Chips From a Surgeon’s Workshop. 
Kolpohysterectomy 
BERN AYS. 
—-rfrj W»”* M**. 
Partially reprinted from the St. Louis Medical and 
Surgical Journal, April 8f June, 18SJj.. 
With ne’w cases and remarks. CHIP NO. Vll. 
Kolpohysterectomy 
SUCCESSFUL CASES OF TOTAL EXTIRPATION OF THE 
UTERUS THROUGH THE VAGINA. 
-WITH- 
EPICRITICAL REMARKS AND A DESCRIPTION OF THE 
AUTHOR’S METHOD OF OPERATING. 
BY- 
AUGUSTUS C. BERN AYS, 
A.M., M.D. HEIDELBERG; M. R. C. S., ENGLAND; F. R. M. S. LONDON; MEMBER GERMAN 
SOCIETY SURGEONS OF BERLIN; PROFESSOR OF ANATOMY ST. LOUIS COL- 
LEGE PHYSICIANS AND SURGEONS; SURGEON TO THE SURGICAL 
AND OPTHALMIC INFIRMARY; CONSULTING SURGEON TO 
THE MISSOURI PACIFIC AND WABASH, ST. LOUIS 
AND PACIFIC RAILWAY SYSTEMS, Etc. 
WITH FOUR DIAGRAMS. 
ST. LOUIS, MO. 
Julius Buechel, Printer. 
1885. A SUCCESSFUL CASE OF TOTAL EX- 
TIRPATION OF THE UTERUS 
THROUGH THE VAGINA. 
WITH TWO ORIGINAL DIAGRAMS. 
By Augustus C. Bernays, A. M., M. D., Heidlbg., M. R. C. S. Eng., 
Prof, of Anatomy and Clinical Surgery at the St. Louis 
College of Physicians and Surgeons. 
Mrs. P , from Texarkana, set. 52, no hereditary incumbrance, 
has always been rather weak, had a great deal of trouble during her 
life with her family, menstruation commenced at 14, has always been 
regular, has had four children, all boys, and one miscarriage. Suffered 
a great deal of pain in back and hips and was thought to have ulcer- 
ation of the cervix. During the year 1883 she lost strength continually, 
was always under treatment in the country, until finally one of our 
Professors of Gynaecology, who has a clinic, told her that she had can- 
cer of the womb and he could do nothing for her. She first came to 
my office Dec. 6th, 1883, and on examination revealed the presence of 
an epithelioma of the vaginal portion of the uterus. The tumor was 
hard and well defined and surrounded the os, in the shape of a horse 
shoe, upon the left side, leaving a small margin at the right angle of 
the os entirely free. A narrow strip of the mucous membrane of the 
vaginal vault upon the left side was also ulcerated and in connection 
with the tumor surrounding the os. The cavity of the uterus proved of 
normal length, the position and mobility of this organ were also nor- 
mal. The parametria and surrounding tissue were found intact. 
Several years ago it would have been thought perfectly correct to per- 
form amputation of the cervix or Schroeders supra-vaginal amputation 
in this case. Only since Schroeder of Berlin published his first series 
of eight cases of Kolpohysterectomy, seven of which were successful, 
have many Gynaecologists and Surgeons arrived at the very natural con- 
clusion that this operation deserves to come into general use. One 
reason for this conclusion which principally caused me to adopt this 
operation was the most aggravating certainty of return with which my 4 
CHIPS FROM A SURGEON’S WORKSHOP. 
amputation and evidemcnts of cancers of the uterus were always fol- 
lowed and that too in the course of a very few months, no matter how 
radical my operations seemed to be. This method of treatment holds 
out a hope to us, and at least promises to stave off the return a little 
longer since we remove the whole of the effected organ. The literature 
of this operation has increased to an enormous extent lately and I have 
now in my possession a history of one-hundred and sixty cases includ- 
ing three cases, that I have found in recent American periodicals, and 
my own. This list sho>vs one-hundred and eighteen recoveries and 
forty-two deaths, which I call a most brilliant showing for a new oper- 
ation. Many of the above mentioned cases being the first attempt of 
the operators. I can not, in the limits of this article, offer either an 
accurate tabulated statement of the cases from literature nor can I enter 
into a discussion of the numerous modifications which the different 
steps of the operation have undergone at the hands of various operators. 
