A HISTORICAL PERSPECTIVE ON UPPER ENDOSCOPY AT RHODE ISLAND HOSPITAL

Medicine and Health Rhode Island, Nov 2005 by DiMase, Joseph D, Thayer, Walter

Endoscopy, a word derived from the Greek endo (within), and scope (view), began with Hippocrates (460-375 BC), who made reference to a rectal speculum using a natural light source. In the Pompeii ruins (70 AD) a three-bladed speculum was found similar to the current day vaginal speculum. Consequently, interest in exploration of internal organs has its origins from the beginning of medicine.

Technical difficulties confronting researchers included design of the instrument and suitable material of construction. However the greatest impediment was a suitable light source. The latter was obviously an essential quality to accurately gain information by precise visual inspection. Over the last 2000 years, endoscopy has relied on a light source progressing from natural light, to candle light, to light from alcohol, turpentine, gas, electric, fiberoptic, and most recently to a video chip.

For a detailed history of the development of gastroenterology, with photos of historic gastroscopes, the reader is referred to "The History of Gastroenterology," by L. Walk. (1) As noted in this article, numerous modifications of the gastroscope took place, but the basic instrument remained a rigid one with a high rate of perforations. In 1928, Wolf, a German electro-optician, and Rudolph Schindler, a German clinician, devised a semi-flexible instrument, with a series of lenses having short focal distances, allowing the image to be passed through the curved tube.2 In 1932, the instrument was presented to the medical society of Munich. Gastroscopy was reborn and streaked across the world. In 1934, Schindler was invited to the University of Chicago, where he established an endoscopic clinic and trained many endoscopists. He can rightly be called the father of American gastroscopy. He was one of the original founders of the American Society for Gastrointestinal Endoscopy.

A few years after Schindlet came to the US, Dr. Russell Bray began practicing his specialty as a gastroenterologist in Rhode Island, after receiving training in Philadelphia. A field of endoscopic excellence had developed in that city under the leadership of Dr. Henry Bockus. To our knowledge Dr. Bray was the first clinical gastroenterologist in this state.

The Schindler gastroscope, made by Wolf in Berlin, was purchased by Dr. Bray. He performed his first gastroscopies using local procaine anesthesia. Later he set up a clinic at Chapin Hospital and still later the first GI clinic at Rhode Island Hospital. There gastroscopies were performed "anywhere I could find a darkened room." 3 The Schindler instrument was replaced by the Eder-Hufford scope, (photo), which had a hot light bulb tip and a hand bulb attachment for gastric distention.

In 1854, a British physicist, John Tyndall, described that light would follow a curved path.4 Ingenius inventions followed,5 and one hundred years later, an undergraduate physics student, Laurence Curtiss, invented the fiber glass bundle conveying an entire image.6

In 1958, Basil Hirshowitz et. al. demonstrated the prototype fibergastroscope at the University of Michigan (photo).7 This was a side viewing instrument which required blind introduction into the stomach.

In 1965 Dr. Walter Thayer who, trained as a gastroenterologist and endoscopist under Dr. Howard Spiro at Yale University, was appointed the first Chief of Gastroenterology at Rhode Island Hospital. Upon Dr. Thayer's arrival, the Rhode Island Hospital purchased an Eder-Hufford gastroscope, a "flexible" esophagoscope, and subsequently the Hirshowitz gastroscope. The Eder-Hufford gastroscope was equipped with a series of prisms and lenses. The distal half had a rubber exterior with a hot light source at its tip. Because it could only be flexed 15 degrees forward and because it was a side viewing instrument, the esophagus, posterior stomach, fundus and antrum could not be seen. Gastric biopsies had to be taken blindly with a Woods tube, a device with a circular blade and a hole. Suction pulled a piece of mucosa into the opening which was then cut with the circular blade.

The esophagoscope was a straight stainless steel hollow instrument with a distal hot light source and a flexible obturator, useful for insertion into the upper esophagus. Both instruments required a trained assistant who positioned the head of the patient for insertion. Although the eye piece had some magnification, viewing with this instrument was just like looking through a pipe. Esophageal biopsies could be obtained with forceps, which were advanced through the instrument.

Gastroenterology was fundamentally changed with development of the Hirshowitz fiberoptic gastroscope, made commercially available in 1961. Principal advantages included flexibility, better visualization, and an outside cold light source. It required blind introduction into the stomach. Controls at the proximal end of the instrument were added later. This allowed the endoscopist to manipulate the distal tip. In the late 60s, forward viewing fiberoptic endoscopes were designed and permitted complete visualization of the esophagus and easy entry into the duodenum. The instrument had a separate channel which allowed the endoscopist to take biopsies and cytologie specimens.