A handbook of uterine therapeutics and of diseases of women

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Preface

Juperne by the number of eases that have come under my observation in which medical men have failed to recognize unmistakable uterine disease, while attending for many years to its more or less complicated reflex symptoms, T am led to infer that of the various departments of medicine, Gynecology is the least known, although there are several English and French works in which it has been well taught from various points of view. I therefore deem it useful to publish a fourth edition of a work which was brought out many years ago to diffuse a better knowledge of the diseases of women, and which was thought worth translating into German and Italian. So much has been done since the issue of the last edition, that I have had to rewrite and to considerably enlarge the book, but the original plan has been adhered to, as it is so useful for the busy practitioner to find embodied in successive chapters the relations of each special medication to the whole range of diseases of women.

Many questions of general interest are discussed in the introduction, so here I shall only remark that three therapeutical teachings are now striving for mastery over the medical mind. One trusts entirely to medicine, and strongly deprecates the treating of diseases of - women by surgical measures. Another puts little or no trust in medicines, and represents the knife as the sure and safe mode of curing most diseases of women ; while a third considers uterine orthopedy as the key-stone of uterine therapeutics. In all I have published during the last thirty years, it has been my earnest desire to combat these exaggerations, by determining the proper scope and the relative value of drugs, of the knife, and of pessaries in the treatment of disease,

51665 iv ‘ PREFACE.

and the guiding principles of the present work may be summed up in the following propositions. Firstly, the paramount importance of female hygiene for the relief, cure, and prevention of diseases of women. Secondly, the constitutional origin of many diseases of women, as well as the impossibility of curing them and of preventing relapses, unless the treatment comprehends such measures as are known to favorably modify constitutional taints. Thirdly, the possibility of curing most diseases of women without surgery, by the better application of old familiar remedies and sound hygiene. Fourthly, the utter impossibility of curing aggravated forms of the most common uterine affections, unless surgery be combined with medicine and hygiene. ;

It is a great satisfaction for me to believe that these principles of practice will meet the approbation of many medical men at home and abroad, for it is the high privilege of those who write in English to address the profession of other English-speaking countries besides their own.

E. J. T.

Introduction

Difficulties attending the study of diseases of women,

Women as medical practitioners, -

Medical theories in gynecology,

The reign of the knife,

Gynecology in England, : 5 ; : : ; ; How to study gynecology, . ; : : ‘ : : : F How to succeed in practice, .

Interrogation of patients,

Examination of women, 5 5 : 5 .

Therapeutical hints, . - . 2 A 5 3

Chapter I. Modes Of Examination And Surgical Instruments

Extra-uterine examination, .

Vaginal examination,

Rectal examination,

Double touch,

Perpendicular examination, .

Genu-pectoral examination,

Ocular examination, . 5 : ‘ Fi Surgical instruments, : Intra-uterine modes of examination,

Uterine sound, and its dangers,

Wax bougies, :

Exploration of the inner ace: : : °

CHAPTER IL

UTERINE SURGERY.

Time for operating,

Anesthesia, . é 7 - : < 5 A .

Lymphangitis, . 5 A b : .

Peritonitis, . 3 : ‘ : ‘ 7 :

ie) ® aoawrwownre &

BR e H= 0

81 22 33 34 v1

Cervical dilatation, Extensive dilatation, Instantaneous dilatation, Hysterotomy, Intra-uterine injections,

Contents

Solid substances in the womb,

Intra-uterine swabbing,

UTERINE DIETETICS AND HOME-TREATMENT.

Chapter V. Sedative Medication

Cerebral indications of sedatives, .

Ganglionic indications, .

CONTENTS. | Ovario-uterine indications, . : : ; ‘ 4 5 Administration of sedatives, . : Sedative drugs, . A : : * . c : ° Cold, . : : : ‘ ' Mesmerism, . 4 ; . ~ : Q : .

Shock, . 5 . :

Chapter VI. Antiphlogistic Medication

Inflammation theory, Bloodletting, . : Leeches, 5 Scarification, - Antiphlogistic drugs, Counter-irritants, .

Electricity, .

Chapter VII. Caustic Medication

Theory of caustic action,

Catheretics or mild caustics,

Nitrate of silver in uterine surgery, Value of strong caustics, - - ¥ Acid nitrate of mercury,

Fuming nitric acid,

Potassa fusa c. calce,

Chloride of zinc, . ‘ -

Actual cautery,

Electric cautery,

CHAPTER VII.

EMMENAGOGUE MEDICATION.

