Illustrating endoscopy 50 years ago

Illustrating endoscopy 50 years ago

This story started with my left knee, which has troubled me intermittently for many years. Preparing for an appointment about it recently I thought that the new young specialist (they are all young now) might be interested to see my series of x-ray pictures from way back.

Why am I telling you? I will explain.

I eventually found the fuzzy old x-ray plates in a large envelope addressed to me at The Middlesex Hospital, which I left in 1986.

Mixed in with them were some drawings that a patient had done at my request to illustrate aspects of my new enthusiasm – endoscopy. His name was Allan Cope. I was sad to lose touch with him, particularly when I was looking for someone of his caliber to illustrate my books about Fred the Snake ( I’d like to share some of his drawings with you.

We started by illustrating the dilemma of some beginners, who might be struggling to open the suitcases holding their new scopes. They were delivered in suitcases in those days, and were often stored in them to travel with, as you will remember from the cover of my book.

Then I thought to illustrate the challenges of learning in the days before videoscopes and monitor screens when the only way for a teacher to share the view was with a ‘lecturescope” side arm device, attached to the head of the endoscope. Learners stood in line to get a glimpse of what the professor was seeing.

Endoscopes have a system for pumping air (or CO2) into the stomach or intestine to make them easier to examine. This slide cautioned our beginners not to overdo the inflation.

As mentioned somewhere before, the early fibreoptic gastroscopes were exactly that, instruments to examine only the “gaster”, the stomach. That was because the Japanese were primarily interested in detecting gastric cancer which was rampant in their country. Olympus later produced a forward-viewing EsophagoFiberscope, and then stretched it a bit, to one called the EFLong. It was indeed a stretch to reach the duodenum with it, as I found when I took that instrument with me to Iran in 1971.

The first “panendoscope”, designed to examine the esophagus, stomach and duodenum, was made by ACMI (American Cystoscope Makers). I used it with enthusiasm in our nacent endoscopy “unit” in the gut hut at St Thomas’s, but encountered two challenges. Firstly, it had an innovative “joystick” control for moving the tip, which was great, but you also needed a hand to press the air/suction buttons, and another hand to push the scope. Not having three hands, we suggested a new technique to deal with the issue. That technique, and the joystick, did not prosper.

The second problem was the popularity of the endoscopy “service” that I was running for a while with that instrument while I was still a trainee/fellow/registrar at St Thomas’s. Bringing the equipment into the hospital and my life felt like the Trojan Horse story of ancient times. It consumed my time, when I should have been studying (or playing golf)

I was concerned also that the increasing demand for procedures might result in the emergence of fulltime “endoscopists”, who would do nothing else all day.

This concern was based on my opinion that endoscopy was (and is) simply a great tool for gastroenterologists, but not a specialty in itself, a conviction that led to my being instrumental in closing down the British Society for Digestive Endoscopy in 1980 (as its last President) and folding it into the British Society for Gastroenterology as I mentioned before.

In retrospect I may have been swimming against the tide, but that is sometimes necessary to get to the right place.

And one more series to illustrate the beginners journey

Some of my readers (if any have kindly got this far, thankyou) will know that my career focussed on biliary and pancreatic disorders and the use of ERCP (Endoscopic Retrograde CholangioPancreatography) to diagnose and treat them. In the early days there was controversy about the best way to obtain an Xray picture of the bile duct, a “cholangiogram”. That involved injecting some contrast medium. The next illustration shows the numerous alternative ways to do that.

From the top: ERCP, then clockwise: laparotomy, laparoscopy, TransFemoral, PTC (Percutaneous Transhepatic Cholangiography) and Transjugular Cholangiography.

For a while there were some (mainly radiologists) who championed PTC over ERCP. However, daily practice and some research studies clearly showed that ERCP was safer (and easier on patients) in most cases. I used the next image in my lectures on the subject to show my opinion/bias. PTC remains a great technique in a few specific cases.

My friend the interventional radiologist at work.

And yes, my knee is somewhat better, thanks for asking.

All part of life’s rich tapestry.