Reprinted from The New York Journal of Gynaecology and Obstetrics, November, 1892. 
NOTES ON THE GALVANO-CAUTERY IN THE TREATMENT 
OF URETHRAL AND VESICAL DISEASES.1 
Alexander J. C. Skene, M. D, 
The discovery that infection, either conveyed by personal con- 
tact or transmitted by foul instruments, was responsible for many 
of the diseases of the urinary organs, marked one great advance- 
ment in this department. About the same time it was noticed that 
minor injuries inflicted by the unskilled use of improper instru- 
ments, chiefly the female catheter, was a most active cause of 
cystitis and urethritis. I mentioned this in a medical society fif- 
teen years ago. An old obstetrician of large and long experience who 
was present said that he had used the catheter many times in post- 
partum patients and had never seen the slightest harm follow. At 
that time I knew of two of his former cases who were under treat- 
ment for cystitis which followed his use of the catheter. ‘My opin- 
ion was not changed by his argument, and many observations since 
then have confirmed the fact regarding the cause of this class of affec- 
tions. This understanding of the causation led to improvement in 
therapeutics. The treatment of cystitis and urethritis with strong 
solutions of nitrate of silver and like caustic agents was found to 
be no more efficient in relieving the inflammation than milder meas- 
ures, and they were far more unsatisfactory in their after-effects. 
The more destructive agents were largely given up by some of the 
foremost investigators. More attention was given to constitutional 
1 Read before the New York Obstetrical Society, October 4, 1892. 2 
Alexander J. C. Skene, M.D. 
treatment and bland instillations. Soon after this, dilatation of the 
urethra, forcible and extensive, was introduced and much said in 
its favor. It did some good, unfortunately, which induced many 
to practice it and do great harm. Urethrotomy and cystotomy 
were introduced about this time, and they have fully sustained a 
deserved position in the surgical treatment of a certain but limited 
class of cases. 
The therapeutic agencies most worthy of confidence at the pres- 
ent time may be divided into two classes, the medical and surgical. 
The former includes all internal medication and the local use of 
sedative and alterative agents; the latter comprises all surgical 
procedures for the relief of malpositions, malformations, neoplasms, 
cystitis and urethritis that are otherwise incurable. This excludes 
the powerful agents, such as caustics, which so long were em- 
ployed. This may appear to you like quotations from back-num- 
bers of medical literature, but there is room for a more general 
knowledge on the subject in the profession at large at least. The 
evidence of this is found in the number of cases that run from the 
acute to the chronic state, in which pathological conditions are 
developed that require special treatment. Furthermore, I have 
observed that better results are obtained by those who depend 
upon general treatment than by many of those who employ active 
local treatment. Much of my time is occupied in treating injuries 
arising from the use of caustics. 
The diseases, the treatment of which I propose to speak of at 
this time, are as follows:— 
First, diseases of the urethra. Neoplasms about the meatus. 
Small papillomata within the urethra, sometimes called granular 
urethritis. Narrowing of the meatus, either congenital or acquired. 
Inflammation of the urethral glands and follicles. Neoplasms of 
the bladder and chronic cystitis. 
In regard to the pathology of these neoplasms, there are two 
forms that I wish to call attention to. One, the rarest, is angioma, 
caused usually by malnutrition and deranged circulation. These 
growths closely resemble rectal haemorrhoids in pathology and the 
causes which produce them. The other is a proliferation caused 
by a chronic inflammation of the glands or follicles in the vaginal 
side of the urethra, usually at the meatus, but occasionally found 
within the urethra. Both varieties have been known as vascular 
growths of the meatus, or caruncle. The diagnosis is, of course, 
easily made when the disease is confined to the exposed portion of 
the meatus, but when these growths are within the urethra, and Galvano-Cautery in Urethral and Vesical Diseases. 