Generous living, . : A E : * . 5 Tonics, E - :

Sedatives, .- é é A

Caloric, . A

Exercise, ; . :

Cutaneous stimulants, . : . : ¢ : . .

Intestinal stimulants, . : . A ; : : : Nerve stimulants, : 3 7 . > .

Ovario-uterine stimulants, . : .

Emmenagogue drugs, . 5 : z : : : :

Chapter IX. Hamostatic Medication

"| PAGE Metrorrhagia, 178 Catamenial fever, . . ; . 182 Climacteric flooding, 183 Vaginal flooding, . ° ‘ 184 Cervical flooding, . c 184 Intra uterine flooding, . 184 Flooding from polypi, . . 185 Flooding from fibroids, 185 Flooding from cancer, . : ; 185 Flooding from the gravid womb, . : 2 P ‘ : és 4 P s 185 Post-partum flooding, 186 Medicinal hemostatics, 187 Bleeding, 187 Cold, 187 Heat, ‘ : 188 Heemostatic drugs, 188 Surgical hemostatics, . 193 Plugging the vagina, 2 193 Surgical styptics, . is J 193 Ovariotomy, ¥ : : 194

Constitutional tendencies, Uterine herpetism,

Rheumatism, Gout, Scofula, fs Syphilis, A Cancer,

Chapter X. Specific Medification

: . 198 : - 129

* 200

: . ° 201

: : : : - 204

Chapter XI. Treatment Of Uterine Misplacement

History of uterine orthopedy, . . A toe, )

Causes of uterine misplacement, .

Symptoms, : General treatment, Bandages, ‘ : Prolapsus and procidentia, Uterine flexions, .

Uterine versions, .

: : ‘ : . : : : . 213

. 226

CONTENTS. 1x

Chapter XII. Treatment Of

UTERINE COMPLICATIONS.

PAGE

Pudendal pruritus, feo Follicular inflammation, . 238 Eczema genitale, . 239 Vegetations, ; - c 240 Vulvo-vaginal gland disease, 240 Vaginitis, 240 Vaginal Sateen hh palagoties, 241 Cervical elongation, 242 Fibroid degenerescence of in Bee. 243 Uterine polypi, . .- : 243 Uterine fibroids, 244 Ovaritis and ovariotomy, 246 Pelvi-peritonitis, 249 Mammary diseases, 249 Trritable tumor of the arene 250 Inflammation of the urethra, 251 Trritable bladder, . 252 Cystitis, 254 Dyspepsia, . : _ 257 Nausea and vomiting, . 260 Enteritis and intestinal irritability, 267 Irritability of the rectum, 269 Hemorrhoids, : 269 Inflammation of the rectum, 270 Semi-paralysis of the rectum, oat aiy(tl Rectocele, 271 Spinal curvature, . 272 Consumption, 272

CHAPTER XII.

TREATMENT OF STERILITY.

Causes of sterility, . 274.

Statistics of causes, : 3 : 3 - i : . 280 Absence of clitoris, : 3 : : ; j Sree eel Unruptured hymen, 281 Labial adhesion, . : 281 Vaginal obliteration, . 281 Vaginismus, . ~ o28e Undersized womb, . 282 Cervical elongation, 283 Uterine displacements, 283 Deformed os uteri, . 283 Cervical stricture, . 284 286

Polypi and fibroids, x F CONTENTS.

Chapter XIV. Prevention Of Diseases Of Women

Means of prevention, . ‘ ‘ : ‘ - . a 3 . 289 A judicious system of denen : ; ; . . ‘ . = : - 289 Careful management of menstruation, ‘ ° . ° . Ss - 290 Marriage, and prudence in married life, F ° < eae 2 . ; - 291 Management of pregnancy and parturition, 4 a F é ‘ . 293 _ Defective uterine involution, . 5 c : . : : : . . 296

A HANDBOOK

OF

UTERINE THERAPEUTICS

AND OF

DISEASES OF WOMEN.

INTRODUCTION.

