hurriedly over his medical journals, dips into a book of reference to glean a fact or two about a case that vexes him sorely. Scarcely acquainted with his family, the man of medicine has little time for visiting libraries, even though his presence may be an example for others to follow. The young physician is too busy making acquaintances, studying cases in his office, and hurrying about attempting to create the impression of a rushing and strenuous existence, to find leisure for visiting the abode of books in his vicinity. And yet these men have lost much more than they gained by ignoring a means of culture and intercourse with superior minds, which would make of them better physicians, because of a wider horizon than mere medicine gives to man. The capacity to appreciate things true and good and beautiful in art and philosophy and literature, by a close acquaintance with these things, enhances one's ability to treat the patient, not the disease; to know one's fellowmen and women, not their momentary appearances; increases one's power to understand and appreciate a thousand things which the person versed only in medical text-books does not even suspect. Physicians absent themselves from libraries at their peril. They may be more successful from the pecuniary standpoint, but it is at the expense of a culture to acquire which it would seem that we are citizens of this world.

***

Of the thousand vexing problems that confront the general practitioner, none causes him more worry than the uncertainty of his obstetrical engagements. Gladly would he give up this part of his practice if 'twere possible; for these cases disarrange the entire routine of his day's work. With an office filled with patients, some having come great distances, and each believing in his or her own heart that the particular ailment, imaginary or real, from which they suffer, is important beyond even a woman in parturition; and the acute disappointments entailed by the absence of the medical adviser are sometimes as bitter as unrequited love, judging from expressions heard when these are informed, with the best grace possible, that "the doctor is called to a confinement case." Meals are allowed to get cold or are missed altogether, causing the good wife much vexation, to which it seems she never can become accustomed; while the nights and nights of vigil wear upon the medical man more than dissipation and the wine cup. The office of the obstetrician is a sacred one, and its spiritual and moral compensations far beyond words to describe; and yet the price is too great which the doctor pays therefor. The day will come when obstetricians, specially trained, will do all this work, leaving to the general practitioners other duties; and yet it is possible that, after all, the family physician would be the loser by the substitution. For the present, however, the general practitioner must continue to be the adviser and helper, even in the hour of woman's greatest pain and-happiness.

THE WEEK'S NEWS.

The Northwestern Ohio Eclectic Medical Association met at Findlay, April 12.

The sum of $150,000 is being raised in Des Moines, Ia., to continue the Drake Medical School.

Many cities are undergoing the throes accompanying "clean-up day" prescribed by local boards of health.

Much interest is manifested in the forthcoming meeting of the National Conference of Charities and Corrections, at St. Louis, May 19 to 26.

April 24 has been designated "Tuberculosis Sunday" throughout the land. Ministers are requested to preach on the subject of the white plague.

Dr. W. J. Little was elected on the medical board at the meeting of directors of the Macon, Ga., Hospital, April 15, to take the place of Dr. R. B. Borron, who resigned recently.

Think of it! Dr. McGuire, of Parkersburg, W. Va., was selected essayist for the May meeting of the local medical society and the subject he selected was "Summer Complaint of Children."

At the P. and S. Hospital, San Antonio, Tex., nine nurses went on a strike because they received day after day a few beans and some hamburger steak for breakfast. They claim to have other grievances.

Dr. J. J. Boone, a Mt. Victory, O., physician recently found guilty of violating the State law which compels doctors to report all births and deaths, has carried his case to the circuit court on error.

Dr. D. J. Healy has handed his resignation as Superintendent of the Frankfort, Ky., Feeble-Minded Institute to the Board of Control for Charitable Institutions. Dr. Healy's resignation will take effect May 1.

The William H. Welsh celebration at Baltimore last week has been most favorably commented on by the lay press everywhere. It has done more to show how we honor our leading scientists than anything that has occurred for years.

There are numerous victims of the cocaine habit in Philadelphia, and as a remedy the President of the Pennsylvania State Board of Medical Examiners, Dr. Henry Beates, Jr., is quoted as advocating the death penalty for the selling of cocaine.

Dr. E. A. Foley, of the Illinois Eastern Hospital for Insane, at Kankakee, has been appointed assistant superintendent of the Illinois Southern Hospital for Insane at Anna, succeeding Dr. Eugene Cohn, who has been transferred to the State Hospital at Peoria.

In the Ohio legislature Senator Beatty's bill, authorizing boards of education to establish special elementary schools for school youth afflicted with tuberculosis in any city school district, and to exclude them from the regular schools, was reported by the house committee on common schools.

