knife is in danger of going through the peritoneum. This guidance by the method of Percy is an important contribution. It enables us to work more briskly, but of course it adds very materially to the mortality, because of the peritoneal shock involved from a hand in the peritoneal cavity during the hour and a half necessitated in doing certain cases.

These then are the enlargements of the Byrne operation which, while not novel, might be said to give a fuller scope and a promise of better results. Dr. Byrne has removed the entire uterus with no more than the ligation of the ovarian arteries. I had to show that it could be done (not because I desire to advocate it) and re

moved the whole uterus with the use of one single ligature. It shows how these large vessels can be shrunk securely. The upper vessels are not as fairly treated by cautery as the lower because the uterine artery is accessible and retreats so little that it can be hardened to the consistency of horn and trusted not to bleed.

We have tried doing a Byrne amputation of the cervix, and, some weeks later, an abdominal hysterectomy, but I must condemn it. One is obliged to wait till granulation is complete. By this time there is a strongly contracted scar-ring which prevents uplifting the fundus and the top of the broad ligament and masks the ureter relations in such an attack from above.

The apparatus* comprises two electrical devices. One is known as a rotary converter. This is used to transform the direct current into an alternating current. An alternating current may be transformed far more easily than a direct current. Therefore, the alternating current is used. This alternating current from the rotary is in turn put through a closed circuit transformer. This closed circuit transformer steps down the voltage from that obtained from the rotary (about 75 volts) to about 20 volts. This 20 volt alternating current is obtained from the secondary of the transformer, and may be regulated from 0 to 20 volts. At the same time, in converting this higher voltage alternating current into a lower

FIG. 6.-One-piece removal taking all endometrium.

voltage alternating current, we are also transforming the quantity of electricity from a lower amperage to a correspondingly higher amperage output, so that one is able to obtain a lower voltage and higher amperage. This, then, is used for heating the cautery knives.

Between the transformer and the knife run particularly heavy cables, in order to lower resistance and to prevent heating. This applies especially to the wires running through the handle to the knife. This handle is very heavily insulated and does not heat up in a long operation. The absence of a switch in the handle seems to me also to make for lowered resistance and cooler structures, but some operators prefer such a switch.

*The outfit is made by the Wappler Electric Manufacturing Company of New York.

The peculiarity of my knife, in which it differs from others, lies simply in its larger mass of metal. Thereby the lower degree of heat is longer held, and thereby also in connective tissue planes the slightly curved blunt blade can push away structures like the bladder.

The difference from previous apparatus, and practically the whole story of efficiency in this outfit, now about eight years in use, depends on two things; a powerful rotary converter and a powerful knife connected by heavy wire. Little knives and thin knives cool

quickly, and, in consequence, the operator heats them far too hot, so that the tissues are charred instead of being cooked to horn. A black scab on the end of a vessel is knocked off by the blood current or the retractor. The tough, white, stiff surface, feeling and looking like horn or rubber, is the tissue to leave in the track of the knife. Thus he who has used the method a few times is not afraid to cook the uterine and trust to the cooking to hold the vessel, but the beginner will sleep better with ligatures about these big vessels.

Steps of the Operation.-Rotten tissue may be curetted from the

cervix cavity, the surface seared well with the flat of the knife. Dragging downward on the uterus and making counter-traction so that the line of incision is taut, the knife edge whitens a millimeter each side of the cut. Charring is to be avoided as far as feasible and also extreme white heat of the platinum. The perpetual refrain of this operation must be that of Byrne "less heat," “less heat," "a deep dry roast," "a deep dry roast." The constant fault is too much heat, and this is unavoidable with light knives and small conducting wires. The attendant keeps his hand upon the switch and the operator calls for more or less current according to the density of the tissues and their vascularity

As soon as the vagina is freed, progress in the loose cellular tissue in front or behind the cervix goes easily-one dissects and one shoves. The slight curve of the knife and its blunt edge clear away the bladder rapidly. The posterior section is freed to the cul-de-sac. We next have the flat band of the broad ligaments to handle. Keeping away from the uterus and a safe distance from the ureter, the base of the broad ligament and the uterosacral ligament are cooked and severed. As we approach the uterine it may sometimes be dissected out by the knife, not too hot, and then carefully shrivelled, not with the edge, but with the flat of the knife. As is well known,