The great variety of methods and modifications, in the details of the 
operation as practiced by different surgeons, are a prbof of the many 
difficulties to be overcome. I believe this operation to be one of the 
most difficult that our duty compels us to undertake and I would not 
advice any one, who has not become thoroughly accustomed to the use 
of instruments in the vagina by previous gynecological practice, to 
attempt it. Such surgeons as have frequently and successfully operated 
for vesico or utero-vaginal fistula may cheerfully attempt this crowning 
achievement of gynecological surgery with a fair prospect of success. 
I would not have dared to make this assertion however before my recent 
experience. When reading the accounts of such elegant and experien- 
ced operators as Czerny of Heidelberg we meet with expressions like 
the following : “The operation lasted three hours and was very bloody” 
or in another place ‘ Since no urine was passed by the catheter im- 
mediately after the operation, wnich had lasted over three hours and 
since none passed, next day, we were much surprised, at the post mortem 
to find a loop of the small intestine, firmly attached in a hole, that had 
been cut as large as a cherry, discovered at the apex of the bladder, the 
patient having died forty hours after the operation.”—Berliner Kliniache 
Wochenaeh’ifr. Nov. 13th, 1882.—It seems to me but little comfort can 
be derived by any one contemplating his first total Kolpohysterectomy 
from such quotations. I will therefore leave the statistical work, as 
well as the comparison of the various modifications and suggestions of 
the different reports about this subject, to later writers and to such as 
are fortunately situated in some well endowed institution of medical 
science where they can devote more time, to the exact study this work 
will require, and are not compelled to be the slaves of suffering huma- 
nity in a great American Metropolis. I merely wish to submit the fol- 
lowing description of my operation and, as my method is a new one 
in regard at least to a technicality for avoiding arterial hemorrhage, I 
hope it will prove instructive enough to repay its perusal. As a further CHIPS FROM A SURGEON’S WORKSHOP. 
5 
apology I will state that my method enabled me to finish the whole 
operation from the beginning of the narcosis until the removal of the 
patient to her bed in the short time of fifty-five minutes. 
On Dec. 12th, 1883, at 10 a. m. at my private hospital No. 915 
Chouteau Ave., Drs. C. Barck, H. Wichmaxn, H. Harnisch, Robt. 
Luedeking, Andrew Leslie, J. R. Ciieaney and G. J. Berxays as- 
sisted me in the above case. The preparations for the operation were 
of a simple nature, I had the vagina thoroughly cleansed, the evening 
previous to the morning of the operation, by injections with water. 
Whenever I say cleansed or use the expression clean, I mean all that 
can be covered by the widest extension of the word, I do not mean the 
use of so called antiseptic solutions or drugs. Many of the latter are 
any thing but clean, and cannot even be said to cleanse the parts upon 
which they are used, on the contrary they are often very unclean and 
poisonous. I always clean the vagina after using caustics, styptics and 
antiseptics with water. Since I have seen, that one, two and three per 
cent solutions of carbolic acid are splendid fluids wherein to breed and 
propagate colonies of bacteria I have ceased to use them in my oper- 
ations and really I have found in numerous capital surgical operations 
that clean water is the best wash for wounds as well as the cleanest 
dressing. On the evening previous a pint of an effervescent solution 
of citrate of magnesia was administered and after the passage, the rec- 
tum was also cleansed by the use of pure water injections. Internally 
I have always found it a wise precaution, since my residence in the 
Mississippi Valley, to administer thirty grains of sulphate of quinine 
the day before an operation, I combine this with chlorate of potash in 
capsules in all cases involving an opening of the abdominal cavity where 
it is desirable to have the bowels somewhat contracted. The narcotic 
used was Mallixckrodt’s Cloroform. The patient was placed on her 
back with hips flexed upon the abdomen in Simon’s overdone lithot- 
omy position, one assistant holding each leg in this position. Abroad 
flat Simon’s speculum was introdnced for the purpose of holding down 
the perineum and compressing the lower part of the rectum. It is im- 
portant that this blade be rather short so that it will not interfere with 
the downward traction to be made upon the uterus. This speculum is 
entrusted to a third assistant, seated on a stool to my left, and if pos- 
sible remains in position during the entire operation. The lateral and 
anterior walls are held wide apart by broad vaginal refractors and, 
after a catheter has been introduced into the blatter and one into the 
rectum which may become very useful guides, we are ready to begin the 
operation. I began by first grasping the vaginal portion with a vulsel- 
lum forceps and forcibly drawing it outwards and to the right, thereby 
stretching the left lateral vault of the vagina, and with it to a great ex- 
tent the left parametrium, in a transverse direction; I now made a small 
incision, merely through the mucous membrane, near the middle of 6 
CHIPS FROM A SURGEON’S WORKSHOP. 