Dr. J. D. Love, of Jacksonville, was elected President at the recent meeting of the Florida State Medical Association. The others elected were: Dr. A. H. Freeman, First Vice-President; Dr. L. A. Peek, Second Vice-President; Dr. F. C. Moor, Third Vice-President; Dr. J. D. Fernandez, Secretary and Treasurer, Jacksonville.

Dr. Benjamin A. Ledbetter, President of the Orleans Parish Medical Society, has given the cistern water of New Orleans much thought and expressed himself recently in an astonishingly original way on the general subject of cistern water. "I am strongly of the opinion that a great deal of typhoid fever existing in our city is caused from cistern water," he said.

The Georgia State Medical Association met at Athens, April 20 to 22. From accounts received it was a rousing meeting. The association adjourned Thursday and went by special train to attend the memorial exercises in honor

of Dr. Crawford W. Long, one of the discoverers of anesthesia by the Jackson County Medical Society. Possibly the barbecue. dinner may have been the attraction.

Thirteen new buildings and additional endowments are needed immediately at the University of Chicago, according to statements made by President Harry Pratt Judson in his annual report recently issued. New departments, including a faculty of medicine and a medical school plant, are other wants listed by President Judson in his first comprehensive statement on the future expansion of the university.

Failure on the part of an East Youngstown, O., physician to return with antitoxin resulted in the death of a little girl, aged three. According to the coroner the child was attended by a new physician. The doctor attended the little girl Monday, and when he left her bedside he promised to return with antitoxin. He failed to keep his promise and the child died from a virulent case of diphtheria. The unusual dereliction on the part of a physician prompts this journal to print the above news item.

At Hamilton, O., the circuit court has reversed the decision of the common pleas court granting Dr. J. C. Stratton, of Middletown, a writ of mandamus to compel the trustees of Lemon township to award him the contract for furnishing medical attention to the poor. Dr. Stratton was the low bidder, but the trustees gave the contract to Dr. Dell. The circuit court held that the trustees had a right to exercise discretion and that they had not of necessity exceeded their powers in awarding the contract to a high bidder. The case was ordered retried.

Women physicians of Utah met at Salt Lake City last week and organized the Woman's Medical Society of Utah, with the following officers: Dr. Luella Miles, President; Dr. Anna Ries, of Ogden, Vice-President; Dr. Elsie Ada Faust, Secretary and Treasurer; Dr. Mattie Hughes Cannon, Chairman of the Credentials Committee and Advisory Board. Meetings will be held on the first Tuesday evening of each month. The object of the organization is the exchange of ideas, discussion of scientific subjects, and to draw closer together the women physicians of the State. Dr. C. O. Probst, Secretary of the Ohio State Board of Health, has directed a communication to Attorney-General Denman, asking for the law covering the question or tubercular patients employed in factories. In his letter Dr. Probst inclosed a copy of a communication from some unnamed person, stating that in a glove factory in an unnamed town in Ohio several persons are employed who are supposed to be consumptives, and asking whether or not there is any law to prevent their employment among well people. The attorney-general will look up the statutes governing that subject for the guidance of health authorities.

The reports of the officers of the Louisville Anti-Tuberculosis Association at its fifth annual meeting showed that the scope of the work of the association had grown wonderfully within the last five years and that already effective results from the battle against the white plague in the preventive campaign have been great, indeed. Within that time two sanatoria have been erected outright and a tuberculosis adjunct made to the city hospital. The association plans further to establish a tuberculosis day camp, where those who cannot be taken at a sanatorium may come for treatment during the day and rest in reclining chairs under the oversight of the nurses, and where they can be seen daily by the physicians and receive at the same time proper nourishment.

President Emeritus Charles W. Eliot of Harvard University takes exception to reports that have been circulated that he is in favor of putting people afflicted with an incurable disease out of existence. The doctor asserted his views, which are of a milder nature, in this statement: "What does it matter, in a hopeless case, if the patient's life is shortened by a few hours or more if he is thereby relieved from excruciating pain? I do not believe in the right of anyone to kill another in order to put the pa

tient out of his agony, but I do believe that we should avail ourselves of these anodynes which nature beneficently provides, even though their use in a hopeless case may shorten the brief remaining span of life."

Local Affairs.

Dr. J. C. Cadwallader intends to resign as health officer of Norwood.

About twenty Cincinnatians have expressed their intention of going to the State meeting at Toledo.