3 
especially the upper third, the diagnosis can only be made by the 
use of the endoscope. I have in these last days found that many 
do not use this instrument for diagnostic purposes, owing to its 
being rather inconvenient and requiring experience in its use. To 
meet that, I find in many cases a diagnosis can be made by exclu- 
sion. Displacements and dislocations can be detected or excluded by 
the touch and sound, and cystitis can be disposed of by frequent and 
careful urine examinations. Most important of all in this connec- 
tion is the cystoscope, which is so valuable in detecting or exclud- 
ing diseases of the bladder which simulate in a marked way certain 
diseases of the urethra, but this instrument is not -always at com- 
mand. I find that the differential diagnosis must be made by the 
majority of practitioners—if made at all—by examinations of the 
urine and the symptoms. When, by exclusion, it is determined 
that the disease is confined to the urethra, the question rests then 
between inflammatory affections and displacements and dilatation. 
The latter can—as before stated—be detected by the touch and 
sound. 
To return to the treatment of neoplasms, the indications are to 
thoroughly and completely destroy the diseased tissue and nothing 
more. To do this wfith caustics in the way usually commended was 
impossible—at least I find it so. The diseased tissue can be 
destroyed, if not by one, by several applications, but the line of 
demarcation between the normal and abnormal tissue cannot be 
clearly and fully drawn, and the action of the caustic limited to that 
one part. After the eschar separates the surface left to heal is large, 
sometimes painful and tender, and during the healing process there 
is great liability to the recurrence of the original disease. This is 
one of the reasons for the frequency with which these growths 
return, as noted by all writers on the subject. Exsection is a more 
surgical method and gives better results (when well done) than 
caustics, but unless sutures are used to close the wound, the heal- 
ing is slow and uncertain, especially if the urine is in any degree 
morbid. 
The galvano-cautery fills the bill of requirements perfectly and 
completely. There is less pain in its use. Healing is more rapid 
and there is less likelihood of the disease returning. 
The cautery instrument which I employ is the fine point used 
by the laryngologists. A larger cautery can be used with advan- 
tage in removing large neoplasms, but for all general purposes the 
small one is the best. I may here mention the fact that it should be 
brought to the desired heat before applying it to the tissues and then 4 
Alexander J. C. Skene, M.D. 
after making one incision or application it should be withdrawn 
from the tissues and reheated. This is necessary because the moment 
this fine point is brought in contact with the tissues there is so 
much leakage of the current that the cautery very soon cools off. 
I mention this because I have so often seen the inexperienced, who 
were not aware of this fact, bothered by the cautery cooling and 
not doing its work. I have no doubt that all who use electricity 
have been greatly annoyed with batteries. It is exceedingly diffi- 
cult to keep them in order so that they will be useful when re- 
quired. I understand that there are good prospects of our being 
relieved from all such care and trouble by utilizing the electric- 
light current used in many parts of our cities. I believe that it is 
now pretty well settled that the current can be converted so as to 
take the place of the storage battery or the faradic current or con- 
tinuous current. When this is perfected we will all be able to use 
electricity with very great convenience. This method may be in 
use with some of you and if so I hope it will be brought out in the 
discussion so that we may profit by the information. 
The method of operating is as follows: 
The neoplasm to be removed is seized by narrow-bladed for- 
ceps at the junction of the normal and abnormal tissue; the forceps 
is closed and locked and the neoplasm cut off. The cautery is ap- 
plied to the forceps sufficiently to heat enough to desiccate not 
char, the tissues held in its grasp. When this is accomplished the 
forceps is carefully removed by first unlocking it, then rocking it 
gently so as not to pull the pedicle or stump apart and start 
bleeding. If the work is well done, the thin stump of desicated 
tissue will project on the surface of the mucous membrane. 
It is important that the patient should not urinate for several 
hours after the operation, because if the stump can be kept dry for 
a time it will not spread but hold together and leave a very small 
surface to heal when the desiccated portion sloughs. The applica- 
tion of oil or vaseline helps to protect the stump until it heals. 
The forceps which I use is the artery or compression forceps of 
Prof. Wight, and it answers the purpose admirably. 
