History of HysteroscopyChapter 1

The earliest publication in endoscopy was that of Bozzini.² Although Bozzini wrote in the German language, Bozzini is not a German name. His father Nicholas Maria Bozzini de Bozza a member of a distinguished Italian family had to leave Italy about 1760 AD after a fatal duel. Travelling to Mainz he married a girl from Frankfurt and Bozzini was born on 25th May 1773. Bozzini studied medicine in Frankfurt and later in Jena. He published his first extensive medical report on his ‘light conductor’ in 1806. While Bozzini was working as a practising obstetrician and gynaecologist, Mainz eventually came under the French rule but he did not want to become a French citizen. For sometime he headed a military hospital with great success. Life was not easy but he published an article in 1807.² In the preface he (Bozzini) wrote, “Every invention owes its origin to a happy combination of various circumstances. It is always born like a child and like a child keeps becoming nearly perfect in a step-wise fashion.” Bozzini dedicated his article to his most venerable friend, the noble and scholarly Herr Friedrich Sigismund Feyerlein, Doctor of both laws, Advocate Ordinary and Procurator to the Frankfurt am Main. Interested readers are advised to read the translation of the original article (Rathert).³2

Bozzini's original instrument was used on patients with diseases of the rectum and the uterus. In April 1809 Bozzini died of typhoid fever at the young age of 35 years. He left his wife and three young children in very poor circumstances. Bozzini's tombstone was found (Rathert)³ in 1954 during the renovation of the outside walls of the cathedral in Frankfurt.

In 1869 Commander Pantaleoni⁴ wrote a 2-page article on endoscopic examination of the uterine cavity. He stated that the invention of the ophthalmoscope and the laryngoscope had led to the invention of the endoscope. Desormeaux⁵ of Paris previously invented such an instrument and called it an endoscope. Almost simultaneously Cruise⁶ of Dublin further improved the instrument by preventing it heating up and by introducing better light.

It is interesting that Pantaleoni used this instrument to examine a lady who had catarrh of the nose for 30 years (chronic coryza) and located a polypoidal vegetation in her left nostril. After repeated cauterisation of the same she was cured. Three years later the same patient was treated by Pantaleoni for postmenopausal bleeding. He used a sponge tent probably as a laminaria for 24 hours in order to dilate the cervical canal. When he performed an examination 24 hours later, he could clearly visualize ‘a polypous vegetation’ at the bottom of the cavity and toward the posterior part of the fundus. On several occasions he cauterized the polyp and re-examined it thereafter with the endoscope. No untoward effects were observed, and Pantaleoni stated that he had treated several other women in this fashion with abnormal uterine bleeding. It thus became apparent that because it was used by a forward thinking physician the endoscope could serve both as a diagnostic and therapeutic tool.

Pantaleoni's publication was not received well in the USA, however Professor Munde⁷ of Dartmouth Medical College wrote a book in which he stated that the real “eye” of the gynaecologist was the tip of the index finger and that this was better than a glimpse of the endometrium which he opined was of little value. He specifically did not like it because the tube was fixed and was unlike tubes in the large bladder which could be moved freely. Not long thereafter in 1893 Morris⁸ described a thin silver plated tube of brass 9 mm in diameter, 22 cm long and bevelled smoothly at the entering end. An obturator was used at the time of entry and then removed leaving the hollow tube inside. Morris used a head mirror to throw light inside and was able to observe the endometrium and the tubal ostia. Only 5 years later, Duplay and Clado⁹ wrote a book with 28 illustrations on hysteroscopy. They used a battery light source and silver nitrate to treat intracavity lesions; the whole apparatus, however, seemed cumbersome, even by the standards of the day.

Only ten years later, in 1908, Charles David¹⁰ wrote his master's thesis for the University of Paris on the diagnosis and treatment of intrauterine diseases with the aid of the hysteroscope. He divided his thesis into four sections: instrumentation, operative technique, clinical studies and clinical observations. According to Alvin Siegler,¹¹ one of the most knowledgeable endoscopists of the latter part of the 20th century this thesis could serve as a review course for modern hysteroscopy.

Gradually refinement in the technique of hysteroscopy was introduced. Two objectives had to be implemented that is, distension of the uterine cavity and better visualisation. Rubin¹² in 1925 compared cystoscopy and 3hysteroscopy. He recommended that CO₂ be used to insufflate the uterus and that bleeding be treated with adrenaline. Reporting on his experience with 42 cases, problems were noted in only 6 instances. Gauss¹³ three years later used water to flush the uterine cavity and distend it. In 1934 Schroeder¹⁴ developed a 180° hysteroscope by which the field of vision was widened. This instrument had a diameter of 10 mm. To prevent bleeding Schroeder added a few drops of 1:1000 adrenaline to the distending solution. His most important contribution was the determination of the intrauterine pressure. When the receptacle containing the distending fluid was placed 650 mm higher than the patient, the intrauterine pressure produced was 25 to 30 mmHg. When the level was increased to 950 mm, intrauterine pressure rose to 35 mmHg and vision became clear. When the pressure was raised to 55 mmHg, the liquid passed through the uterine cavity into the peritoneal cavity.