Dr. J. A. Macready is the new district physician in the Ninth Ward, Dr. William Stephan having resigned.

Dr. Roy W. Kinsey, of Minier, Ill., of the Eclectic Medical College, has been appointed resident interne at the Seton Hospital.

Again the office of receiving physician at the City Hospital will be vacant. The present incumbent, Dr. Robert Mussey, will resign June 1.

Dr. Grear Baker will read a paper on "The Aftertreatment of Gynecological Procedures," before the West End Medical Society, April 26.

Dr. B. Merrell Ricketts has been invited to be present at the celebration by the New York Academy of Medicine of the eightieth birthday anniversary of Prof. Jacobi.

The State Board of Health and the municipal boards of the southern part of Ohio have been meeting at the Sinton the past week. Sewage disposal was the main topic of discussion.

It is a pleasure to reiterate our reference to the forthcoming meeting of the Ohio State Medical Association at Toledo, May 11 to 13 inclusive. Cincinnati should be well represented.

The following have received the appointment of internes for the Jewish Hospital: Casper Burton, John Hansher, Charles Stoffregen, Henry Schneider; alternates, O. Bloom, Jos. Hunter.

Drs. Louis Schwab, C. R. Holmes, A. L. Zwick and Superintendent Withrow of the Anti-Tuberculosis League are to speak to the children at the refuge home on health matters Sunday, April 31.

The Union District Medical Society will meet at Hamilton, O., April 28. The program is distinctly worth while. A bunch of Cincinnati physicians will participate in the discussion. Besides, there'll be a big dinner.

Dr. W. A. Young will read a paper, May 6, on "Diverticulæ and Their Relation to Abdominal Disease," before the Campbell-Kenton County Medical Society. The sessions are held at Carnegie Hall, Newport, at 3:30 P. M.

"Rare and Anomalous Conditions, Obstetrical and Gynecological," by C. D. Palmer, M.D., was the subject discussed by the Cincinnati Obstetrical Society, April 21. The society met at the home of Dr. Rufus B. Hall, upon invitation of Dr. Joseph Hall.

Dr. Francis Dowling, who has had unusual opportunities of becoming conversant with the history of things medical in France, will make an address before the Academy of Medicine, April 25, on "Some of the Former Medical Giants of France." There will be thirty lantern illustrations.

The Finance Committee of the Cincinnati Anti-Tuberculosis League having charge of the outing to be held at Chester Park, on June 18, has received the first batch of 50,000 tickets from the printer. The committee is modest in its predictions, but there'll be a crowd at the park on that day, you may be sure.

It is doubtful if a play has appeared in Cincinnati for years which has been more detrimental to the morals of the rising generation than "Arsene Lupin," showing at the Grand this week. People of orthodox views follow the old cry against sexual immorality as portrayed on the stage, or inveigh against even the suggestion of salaciousness in literature. But they applaud and extol a play like "Arsene Lupin," in which cunning and duplicity are combined to show how small a thief can be, and how the law is a mere contrivance to be outwitted by a superior though de(Continued on page 452.)

IN

Contributed Articles.

A STUDY OF THE ETIOLOGY OF

STERILITY.*

BY JAMES W. ROWE, M.D., CINCINNATI,

N this age physicians are more commonly consulted with a view to prevent conception than to facilitate it. Nevertheless, professional advice is occasionally sought by people who are childless unwillingly, and at such times it devolves upon us to give some thought and study to the subject of sterility. Among our forefathers childlessness was considered a great misfortune; among ancient peoples it was regarded as the curse of Heaven.

Sterility is the inability to produce offspring. A marriage is sterile when it has never produced a living child. In attempting to arrive at the cause of such a condition it is necessary to examine both husband and wife.

The man generally refuses examination. He considers the potentia cœundi equivalent to the potentia generandi, or he has the suspicion that he himself is at fault and dreads the disclosure. Humanity may pity and sympathize with the sterile woman, but it has a peculiar contempt for the incompetent man. Woman herself, although caused unutterable suffering by her husband's sexual power, would be the first to despise him if she felt it was lacking. For these reasons men are very chary of examination. Attempts have been made by statistics based upon examinations to arrive at figures representing the proportional responsibility of the sexes for sterility. Formerly it was taught that in 90 per cent. of the cases the woman was responsible and in 10 per cent. the man. Modern authors have changed these figures, and consider that in 26 per cent. of the cases it is the fault of the male. Pinard goes still further and declares the man at fault in 40 per cent. The richness of the discharge in spermatozoa varies. After a period of masturbation or of sexual excess there is a marked oligospermia, but if the cause is removed this is likely to be transient. Finger examined the testicles of men recently dead and found in 25 per cent. absence of spermatozoa. He also examined 242 cases of epididymitis gonorrhoica duplex and found azoospermia in 207. Liegois, in 83 similar cases found azoospermia in 75. Azoöspermia is also found and sometimes cured in syphilis. Furbringer examined 600 husbands of sterile women, and found in 83.3 per cent. azoöspermia or marked oligospermia. This is a remarkable percentage, so high that the accuracy of his observations is bound to be called into question.