this tense mass of tissue a little toward the bladder, through this punc- 
ture I forced an aneurysm needle, armed with a very heavy double silk 
ligature, in such a manner, upwards and backwards, that I was bound 
to surround about one inch of the parametran tissue along the side of 
the uterus. I then forced the blunt point of the instrument down and 
outwards until it formed a prominence under the mucous membrane of 
the vagina, opposite the point of entrance but about three-fourths of 
an inch distant towards the rectum, cutting down upon the point it was 
immediately projected and the ligature caught by a tenaculum, after 
which the curved aneurysm needle was withdrawn, rethreaded and the 
same proceeding performed on the right parametrium. 
These ligatures embraced the lateral portions of the fornix of the 
vagina and as much of the parametrium as I could possibly reach, per- 
haps even a portion of the broad ligament proper. My intention was 
to grasp the uterine arteries in this ligature and thus obviate the prin- 
cipal sources of haemorrhage that we must encounter. 
Mikulicz advised and used a superficial ligature, somewhat similiar 
on both sides, for the purpose of using, them as loops with which to 
draw down the uterus. My ligatures had an entirely different purpose 
and were placed without the area of the tissue to be extirpated, far enough 
away from the cancerous tissue to avoid the danger of cutting them 
during the next steps. Mikulicz’s ligatures were placed near the 
uterus and were within the area to be cut away; next I firmly tied one 
of my threads on each side, intending, if necessary, to use the loose 
ones as loops to draw down the parametria at a later stage, if this 
should be found expedient. Having assigned one assistant for sponges 
and one for instruments, I now proceeded to make a nearly circular in- 
cision through the fornix of the vagina around the neck of the womb 
and well within my prophylactic ligatures. There was very little 
bleeding indeed and I continued to dissect up around the neck of the 
womb, carefully working upwards between the bladder and uterus in 
front, and between the rectum and uterus behind. By placing the nar- 
row blade of the knife flat upon the womb and sticking close to it, this 
circumcision can be very safely and rapidly done, with little danger of 
cutting into the bladder, until we are high enough upwards to open the 
peritoneal cavity. We are made aware of any opening into the abdomen 
bv the slightly whizzing sound of entering air, or, as in my case by, the 
escape of a little serum. I took up a probe pointed knife and under 
guidance of my finger finished the circumcision of the peritoneum 
around the body of the uterus, thus far hardly an ounce of blood was 
lost and I had every reason to be satisfied with my primary ligatures, 
as they had entirely obviated the necessity of applying any ligatures 
to stop hcemorrhage. 
I now introduced my index finger, of the left hand, into the anterior 
cul de sac and, under its guidance, slipped a Langenbeck’s blunt re- CHIPS FROM A SURGEON’S WORKSHOP. 
7 
tractor over the fundus of the uterus and now, withdrawing my finger, 
I held the os uteri with a vulsellum in my left hand and the fundus 
with a retractor in my right. By allowing the neck to go upwards with 
my left hand, I readily succeeded in doubling the organ upon itself and 
drawing the fundus with its attachments into the vagina through the 
anterior cul de sac. I grasped the fundus, with a one-pronged Hegar’s 
womb-holder and drawing it first to one side I passed a handled needle 
with a double ligature, along the side of the body of the womb, in such 
a manner that I could pierce the broad ligament below the point where 
it covers the ligamentum rotundum. Again, catching the thread with 
a tenaculum, the needle was with-drawn and the ligatures fastened in 
such a manner that it firmly included the fallopian tube, the ovarian 
artery, the round ligament, in fact everything contained in the fold of 
the broad ligament. This being carefully done on both sides, I cut off 
the womb, well within the ligatures, in such a manner that they had 
sufficient peripheral tissue to prevent their becoming loosened too soon. 