In 1952 the ‘cold light’ source was revolutionised when system of ‘rod lenses’ was patented by the British physicist Sir Professor HH Hopkins.¹⁵ British and American companies paid little attention at the time. However, it was Dr Karl Storz who quickly realised the importance of the rod lens system and contacted Professor Hopkins to work with him to develop the cold light system. Fourestier et al¹⁶ ultimately used quartz bars to conduct light from the external source to the proximal end of the endoscope. In 1957, Palmer¹⁷ who also made fundamental contributions to laparoscopy introduced a hysteroscope of a very small diameter so that dilatation was not necessary.

The first gastroduodenal fibrescope was introduced by Hirschowitz¹⁸ in 1954. The oesophagoscope was the second flexible fibrescope. It was 10 years later, after the creation of the gastroduodenoscope that this technique was used in gynaecology and obstetrics. Mohiri and Yamadori¹⁹ were the first to record foetal images in pregnancy using the first fibrehysteroscope. They produced the first film in the world on antenatal diagnosis of foetal malformations.

Flexible hysteroscopic methods remained unknown in US and Europe until Rene Marty and Valle²⁰, Lin Bao Ling, Iwata Y, et al²¹ popularized the flexible hysteroscope. Bernard Blanc, Rene Marty and Remy de Montgolfier²² published their book recently “Office and Operative Hysteroscopy” in 2002.

Today, several companies have fibrescopes, i.e. Storz, Olympus, Fujinon, Circon and Leisegang. Their outer diameters vary from 2.5 mm to 3.7 mm and various accessory operating instruments of different sizes are available. We will not go into the details, as we have no experience of fibro-optoscopy. The interested reader is advised to refer to the above mentioned book.

In 1963 Silander²³ mounted a transparent balloon at the end of the endoscope which was distended in the cavity for better vision. High molecular weight fluid was introduced by Edstrom and Fernstrom.²⁴ The uterine cavity was distended with a concentrated viscous solution of 35 per cent dextran for improved visualization. Lindemann²⁵ was the first to show the safety of CO₂. Gallinat and Lindemann²⁶ introduced the hysteroendomat in 1970 after experiments on German Shepherd dogs that received direct femoral vein insufflation of CO₂. Flow rates of 200 cc/min, minimal variations in pulse rate and breathing occurred. However, toxic effects occurred at flow rates of 400 cc/ min and the animals died within 1 minute when 41000 cc/min were insufflated. Gallinat showed that CO₂ was 20 times more soluble in blood than air. His refined instrument measured the intrauterine pressure, the volume of gas inflated and the pressure of gas in the outside cylinder. Barbot²⁷ and co-worker introduced the contact hysteroscope in Europe. Baggish²⁸ followed in the United States, and Hamou²⁹ in France introduced one single instrument—for panoramic and contact hysteroscopy—the microcolpohysteroscope in 1980.

These technical refinements greatly influenced therapeutic applications. Hysteroscopic removal of submucosal leiomyomata was first performed by Norment in 1956.³⁰ Neuwirth and Amin³¹ used the urological resectoscope and excised submucous fibroids in 1976. In 1983 DeCherney and Polan³² first used electrodiathermy for intractable bleeding due to a variety of reasons in patients who were found unfit for major surgery, particularly those with endocoagulopathy.

Endometrial Laser Ablation was first performed by Goldrath³³ and co-workers in 1981 and later by Davis³⁴ in 1985. TCRE using electrical energy was first performed by De Cherney and Polan³² in 1983 and later by Magos³⁵ and co-workers in 1989. Progress in instrumentation continued and in 1987 Vancaille³⁶ described the use of a roller ball to perform destruction of the endometrium in cases of DUB.

The most common diagnostic hysteroscope is the 5 mm (telescope and sheath) office hysteroscope which as a rule requires no dilatation of the cervical canal. For operative procedures the 7.0 mm and 8.5 mm diameter instruments are used; however both need anaesthesia for cervical dilatation unless the cervix is patulous from prior deliveries. Stefano Bettochi³⁷, using Karl Storz technology, developed a new generation of small diameter instruments ranging between 1 and 2.9 mm. Continuous flow sheaths with a total diameter of 5 mm are available enabling the surgeon to use semirigid instruments of 1.6 mm size. The spoon and the crocodile biopsy forceps provide enough material for the histopathologist.

Second generation methods for ablation are easier to perform, require less skill and training, can be carried out under local anaesthesia, are effective with fibroids, and most important as effective as the classical methods and with lower complication rate than TCRE/ELA. These newer methods make use of electrical energy, radiowave energy and microwave energy. Vaportrode, Thermal Balloon, ELITT device, Cavaterm^TM, Novasure^TM System, VestaBlate System, Opera System (STAR), Hydro Thermal Ablator (HTA) and Versapoint are the newer methods at the time of this writing.

The details of the above methods are described in the appropriate chapters.