To the student in medicine, there are few subjects which present greater difficulties than the study of the diseases peculiar to women, particularly in England. The diseases are common enough in the out-patient departments of any of the larger hospitals, but the special hospitals for diseases of women are small. In our great hospitals few beds are given to the obstetric physicians, and clinical instruction in diseases of women, like all other clinical instruction in England, is scarce and incomplete when compared with its daily delivery in continental hospitals. The result is that the student starts in practice with the most meagre knowledge of that great class of diseases which he must daily encounter if he has any practice at all. A wrong diagnosis is the result, treatment worse than useless is adopted; the patient continuing to suffer, either finds better advice elsewhere, or her real condition is undetected, and she remains for the rest of her life a helpless incurable, seldom free from pain, and worn out in body and mind. A glance at what gynecologists have done, at the present state of gynecology, at the conflicting tendencies of leading men, and at the impediments that lie in the student’s path, will not be out of place. The youthfulness of gynecology is the first thing to observe, for it may be said to date from 1816, when Recamier insisted on the necessity of studying diseases of women as much as possible by ocular demonstration, like all other diseases. This taking of gynecology out of the shadowy regions of conjecture, had no effect on English obstetric practice, and there is no mention of the surgical treatment of the most common diseases of women in Sir C, Mansfield Clarke’s work published in 1821. It was the custom then, in the absence of fever, to treat uterine symptoms by port wine, tonics, a strengthening plaster to the back, rest on the sofa. In case of discharges, oak-bark or alum injections were given through a pewter or a glass syringe, or the patient was told.to pass up the vagina a sponge soaked in a strong astringent solution. The treatment was the same, whether the patient suffered from vaginitis or cervical inflammation, from erosion or ulceration, from hard hypertrophy or soft hypertrophy, with or without extensive ulceration. The pathology of the best works was on a par with their therapeutics, for ‘the diseases I have just mentioned were jumbled together under the name of Leucorrhwa, which now occupies but a small space in our best text-books, and does not head a chapter in the present work. The too-abundant secretion of unchanged vaginal mucus that occurs in some women, and particularly in those of a lymphatic constitution, is a circumstance of slight importance, and if the vaginal discharge be muco-purulent or pus, these altered secretions depend on inflammation of the womb or on vaginitis,

In England, gynecology may be said to have begun with the publication of Dr. Henry Bennet’s first edition, in 1845. This work opened the eyes of the most intelligent men of the profession all over the kingdom, but, to the amazement of foreign pathologists, so late as 1850, the leading men in town got up the largest meeting ever held at the Royal Medical and Chirurgical Society to discourage ocular examination for the diagnosis and the treatment of uterine diseases, Sir Charles Locock alone protesting against such an absurdity. Nevertheless, independent observers, availing themselves of accurate modes of examination, and working in separate fields of observation, have founded a school of British gynecology second to none.

One reason why it is so difficult for young practitioners to understand diseases of women, is that one sex alone is qualified by the power of continuous work, and by the nature of his mental capacity, to investigate what the other sex has alone to suffer. That freedom of investigation, and of explanation which has led to the accurate knowledge of’ the diseases of the lungs and of the heart, fails us when the functions of the generative organs of women become deranged. Modesty, the safeguard of society, raises such a barrier between the patient and the practitioner, that she long conceals her sufferings, and when at last modesty bends to the duty of self-preservation, she naturally prefers the elder practitioner, and thus deprives the younger of the average opportunities of studying her diseases. If women were able to compete with men in the practice of medicine, the greater freedom of intercourse between the female doctor and her patient would have the advantage of leading to the earlier discovery of diseases of women, and to their earlier treatment.. On the other hand, the predominance of emotion over reason, the monthly upset of health, the crippling of physical power by pregnancy, parturition, and lactation, and the strange effects of these necessary states of womanhood on a woman’s mental and emotional faculties, will not allow many women to go through the same course of medical studies as we do, and to make an effectual use of their knowledge; while any large number of imperfectly educated medical women would add considerably to the bills of mortality. As a motive power, ambition in women is not to be compared to the healthy promptings of sexual instincts which must lead women to marry, and then the education of children and the interminable cares of a family will take away from most women the desire of adding our pursuits and responsibilities to their own.

With regard to the tendency of gynecological practice since 1816, it was chiefly medical up to 1848, when Simpson’s influence began to be felt in a surgical direction, which culminated in Dr. Marion Sims’ notes on uterine diseases, and is still in the ascendant. Taking first into consideration the medical theories that have been brought forward, some, like Dr. Bennet and myself, have considered inflammation as the great cause of pathological mischief, while others have politely bowed it out of their explanation of disease, one man saying that, unless cancerous or scrofulous, he has never seen an ulcer of the womb; and another, that he has seen it so frequently that it can have no pathological value whatever; one authority stating that uterine displacements are only troublesome when complicated by congestion and inflammation; and another, that displacements are the chief causes of congestion and of all other diseases of women. Some representing the body of the womb as bearing every interference with impunity, and others looking upon it as a noli me tangere. Some maintaining that slitting up the womb is an operation seldom required, and others, that it is very useful in many complaints, and a justifiable operation when none other ean be suggested. As this is to be my last work, 1 am glad its teaching is in perfect concordance with what I taught in the first book I published in 1850. The doctrine accepted by Dr. Bennet from the French school was, that the cervix was the ‘fons et origo” of the most common uterine diseases, whereas, in my work on ovarian inflammation and diseases of menstruation, I claimed for the ovaries a pathological influence over the womb, analogous to their recognized physiological influence over the same organ, and I have elsewhere? summarized that work in the following propositions:

