Hans Frangenheim - Culdoscopy vs. Laparoscopy, the First Book on Gynecological Endoscopy, and "Cold Light," Litynski G. Figure 1. Dimitri Oskarovic von Ott at work. (Figure 4-3 in Highlights in the History of Laparoscopy.) In 1942, Decker began to work exclusively in the gynecol- ogy department and soon turned to a vaginal approach to view the abdomen (Figure 2). "The route to the pelvis by abdominal puncture with the aid of vaginal manipulation and various postures did not give uniformly satisfactory results," explained Decker. He attributed the failure of proper visualization to the presence of intestinal loops and the inability to isolate the pelvic organs correctly. To solve this problem, Decker built an endoscopic instrument. The "Decker culdoscope" represented in principle a modified peritoneoscope, consisting of a trocar and an optical sys- tem. But the most important alteration involved not the instrument, but rather the investigatory technique: female patients were examined in the knee-chest position. "This method has several advantages," noted Decker. "Very few instruments are needed, the air enters the abdomen only if the tubes are patent, not spastic, and as a result of negative pressure."10 As World War II drew to a close, Decker began to advocate culdoscopy. He published a series of studies dating from 1944 to 1952 in the medical press.11 This method won over many physicians in the United States and came to occupy a privileged space in the range of endoscopic examination methods then available. Decker encouraged the use of cul- doscopy in the knee-elbow position, although it took at least four people to bring the female patient into this posi- tion, buttocks raised, and hold her there. The average length of an operation with a laparoscope, including gen- eral preparations and creation of a pneumoperitoneum, was about 30 minutes; a culdoscopic operation, in contrast, required only a few minutes (Figure 3). Decker was so successful with his publications on the cul- doscopy that for over 20 years this method was practically the only endoscopic examination of the abdominal cavity in the United States. As a German gynecologist put it, "In the majority of cases, the Anglo-American countries prefer the culdoscopy over the laparoscopy, most likely due to Decker's influence."12 358 JSLS (1997)1:357-361 Figure 2. Culdoscopy according to Decker. (Figure 4-4 in Highlights in the History of Laparoscopy.) Figure 3. In the USA culdoscopy replaced laparoscopy for over twenty years. Gynecological Endoscopy in Germany, and Hans Frangenheim At the conclusion of the second world war, Germany faced enormous difficulties. Countless towns and cities had been destroyed, some almost totally, and entire industrial branch- es had collapsed. The country was divided into four zones and remained under Allied administration until 1948. During this time Germany was essentially isolated from the rest of the world. For German physicians, this meant that they had almost no access to international scholarship after the war (nor had the National Socialist regime permitted much contact with outside science during its tenure). This situation persisted until the late 1940s. The first report on culdoscopy appeared in Germany in 1949.13