This method of operating is sufficient in the ordinary forms of 
angioma. When the neoplasm is caused by a chronic inflamma- 
tion of the urethral glands, the best method is to pass a fine probe 
up into the canal and cut down upon it with the cautery point from 
the vaginal surface; in other words, lay the ducts of the glands 
open. This divides the neoplasm on one side, and an incision 
should be made with the cautery on the opposite side, which Galvano-Cautery in Urethral and Vesical Diseases. 
5 
divides the neoplasm into two equal parts, then each part is grasped 
in the forceps and removed in the way I described. 
I have succeeded in completely curing the chronic inflammation 
of the glands by laying their ducts open in this way and removing 
the neoplasms at their terminal ends, excepting in a few cases where 
the inflammation still persists in the glands. To correct this I gen- 
erally do a second operation. I pass the cautery point into the 
gland and cauterize it sufficiently to destroy it. I have always 
succeeded in curing all cases except in tuberculosis of the urethra. 
That disease has recurred as a rule. 
The method of operating in cases of narrowing of the meatus 
urinarius is this:—l pass the bivalve speculum into the urethra and 
put the meatus on the stretch. The band of tissue below or on the 
vaginal side which extends from one blade to the other is made 
tense and is easily divided with the cautery; in fact it is necessary 
to be deliberate in making the incision or else haemorrhage will 
follow, not a haemorrhage which will give any trouble except 
delay, and it prevents continuing the use of the cautery to com- 
plete the operation. 
In those cases of papillae within the urethra, caused by hyper- 
plasia around the follicles, the treatment with the cautery is 
difficult, but if properly employed gives the most prompt relief in 
those cases of chronic inflammation which have been called gran- 
ular urethritis. After having made a clear diagnosis and local- 
ized the points to be destroyed I introduce the endoscope, with an 
open end, up as near to the neck of the bladder as can be without 
permitting a flow of urine; the instrument is then withdrawn until 
one of the points to be touched comes into the field of vision; the 
cautery is then passed up and the point slowly touched once, 
which is as a rule sufficient. The instrument is withdrawn again 
until another diseased portion appears when it is treated in the 
same way, and so on until the treatment is completed. 
I might state here that the most troublesome of all diseases, 
both in the way of causing suffering to the patient and bother- 
ation to the surgeon, is fissure at the junction of the urethra and 
bladder. 
I am now making observations on the use of the cautery in the 
treatment of these painful fissures or ulcers and I am inclined to 
think that it will prove to be efficient, but it is extremely difficult to 
use. When the fissure is exposed by means of the endoscope there 
is a continual oozing of urine which interferes with the use of the 
cautery. If the fissure is on the vaginal side of the urethra I use a 6 
Alexander J. C. Skene, M.D. 
fenestrated endoscope, bringing the fissure into the field of vision. 
I make pressure against the endoscope from the vagina with the 
finger, which forces the diseased portion of the mucous membrane 
into the fenestrum and prevents the outflow of urine. I then dry it 
with a small piece of bibulous paper and apply the cautery by 
simply drawing the point slowly through the ulcer so as to com- 
pletely destroy its surface. To a certain extent lateral fissures can 
be managed in the same way, but when the fissure occurs above, 
which fortunately seldom happens, it is almost impossible to em- 
ploy this treatment. Perhaps when I have had more experience I 
will be able to report quite favorably of this treatment. Up to the 
present time it is not completely satisfactory. 
In treating those forms of urethral affections thus far alluded to, 
I find that with the use of cocaine general anaesthesia is not neces- 
sary, at least in patients that possess a fair degree of self-control, 
but I should urge the use of an anaesthetic until the surgeon has 
acquired some skill and dexterity in the management of the cau- 
tery. 