First.—That the recognized frequency of inflammatory lesions in the ovaries and in the tissues that surround them has a much greater practical import than had been hitherto admitted.

1 Progress of Pelvic Pathology. Transactions of the Obstetrical Society, vol. xvi.

Second.—That of all the inflammatory lesions of the ovary, those involving the destruction of the whole organ are very rare, while the most numerous, and therefore the most important, may be ascribed to a disease that may either be called subacute or chronic ovaritis.

Third.—That, as a rule, pelvic diseases of women radiate from morbid ovulation.

Fourth.—That morbid ovulation is the most frequent cause of ovaritis.

Kifth.—That pelvi-peritonitis is commonly caused by ovaritis.

Sixth.—That blood is frequently poured out from the ovary and from the oviduct into the pelvic cavity.

Seventh.—That subacute ovaritis not unfrequently causes and prolongs metritis.

Kighth.—The subacute ovaritis often entails considerable and varied disturbance of menstruation,

Ninth.—That some chronic ovarian tumors may be considered to be aberrations from the normal structure of Graafian cells.

It will be seen in the paper to which I refer, that most of these propositions have been amply confirmed by Aran, Bernutz, Sirédey, Gaillard, Negrier, Charcot, and Clairou.

These propositions have been accepted with slight modification by Dr. Gaillard Thomas, and the practical importance of subacute ovaritis has been admitted by Dr. Mathews Duncan,* and by Dr. George Kidd.?

While physicians have thus considerably varied in their interpretations of diseases of women, many eminent gynecologists have lost faith in medicine, teaching that most diseases of women are best cured by the knife, and that those who attend women ought to be called surgeon-accoucheurs, y

How uterine surgery has grown since 1816, when Recamier thought ulcers of the womb might be cured by some simple salve spread on lint, and applied through a speculum, Uterine surgery soon took to leeching, and to scarifying the womb, and to caustic treatment; then Simpson set men to impale the womb on a fixed stem, and to deeply cut through the cervix to cure sterility. The mischief done by Simpson, and by the routine practice of his pupils, was limited to women in want of children, but Dr. Marion Sims pretends that bilateral cutting of the cervix, down to its vaginal attachments, not only cures sterility, but dysmenorrhea, uterine displacements, and chronic inflammation of the womb. Huguier had taught us to amputate the cervix when it had become much too long, but, says Dr. Marion Sims: “If women want children, we must amputate the cervix when it projects more than half an inch into the vagina.” It

' Address to the Obstetrical Section, Edinburgh Meeting. British Medical Journal, August, 1876.

* Address to the Obstetrical Section, London Meeting. British Medical Journal, August, 1875.

is really difficult what most to admire in Dr. Marion Sims’ “ Notes,” the author’s surgical ingenuity or his profound ignorance of pathology. That work has nevertheless struck the key-note of modern practice, and it still inspires many of our younger men with the belief, that as Dr. MacDougall was after all right ‘about ovariotomy, so Dr. M. Sims is right in placing the knife above all other modes of treating uterine affections. “ Primum non nocere” was all very well for olden time, now the motto seems to be “ Primum operare.” Sometimes in consultation with a junior, when I have objected to slitting the cervix, a pessary has been proposed, and if I could not see its utility, I have been imploringly asked, “ What then are we to do?” asif uterine therapeutics consisted in nothing else but cutting or supporting the womb.

In England, the womb is still under the reign of the knife, and it seems to me the same in America; for Dr. Peaslee’s strong protest against Dr. Marion Sims’ operation, is rather against the depth to which he cuts, than against the expediency of the operation, or its too frequent performance, and to Dr. M. Sims’ 500 cases, Dr. Peaslee opposes his 500 cases, in which his purpose was only to cut through the mucous membrane lining the cervix.

