VAGINAL HYSTERECTOMY BY GALVANO-CAUTERY. BY JOHN BYRNE, M.D., Brooklyn, N. Y. (With seven illustrations.) ON July 27th, 1895, I removed the uterus, tubes, and ovaries by means of the galvano-cautery knife alone, neither scalpel nor scissors having been used throughout the entire operation. This is the first time in the history of surgical gynecology, so far as I know, in which the operation of vaginal hysterectomy has ever been done, or even attempted, by any such means. Though for many years I have been favorably impressed as to the practicability of doing this operation by the delicate cautery knife, I could hardly have hoped for so convincing a proof, not only of the well-known advantages assured by this method over all others, but of the facility with which it could be accomplished. My second case occurred August 14th, but the difficulty experienced here was much greater, as a glance at its leading features will show. There was complete prolapse of the uterus, rectum, and bladder of nine years' standing, and for four years previous to her appearance at my clinic no attempt whatever had been made to return the parts within the pelvis. The mass, which was of the size of a large cocoanut, was hard, almost solid to the touch, and deeply ulcerated from long exposure and friction. Warm applications of carbolized glycerin and water were used for a few days, when the parts were returned with some difficulty. By the use of large, firmly rolled tampons soaked with carbolized glycerotannin, and the free use of hot water kept up for several weeks, it was hoped that her condition would be so much improved as to call for supra vaginal amputation by galvano-cautery only, and keeping the vagina on the upward stretch until cicatrization would be complete. This treatment, in cases less aggravated, has been uniformly successful in my hands for many years. In this instance, however, I abandoned the idea and decided on vaginal hysterectomy. As to the mode of procedure in performing vaginal hysterectomy by galvano-cautery, there is really no material difference from that usually adopted where other means are employed. The circular incision of the cervix, the careful dissection of the vesical wall from the uterus, opening of the cul-de-sac of Doug H.A.KAYSAN, BROOKLYN, NY. FIG. 2.-Diverging intrauterine volsella. las, and the severing of the broad ligaments as clamp or ligature is applied, are steps in the operation alike in all methods. In G.TIEMANN & CO. FIG. 3.-Cautery knife. Dome-shaped electrode and universal handle. my second case, however, more than ordinary difficulty was experienced, and great care needed in separating the uterus and bladder because of the deformed shape of the former and the abnormally extensive and irregular utero-vesical attachment. The cone-shaped cervix measured fully two inches in diameter below and tapered in a curved manner toward the os internum, at which point the body of the uterus bent abruptly forward. This part of the operation was, therefore, proceeded with in a slow and cautious manner, and the vesical wall was kept on the stretch by a suitable volsella and otherwise protected by an assistant as the dissection progressed. Though the uterine artery had been secured at an early stage by compression forceps, I deemed it best to include the middle third of each FIG. 4.-Anterior view of uterus and adnexa removed by galvano-cautery. broad ligament in a second forceps. The peritoneal cavity being now accessible, the ovaries and tubes, which were found to be adherent to a considerable extent, were released, and these with the fundus were turned out posteriorly. The ovarian arteries were ligated by silk, which was cut short, and the vagina treated in the ordinary manner. With regard to this new departure in vaginal hysterectomy, I have only to say that from my experience in two cases, and also in a third in which I secured the uterine arteries, released the vagina, and severed a large part of the broad ligaments preparatory to opening the abdomen for the removal of an enormously large myomatous uterus, I am fully convinced that in galvanocautery the hysterectomist will find an agent of incalculable value. Ablation of the uterus by this means is, in its very nature, an antiseptic operation, and all tissues severed are left in an absolutely aseptic condition. Moreover, in a reasonably early stage of cervical cancer, and before fixation takes place, if gynecologists could only be persuaded to leave the beaten track and give this ideal method a trial, they would no longer find it politic to evade plain questions touching periods of recurrence in their cancer cases, by replies such as "I have not been able to follow my cases," or, as in the laconic if not polite response of a Western hysterectomist of many uterine trophies, "I have no time to look up my records." When fixation has already been reached and the lymphatics and cells in the broad ligaments have doubtless arrived at a primary stage of degeneration, there is but one operation of any lasting value, and that is supravaginal excision by the cautery knife, NOT LOOP, and thorough additional cauterization of the bottom, sides, and edges of the excavation-in other words, a dry roast. This conclusion has been reached through a careful study of the subject and a large clinical experience running through a |