On examination the womb is now found to be quite loose and only 
held or swung, as it were, on an axis of parametran tissue, which is left 
between the gap cut into the broad ligament from above and the in- 
cision, or rather circumcision, which started from the neck. By pul- 
ling the womb first to one side and then to the other, a ligature is 
quickly thrown around this mass of tissue on both sides with the ane- 
urism needle and these remnants firmly tied. All that was left to do' 
now was to cut through these tissues, close to the body of the womb,, 
when it fell out of the vagina with the vulsellum and Hegar’s womb- 
holder attached! I now cleansed the field of operation with warm water, 
drew the six ligatures together in a bunch and performed the toilet of 
the pelvic cavity. There was some little insignificant bleeding from 
an unknown source which ceased after a few sponges had been intro- 
duced. Water, which was allowed to run through the vagina from an 
irrigator, returned perfectly clear. An examination with my finger 
convinced me that the fornix of the vagina was well contracted, there 
was no tendency to prolaps of the bowels, and by very slightly drawing 
on the six ligatures the vault of the vagina was almost entirely closed 
by the stumps of the broad ligament, which were drawn down to a 
small knot on each side by the three ligatures. Not knowing exactly 
what process of healing would ensue, I determined to simply leave the 
wound open, apply no sutures, either to the peritoneum or to the vagi- 
nal mucous membrane, but to trust that any secretions of the wound 
might be led outwards or drain, as it were, along the thick silk threads, 
into the vagina where they could be readily removed. I believed also 
that in this way I could secure the best physiological, as well as 
mechanical rest to the parts and would not be obliged to remove 
sutures on the fifth or sixth day. I therefore, without placing any 
tampon of cotton or any drainage arrangement whatever into the lig.I 
Fig. 1.—Shows the Epithelioma at the Os; the Vagina dilated, the 
womb pulled down by a vulsellum. The three ligatures are numbered in 
the order of their application. En, is the point of entrance of my pro- 
phylactic ligature, Ex, its point of exit. The dotted line shows the 
amount of tissue which it encompasses. The other ligatures are repre- 
sented loosely drawn together in the diagram. 
Fig-H 
Fig. 2.—Shows the vault of the vagina partly closed by the stumps of 
the parametria or the broad ligaments. The three ligatures are all well 
tied and the ends hang down into the vagina. The Fallopian tubes and 
the broad ligaments are seen to come together and partly fill up the 
space which was left by the removal of the uterus. It becomes apparent 
that the small opening left in the peritoneal cavity between the ligated 
parametria will be obturated by a kind of valvular closure between an- 
terior and posterior flaps of the vaginal fornix, and this kept in situ by 
the involuntary abdominal press. CHIPS FROM A SURGEON’S WORKSHOP. 
vagina, had the patient carried to her bed and an injection of morphine 
administered. My orders to the nurse were no nourishment at all for 
24 hours and only a little chopped ice to allay thirst. The temperature 
of the patient at no time during the healing process reached 100° with 
the exception of one afternoon during the 6th day, when she had a 
chill followed by a temperature of 104°, that lasted about three hours. 
The house physician sent for me hastily that day, but an examination 
showed nothing particularly alarming, about one-half teaspoonful of 
slightly bloody matter was found in the cavity of Sims speculum. I 
will not weary the readers with a tabidated account of the daily pulse 
and temperature, but let the following resume, give a short account of 
the healing process and after-treatment. During five days the wrater, 
used for injections, always returned slightly reddened to the bedpan but 
was not in the least offensive in smell. These injections were made 
three times daily and once about midnight. After this period there 
was a slight purulent discharge and about the eight day it became 
slightly offensive. About this time, also, a tender spot, in the right 
ovarian region, the size of a hens egg, developed, which remained for 
ten days and then gradually disappeared. During this period the pulse 
ranged from 100-120 beats, but, as the patient has some old heart 
trouble, traceable to an attack of aiticular rheumatism during her 
youth, no conclusions could be drawn therefrom. On the 16th day 
the first ligature came away, its loop was found to be about the size 
of a small lead pencil, the others gradually came away by the in- 
jections, which were reduced to only two per day, after the third 
week. The secretions now became very thick and of a yellow color. 
The patient left her bed, for the first time, on the 28th day, she 
gradually improved in looks, her appetite came back and she gained 
considerable in weight and left the hospital rejoicing on March the 
13th. The vagina had completely closed up, there was no secretion 
at all, as there was no wound. The vagina ended in a blind sack, 
like the finger of a glove, and there was no hardness to be felt 
anywhere. 
From this single experience I should be very much inclined to be- 
lieve, with Billroth, that the operation of Kolpohysterectomy will 
soon become as safe and well established in surgery as the removal 
of the breast for cancer. I must add, however, that this can only 
be true of such cases where the disease is confined to the vaginal 
portion or the os. This would postulate the very early discovery of 
the cancerous disease. Since visits to the Gynaecologists office are 
fast beginning to take the place of “ladies fashionable morning calls” 
in larger cities of our country, we may cheerfully hope that the 
•diagnosis of cancer of the womb will be made in its earliest stages 
when this operation will find a large, hitherto unknown, field of 
usefulness. 10 
CHIPS FROM A SURGEON’S WORKSHOP. 