The worst of it is, that we have no convenient means of stamping out dangerous gynecological tendencies, as they have in France. When, many years ago, it became known in Paris, that in the hands of Valleix the intra-uterine stem pessary had caused the death of several women, the propriety of its use was brought before the French Academy of Medicine. In that eminently representative body, obstetricians like Paul Dubois had their say, but the question was principally discussed and decided by what we call pure physicians and surgeons, and it was they who put an extinguisher on the use of intra-uterine pessaries in French practice. It was well known to the profession, some years ago, that a talented surgeon was acting upon the very extraordinary notion, that the clitoris caused most of the nervous diseases of women. Our leading men could only shrug their shoulders and say to us: “Settle it among yourselves.” We expelled the man from the Obstetrical Society, and although it was most righteously done, on purely public grounds, yet, as the grounds of conviction could not be published, and the sentence was not given by a public body representing the whole profession, it is still generally believed abroad, and more particularly in America, that this man was a victim of professional envy. If instead of considering gynecology as a specialty, an offshoot of midwifery, it was looked upon here, as on the Continent, as a branch of medicine that no well-educated medical man could afford to ignore, then here, as abroad, hospital men would treat diseases of women instead of sending them to obstetric physicians, and thus the knowledge of diseases of women would become perfected and be disseminated—as it has been in Paris, for instance, by such men as Aran, Huguier, Bernutz,

Richet, Sirédey, and others, who have nothing to do with midwifery. If our leading men had a moderate knowledge of diseases of women, they would seize the salient symptoms of uterine disease in the midst of other symptoms, and they would be less liable to damage their reputation, by hitting at a symptom when there is a disease to treat. Nothing would contribute more’ to the advance of all that relates to our branch of the profession than a good acquaintance with its pathology by our leading men. Standing on neutral ground, as umpires between us, they would exert a healthy control over extreme views, and put an early extinguisher on crotchets that menace to become too offensive,

For the last twenty years there has been a Medical Council, and its twenty-four members have been frequently changed, but not one man has ever sat at the Board who understood what relates to the obstetric branch of medicine, or who was taking an active interest in it, either as a teacher of midwifery or as a practitioner in diseases of women. If our leading men were well acquainted with diseases of women, the Medical Council would see that the too limited time now allotted for their study to medical students should be extended, and it would have insisted on the midwifery of the lower orders of our countrywomen being put on a respectable footing, instead of allowing it to remain a national disgrace, notwithstanding the repeated and urgent appeals made to it and to the Goyernment by the Obstetrical Society of London.

Leaving this unsatisfactory state of things to be righted at last by the slow influence of public opinion, I resume the more becoming task of giving hints to students and to young practitioners, condemned by the undeniably deficient medical arrangements of this country to grope their way to a knowledge of diseases of women, even by such light ag they can gather from the precepts of volunteer teaching. After making the best of his opportunities at home, any young man who really wants to understand diseases of women before beginning to treat them on settling down to practice, should spend a year in Vienna or in Paris, which affords such large opportunities for studying the diseases of women—opportunities so generously placed at the disposition of all; or better still, he should become dresser to some of the eminent physicians who particularly study uterine pathology, like Dr. Bernutz, or to those who do duty at the “ Hopital de ’Ourcine.”

When a certain amount of clinical knowledge of diseases of women has been gained, it will be time enough to see how they have been interpreted by different writers, and I am glad to think that the best and most practical works on’ diseases of women have been written in the English language. It is so natural that I should entertain a strong conviction in favor of my own works, that I am afraid I shall not be altogether trusted, when I say that the best thing a beginner can do is to first study the physiology and diseases of menstruation in the third

INTRODUCTION. i edition of my “Uterine and Ovarian Inflammation.” I claim to have there shown that diseases of women spring out of morbid menstruation, and that the study of its physiology and pathology is the way to unravel the complications of diseases of women.

On settling down to practice, the young practitioner vill find how different it is to watch disease in an hospital and to assume the responsibility of a case; and he will feel the difference between medical science and medical art, by the difficulty of applying science for the good of his fellow-creatures. He will see how difficult it is to obtain a full knowledge of the circumstances of a case, for, instead of making it clear to him, the patient will often ingeniously evade his questions; or, without meaning to deceive, she may say what is not true, so that he will be frequently led wrong. ‘This difficulty often increases in proportion to the degree of refinement of his patient; indeed, information having important bearings on the case often comes out only after many interviews. He will find that some are “malades tant mieux,” taking an unreasonably sanguine view of their complaints, while others consider every symptom so despondingly, that they fully deserve to be termed ‘‘ malades tant pis.” He will find that, until forced to remain in bed, many young women will never own they are ill, partly from bashfulness and partly from a fear of being bothered and made to adopt precautions, while those who have passed forty are often prone to exaggerate occasional indispositions, being led to do so from overrating the dangers that accompany the change of life. Different patients give us quite an opposite character, because they make us, to a certain extent, different from our usual selves.