In regard to the use of the cautery in diseases of the bladder, I 
will say that my experience with it has been limited to the removal 
of neoplasms, mostly malignant, from the bladder. I must call to 
mind the fact that Dr. Byrne uses the cautery for making a vesico- 
vaginal fistula, and I am satisfied that it is the quickest, simplest 
and best method of doing so; I have tried all the other methods 
and am confident that this is the best, when the fistula is to be 
maintained. But I chiefly desire to call attention to the use of the 
cautery in the removal of neoplasms or epithelial growths of the 
bladder. I can best illustrate the value of the cautery and method 
of using it by stating that I recently had a case in which I was able 
to make an accurate diagnosis of an epithelial growth, about an 
inch and a half in diameter, on the anterior wall of the bladder. 
The patient had for months suffered almost continuously from 
haemorrhage. 1 made a vesico-vaginal fistula by dividing the tis- 
sues with the knife and scissors, then by having pressure made 
over the pubes, I seized tfie growth between my finger and a scoop 
and brought it down to the vaginal fistula and succeeded in draw, 
ing it through into the vagina, and with it, of course, a portion of the 
anterior wall of the bladder. I clamped the base of this growth 
with the forceps and then cut it off with the cautery and desiccated 
the portion within the grasp of the forceps, most of which was 
normal mucous membrane; the forceps was then removed, the 
bladder thoroughly washed out and the vesico-vaginal fistula closed Galvano-Ca7itery in Urethral and Vesical Diseases. 
7 
with silk sutures. The bladder was drained for twenty-four hours 
after the operation, and then catheterized every four hours for three 
or four days, and the patient made a complete recovery. It is now 
about eight months since the operation and there has been no re- 
currence of any symptoms whatever. 
The advantages gained by the use of the cautery in this, as in 
other cases I have operated upon, are these:—That all haemorrhage 
is arrested at once; that the surface left to heal is very much 
smaller, and in fact becomes glued together as it were, and par- 
tially healed before the desiccated portion sloughs off. It might 
be said that the base of the tumor heals under a scab, which leaves 
no ulcerating surface in the bladder to give trouble afterwards, nor 
any raw surface that can possibly bleed after the operation. 
By removing small growths in this way I have been able to 
close the vesico-vaginal fistula immediately and so complete the 
treatment at one sitting. Heretofore when I have removed a neo- 
plasm from the bladder through a vesico-vaginal fistula I have 
been obliged to leave the fistula open until the bladder had recov- 
ered from the damage done to its tissues during the operation. 
This I conceive to be a great advance. Of course this operation is 
practicable only in small neoplasms. In those of a larger size that 
cannot be brought out through a vaginal fistula I prefer the supra- 
pubic operation; but in place of removing the neoplasm by means 
of a curette, which I believe is the usual way of operating, I grasp 
a portion of the tumor at its base with fixation-forceps, making 
sure that I get down to the normal mucous membrane, and remove 
that portion in the way described. I then seize another portion 
and remove it in the same way until the whole is removed. If the 
disease does not extend beyond the mucous membrane it is very 
easy to diminish the base of the tumor very much by the use of 
compression-forceps and cautery, and leave a very small surface 
to heal afterwards. In those neglected cases where the tumor is 
so large that it is impossible to remove it in this way, after doing 
the supra-pubic cystotomy, the mass may be broken down and 
removed with the curette and the whole surface thoroughly cauter- 
ized, using a larger cautery; but even in such cases the raw surface 
should be picked up in sections in compression-forceps and cauter- 
ized thoroughly. . That is the only way that the haemorrhage can 
be thoroughly stopped, and the base or raw surface is much reduced 
in size. Drainage is necessary after the operation. Last week 1 
operated in a case of epithelioma at the base of the bladder. The 
fistula was made a little to one side of the median line in order to 8 
Alexander J. C. Skene, M.D. 
avoid the diseased part. I tried to dissect up the mucous mem- 
brane that was diseased, but found that that was impossible; 
neither could I grasp all of the diseased part in forceps. I was 
compelled to apply the cautery freely and leave the fistula open 
for drainage, and also to enable me to use the cautery again in 
case I find that all the neoplasm has not been removed.2 
2 Since reading the above the case has progressed favorably and promises 
to make a complete recovery.