave mirror that reflects light more intensely and precisely. Borel is also considered among the first to apply the microscope to medicine. Of course, the invention of the microscope itself (in the late 16th century) catalyzed tremendous advancements in biology and medicine. In 1683, Antony van Leeuwenhoek, a renowned Dutch scientist, became the first in history to actually visualize living bacteria when he used a microscope to examine his Petri dish filled with water. Other crucial innovations in optics during this era include Galileo’s improved telescope, while Newton advanced theoretical knowledge of light and optics with the publication in 1704 of his other brilliant work entitled Opticks.

As can be said of today’s surgical practices, it is frustrating to note how long it took for many of these technologies to find their way into the fold of endoscopic usage. As the next chapter and others will reveal, so many of the world’s most important discoveries were actually initially the subject of scathing ridicule, dismissed as irrelevant- or irreverent– or, at other times simply blithely overlooked, only to be re-discovered years later.

1. Of course Europeans were not the only ones contributing extensively to the advancement of the sciences at this time. In fact, during this early 16th century time frame, Europeans were actually much less advanced than other societies in many important ways. China’s Ming Dynasty and the Middle East’s Ottoman Empire, with several centuries’ head start, continued to reign as two of the most sophisticated societies of their time, with highly developed centers of culture and science. Thus, it is more accurate to state that endoscopy’s further advancement during this era resulted from the continued exchange of scientific knowledge from multiple societies.
2. Known also by his latinized name Jerome Cardan.