The cold, suspicious manner of some, so paralyzes one, that it requires a strong mental effort to plan their treatment; while the open and confiding manner of others, magnifies the power of curing them. So much for the patient; as for the doctor and his chances of success, he may have many good qualities, but unless he combine firmness with gentleness he will not get on. If rough, he will frighten his patient; if weak-minded, she will despise him. He should be married, or many will deny him the right to know anything about women, and he must allow himself no eccentricities of dress or manner; for, in the estimation of women, no amount of genius would excuse the eccentricities of an Abernethy. His behavior to his patients should be quiet and expressive of sympathy, which will not be less acceptable from being tinged with seriousness, and unless he be kind, he will be unable to bear with their caprices, despondencies, and mental infirmities, during the course of chronic disease. Melancholy looks make a patient feel worse; a cheerful face is a good tonic; but one must laugh little with patients, and not at all at them, for however ridiculous their fancies may be, they must be reasoned, not laughed out of them. He should not only be quiet in manner but also in voice, which should not be loud and boisterous. He should be cool and collected, even when he has only ten minutes to give a patient, for a hurried speech and manner would flurry her, making her forget what she most wished to’ask, and leaving her dissatisfied with the visit.

Extreme neatness and cleanliness in all minor cperations, and in the dressing of local complaints, can only be attained by practice. It is of the utmost importance, however, to strive to attain this neatness—for patients, however rich, will not pardon large stains being made on their towels or personal linen, and are apt to consider them as proving want of knowledge as well as of dexterity and practice. It will be obvious that, if there be the slightest suspicion of an ulcer being syphilitic, the speculum should be very carefully washed with a solution of permanganate of potash or of carbolic acid. Few know the importance of a first visit— how women, suffering from uterine complaints, have thought it over, what consultations have been held about it with friends and relations, and how many months or years of suffering it has taken to bring them to seek this first interview, which will decide whether the patient can have confidence in the doctor. How is confidence to be inspired? An eminent consulting surgeon, who has made a large fortune, thinks that a solemn oracular manner, and monosyllabic answers, makes most impression on his patients. I believe that a minute and logical investigation of the facts of the case is the safest plan, and that the best way of convincing a patient that one is master of the case, is to take the trouble of explaining it, so that she may leave the consulting-room convinced that her complaint has been understood by one anxious to cure her—a frame of mind eminently calculated to give efficacy to treatment.

Without discretion there is no possibility of success for a lady’s doctor, as he learns and is told somuch. He must not only keep as a sacred trust what has been confided to him, but he must be able to appear not to see what stares him in the face. For instance, if an unmarried woman says she has only profuse menorrhagia, it is better not to dispute the point, even when he has identified the umbilical cord. It is useless to the patient and damaging to one’s self to exact a painful confession, when without it the case can be well treated.

Another secret of inspiring confidence is to be hopeful. It is a consolation attached to an arduous profession, that we can conscientiously pass our lives in raising the hopes of sickening despondency. It makes amends for the fatigues, the perils, the ingratitudes that must be encountered, to be able so often, by a word, to dispel fear and restore a family to happiness. With rare exceptions, of which cancer is a prominent example, those who treat diseases of women may deal largely in hope, and our duty then is not well done toward a patient, if we do not persuade her that her cure is certain, though delayed. One great advantage of experience is, that it teaches us hope. In those early days of practice when it made me blush to receive a guinea, if I met with cases where the best treatment produced at first little or no good, I lost courage, and I infected the patient with my own despondency; but now that I have repeatedly seen such patients recover, if their faith can be kept up so as to make them persevere with more or less active treatment for a considerable time, one is justified in instilling hope, which so powerfully helps every mode of cure. The hope that is held out will, of course, be proportionate to the nature of the disease and its duration, or the practitioner’s reputation will be seriously damaged. Should inflammation of the womb, for instance, occur after the change of life, it would be wrong to promise a speedy cure, for the repair of diseased tissue then proceeds. at a slower rate than usual, When extensive ulceration of the cervix occurs during pregnancy, a cure should not be promised till after childbirth, and the patient should be warned that the disease makes her liable to miscarry; otherwise a miscarriage will be attributed to any treatment that may have been instituted to keep the disease in check.