The patient should occupy the dorsal position and be cautioned to keep absolutely quiet. The sound electrode is inserted to the fundus, oy the finger in the vagina, and the celluloid sheath is pushed down to the cervix so as to thoroughly protect the vagina. This elec trode is held and steadied by the hand during the entire seance. The layer of clay is uniformly adapted to the abdomen, and the metal plate is pressed gently into it. The rheophores are then connected, and after waiting awhile till all reaction induced by the insertion of the sound has disappeared, the current is very gently and gradually turned on, avoiding all shock. At the first seance Apostoli has found it advisable not to ex ceed 100 milliamperes, but later, when he has tested the tolerance of the patient, he aims as high as 200, even 250 milliamperes. During the passage of the current it is very important to keep the entire intrauterine portion of the sound against the uterine wall, and to bring it as far as possible successively in contact with every portion of the endometrium in order to disseminate and to equalize the caustic action. In general the seance should last from three to ten minutes, the duration depending on the nature of the individual case and on the sensibility of the patient. The true guide to the dosage is the rule never to cause the patient much pain. The seance is ended, even as it began, gently, and avoiding any shock. After the séance, rest for a number of hours should be enjoined, and the patient will very likely suffer from uterine colic for a certain period, and for this reason the post-operative period is often much more painful than the operation itself. As regards the number of seances requisite, Apostoli has found that according to the recent or very chronic nature of the case they vary from three to thirty, the latter figure being only very exceptionally reached. If the patient belongs to the better classes and is able to rest for a sufficient length of time after each séance, she may be subjected to treatment two to three times a week, but where she belongs to the working class once or twice should be the limit.
Owing to the novelty of the method and its radical nature we will reproduce here Apostoli's answer to the objections which might be formu lated against it: "1. The operation is a difficult one.—My method being purely a species of therapeutic hysterometry, since it consists only in the intro duction of a sound, which remains in situ for awhile and serves as the carrier of the current, this objection applies entirely to the introduction of this instrument. Without denying that there are cases where the introduction of the sound is a difficult matter, I may say that, in general, after a little experience, the insertion of the instrument is easy enough, and further it is simply a necessary accompaniment of gynecological practice, since diagnosis depends on the touch followed usually by hyste rometry. As for the electrical technique the details into which I have entered should place its utilization within the power of all.
" 2. The operation is a cause of sterility.—Even if this objection held, I do not think it would have more than a relative importance, and not sufficient to cause us to reject the method; in view indeed of the fact that we are dealing with an affection which ipso facto is often associated with sterility, and in view of the further fact that the affection literally often poisons the life of the patient and very frequently does not yield to classic measures of treatment, for these reasons, even though it entailed sterility, my method would be justified. Happily these fears of sterility are very mach exaggerated, and for two reasons: I am in the first place able to affirm that sterility is not necessarily entailed, since I know of many cases where pregnancy has ensued after a series of chemical galvano-cauteriza tions of the endometrium; and then again all gynecologists who are in the habit of curetting the uterus testify that pregnancy may ensue after it. Now what is my method but a galvano-chemical curetting, less brutal and more progressive than surgical curetting, and leading similarly to exfoliation of the mucosa and to its regeneration.
" 3. The operation may cause atresia of the uterus and consecutive dysmenorrhea.—It is possible, and frequently, that we may witness more or less complete and extensive atresia of the cervico-uterine canal as the result of a series of galvano-caustic intrauterine applications, in particu lar the positive, and at the outset I agreed with Tripier in fearing this result; but observation of a large number of patients has taught me that dysmenorrhea was far from following on atresia of the canal, but that usually it was a nervous phenomenon, reflex from the ovaries. I purpose
soon to prove this by the relation of numerous cases " 4. The operation is dangerous.—This objection, the greatest of all, is the reflex of our modern gynecological customs, in particular the French; our therapeutics, in Paris, have been largely external and directed against the cervix. Nevertheless it is in France that the process of curetting the uterus saw the light; it is a Frenchman, Wcamier, who first scientifically resorted to the procedure, and yet it is in the same country that it is actually least resorted to. Now if my operation is dangerous, a fortiori should be curetting, and yet here is what an authority among gynecologists. Carl Schroder, says: ' When resorted to under strict antiseptic precautions, this procedure is without danger. I have curetted and irrigated thousands of times in case of chronic endometritis; only one of my patients died of infection, and she before the antiseptic era. I have sometimes seen exacerbations of an existing perimetritis, but I have never, so to speak, seen this operation result in new inflammatory manifestations.' Remember too that curetting is a surgical procedure, in general badly supported, and that it, says Schroder, ' produces, as a rule, such pain, that it is preferable to administer chloroform, except where the patients are not specially hyperesthetic.' In view of this testimony, and it is in agreement with that of the majority of foreign gynecologists, in favor of a procedure more painful than mine, for I have never been obliged to anesthetize a single one of my patients suffering from metritis, what is the worth of the objection to my method that it is dangerous? Nothing to speak of. What weight indeed could a purely theoretical objection have, when I state that during the past five years I have resorted to galvano-caustic intra-uterine application with perfect security, as well in the treatment of fibroids as of metritis, nearly four thousand times. If there have been accidents, and I have hastened to report. them, I alone am to blame and not the method; they were the result of inexperience while I was learning the way. In conclusion, the possible dangers asso ciated with the intra-uterine use of the galvano-caustic properties of the electric current are similar to those that may follow the introduction of the sound, and with reference to this point De Sinety says: ' Many writers have claimed that the uterine sound was responsible for many accidents, but we believe that the operator is at fault rather than the method; this method of exploration in our hands has never been risky, but on the contrary has furnished us very valuable information.' " The following, briefly stated, are the accidents to be feared: "a. The induction of nuscarriage.—If this should happen it is not the method but the operator who is to blame. For this reason conjugal relations should be proscribed during the application of the method of treatment, the first seance should be held as soon as possible after a men strual period, a careful examination should precede each application.
"b. Exacerbation of an existing peri-nietritts.—This may depend on the patient, on the operator, on the method: Galvano-cauterization may be resorted to too intensely or too frequently; sufficient attention may not be paid to antisepsis, or the sound may be introduced carelessly; the patient may exert herself too much after the operation, or may be sub jected to repeated coitus.
"c. Arnie attack of hysterical women, suffering from ovarian pain, it may happen that an operation, not intense, provokes sharp pains in the abdomen, which simulate to the inexperienced an attack of peritonitis; happily this is the rarest of all occurrences; the more sudden the storm and the more violent, the more readily it ceases spon taneously or yields to simple means, and it is here that my method of uterine, or if need be vaginal faradization, with a current of high tension and long continued, answers so markedly." We have detailed thus at length this method of Apostoli's because, if it should prove as effective in the hands of others as it has in his, we will possess, what we still lack, an efficient method of treatment of aggravated cases of areolar hyperplasia and of chronic endometritis. As yet he has not recorded any of the numerous instances in which the method has been utilized, and although he makes a strong plea in favor of the method in the monograph from which we have liberally quoted, judgment must be deferred until the record which he promises can be carefully studied.