The easy manner of after-treatment and, in fact, the slight shock, 
which my patient sustained by the operation, was a revelation to 
me and set me to thinking whether or not ovariotomy might, in some 
cases, be advantageously performed through the vagina. On January 
6th I operated upon a case of cyst of the board ligament through the 
vagina, and although this case was followed by considerable inflam- 
mation and suppuration, which drained off nicely through the large 
opening into the posterior cul de sac, the patient has entirely re- 
covered; I am therefore still more sanguine in my opinion about the 
vaginal method for removing small tumors of the pelvic organs, than 
at first, and I will take occasion, in the near future, together with 
an accurate report of the above mentioned case to give my reasons 
for this opinion. 
Finally, let me say, I had so much reason to be pleased with my 
primary or rather prophylactic ligatures en masse, that I earnestly 
recommend them to all surgeons who may have occasion to perform 
this operation. Any amount of time spent in the careful and proper 
adjustment of these ligatures will never be regretted. When we com- 
pare the time consumed, or rather lost, in the very difficult and tedious 
application of ligatures to bleeding vessels in this operation, by the old 
method, with the time necessary to the application of my ligatures an 
enormous gain in their favor will be found. 
The safety and certainty which is reached by this, almost bloodless 
method, is a great boon and relief to the operator and, no doubt will 
help reduce the percentage of mortality that still attaches to his cura- 
tive measure. I am aware that complicated instruments and contri- 
vances, for ligating the uterine arteries, have been described and sug- 
gested. They have been given up however as impracticable. The 
simplicity of my method lets me think that a bettter fate awaits it. 
Note.—Since the above operation I have constructed an instrument, 
for the purpose of drawing down the womb, which differs from others 
by being so constructed that it holds the womb firmly from within its 
cavity or canal. 
At the same time it can be used to draw the entire womb to either 
side, so as to make the opposide parametrium tense and easily accessi- 
ble for the application of my prophylactic ligatures. The instrument 
is also made with a view to allow of firm traction where the tissues of 
the womb are very friable. 
An accurate description with cuts of this instrument will soon be 
ready for publication. 
Just one year ago the above article was written. I have no reason 
to revoke any of the statements then made. My experience during 
the year has been limited to two cases. I have examined 16 cases CHIPS FROM A SURGEON’S WORKSHOP. 
11 
of carcinoma uteri during the year but only two were favorable for 
total hysterectomy. Both patients made an easy recovery. I have 
no more hesitancy or misgivings in performing total hysterectomy 
per vaginam now, than I have about amputating a cancerous breast. 
Billroths prediction has been fully verified in my practice. 
My method of operation enables me to finish the entire work in 
from one-half to an hour. The last operation was performed on 
March 26th. Drs. Thornton, Barck, Heidorn and Wichmann as- 
sisting Mr. Burrus and Mr. Hanser a student of surgeon Senn of 
Milwaukee also attended. The whole affair lastet 40 minutes. The 
womb was quite large, and I accidentally cut one of my proyhylac- 
tic ligatures which necessitated the application of several ligatures, 
in the wound. Barring this accident the operation would have been 
finished in 25 minutes. 
I furthermore insist that it is bad practice to unite the laquear 
of the vagina with sutures. I tried this in my last case, and found 
a temperature of 103}£ the next day and vomiting; I therefore im- 
mediately removed the sutures and more than a tablespoonful of of- 
fensive bloody serum was discharged into the vagina which had been 
dry up to that time. The fever never reached 102 again and my patient 
has completely recovered. She attends her household duties at 
present. 
It is not necessary to insert any kind of drainage arrangement what- 
soever, but I always have the vagina washed out three times in 24 hours 
as long as there is any secretion. The loops of small intestine which 
are visible after the removal of the womb can not protrude into the 
vagina as the stumps of the parametria almost close the vaginal vault 
and besides the mesentery is not long enough to permit prolapsus. 
All the above observations refer to picked cases, where the car- 
cinoma has not encroached upon the parametria, in fact such cases 
where the disease is confined to the womb and when that organ is 
fully moveable. All other cases will have to be treated by palliative 
means, such as curetting or supravaginal amputation etc. 
Mrs. Parkins of Texarkana the first one of my cases has enjoyed 
perfect immunity from a return since her operation, the length of 
time is now exactly one year and five months. 
In all three cases the success of the operation was proven by the 
satisfaction expressed by the patients. 
May 15th, 1885. The Uterotractor. 
A NEW INSTRUMENT, WITH TWO ILLUSTRATIONS. 
By Augustus C. Bernays, AM., MD., Heidlbg., M. R. C. S. Eng. 
Professor of Anatomy and Clinical Surgery, St. Louis 
College of Physicians and Surgeons. 
During a recent operation for the total extirpation of a cancerous 
womb through the vagina, I felt the want of an instrument by the use 
of which I could easily handle the womb without taking up too much 
space or darkening the field of view. It also appeared desirable to 
have the instrument strong and so constructed that it would hold the 
womb firmly even when the tissues had become friable by the can- 
cerous growth. The following woodcuts represent the instrument 
which answers these indications. The drawings show the instrument 
■open and closed thereby saving an elaborate description. CHIPS FROM A SURGEON’S WORKSHOP. 
13 
The advantages offered by this new surgical tool are the 
following: — 
I. It takes away no space in the vault of the vagina surrounding 
the cervix, since it seizes the womb from within its cavity. When 
closed the scissor like handles approach one another so that they 
occupy but little space either within or without the vagina. 
II. The instrument can be introduced into the cervical canal or 
the womb-cavity, any distance desired. Whatever amount of traction 
mav be brought to bear upon the tissues of the womb, a corresponding 
resistability can be created by opening the branches of the tractor 
more or less. 
III. The four tooth-like prongs of each branch are not the only 
factors that resist tearing out, the wedge shape of the open branches 
also forms an important obstacle tending to prevent this accident. 
A glance at the figures will show the point of the wedge situated in 
or near the cervix while the broad end of the wedge looks towards 
the fundus. 
IV. The Uterotractor can be held either in the left hand of the 
operator or can be entrusted to an assistant. A great advantage to be 
derived from the use of my instrument lies in the circumstance that 
the traction is not solely made upon the vaginal portion as by the 
vulsellum or Museux’s forceps or bv the loops of thread heretofore in 
use. The instrument has its point of attachment upon the whole 
length of the uterus if desired. We are thus enabled to move the 
organ in toto, from right to left and can put the opposite parametrian 
tissue, yes even the whole of the broad ligament on the stretch. This 
is of considerable importance for my method of Kolpoiiysterectomy 
(see the St. Louis Medical and Surgical Journal, April, 1884), and 
will, no doubt be greatly appreciated by those operators who tie the 
bleeding points in the wound as they proceed with the extirpation. 
V. The Tractor can be introduced as easily as the uterine probe, 
and can also be removed at any time with but little trouble. It may 
also be used to facilitate the tipping over or doubling up of the womb 
upon itself through the anterior or posterior cul de sac. 
The laceration of the organ which must be caused by the use of the 
instrument is of no importance as it is intended only for those opera- 
tions which propose the total removal of the womb. My instrument 
also obviates the sometimes disagreeable sponging necessitated by the 
vulsellum or other forceps used for dragging down the womb. A little 
absorbent cotton wound around the joint of the blades stops all 
bleeding if there be any from within the womb. 14 
CHIPS FROM A SURGEON’S WORKSHOP. 
I am of the opinion that Hystereclomy can be performed by 
the assistance of the Uterotractor without the necessity of turning 
the fundus out into the vagina, as we are now doing. This suggestion, 
however, needs to be practically proven. 
The drawing represents the instrument one quarter natural size. 
The four teeth on each blade are bent upon the flat and are some- 
what roughened on their concave side. The instrument is of very 
simple construction being made of only two pieces connected by a 
joint screw. It is easily kept clean and I predict that a single ex- 
perience in its use will convince any operator of its many advantages. 
I am indebted to Mr. Andrew Leslie of the firm of A. M. Leslie 
& Co., surgical instrument-makers, No. 204 North Fifth Street of this 
city for his kind assistance in the execution of my ideas, and it 
gives me pleasure to express my thanks in this place. 
I would be much pleased to exchange any of my “chips” with 
my colleagues for their own productions, and will gladly mail them 
ito any address, as well as acknowledge the receipt of any favors. • 
April, 1885. 
AUG. C. BERNAYS, 
201 S. Broadway, St. Louis, Mo.