Generally speaking, if the average number of spermatozoa is found, and these are alive and in motion, the man is considered competent. Yet mo*Read before the Academy of Medicine of Cincinnati, February 14, 1910.

tion is not a sure criterion, for if the spermatozoa of the frog are frozen and thawed again, they recover motion but cannot fertilize. Disturbed circulation in the testicles, as congestion, or the toxins. of disease may, so far as we know, destroy the fertilizing power without inhibiting motion. If an examination of spermatic fluid is to be made, it is better to obtain it after a period of say two weeks' sexual abstinence, as under these circumstances the spermatozoa are likely to be more abundant and more active.

In seeking the cause of sterility in any married couple, it is most logical first to exclude, as far as possible, the husband as an etiological factor; second, to look for local pathological changes in the wife; third, to seek for general constitutional conditions of such a nature as to hinder reproduction. Failing to find here an explanation we take refuge in psychic influence or the inadaptability of the spermatozoon to the ovum.

On the side of the female three postulates present themselves: First, the ovum must be capable of development; second, it must be accessible to the spermatozoön; third, it must be provided with a suitable place for development.

We are hampered considerably in our judgment by the impossibility of direct visual examination either of the ovum or of the essential generative organs of the female intra vitam. Spermatozoa may be seen alive under the microscope by thousands, but we can never obtain a single living human ovum. The condition of the female contribution must, therefore, be an absolutely unknown quantity. Our only recourse, then, is the examination of the essential organs of generation by the sense of touch, and this is very unsatis factory, as we cannot even touch them directly, but must feel them through other tissues. The numerous mistakes in gynecological diagnosis bear testimony to the possible fallacy of our conclusions. How often does the exploratory incision furnish a surprise for the operator. By means of tactile examination we find deformities, swellings, inflammatory processes and malpositions of the uterus, any one of which may be the cause of sterility, but the fact must not be lost sight of that under any of these conditions, unless very severe, conception has occurred.

At just what period can we, in a general way, declare a marriage sterile? Some observers say after one year, others after five. There are certainly many married couples in this country whose first year of married life has been fruitless, but who subsequently have had children. The first figure is unquestionably too small. Chrobak says after two years; Kisch and Kleinwacter after three years. Then there is the condition of sterility acquired after the birth of one or more children. American and English writers have discussed at length this condition to which they give the name "one-child sterility." Various European writers place the limit for this form at from three to five years from the

birth of the last child. This is a hard matter to estimate correctly, as only in a proportion of cases can we be sure that there is a real sterility and that the condition is not due to measures used to prevent conception. Sterility may be acquired without a preceding birth, and often the same observer places a different period for the estimation of congenital and acquired sterility. E. Fraenkel suggested that five years of fruitless marriage be considered as the period of time necessary before a marriage could be considered sterile, whether the sterility be of one kind or the other. He based this suggestion upon the observation of Kisch, that after four years of childless married life only one-thirty-ninth of all women become pregnant; in other words, thirtyeight thirty-ninths of married women become pregnant during the first four years of married life, if they are going to become pregnant at all.

There are varieties of sterility. Absolute sterility denotes a condition in which a woman cannot conceive at all. Relative sterility denotes a condition in which a childless couple, after divorce or separation, show themselves competent with other mates.

Sterility may be congenital-that is, the anatomical structure of the genitalia may be such that procreation is impossible. It may be acquired, when due to disease or injury incident to sexual intercourse or any other cause. It is primary when a woman has never conceived. It is secondary when, after a birth or miscarriage, she is incapable of further reproduction. Under the last two varieties we may make subdivisions, according as the fault lies in the development of the woman or is acquired as the result of marriage. Two very pertinent questions arise in this connection: Allowing that the husband is competent to procreate, in how far is the woman herself the cause of the sterility? In how far has the sterility resulted from marriage?

In studying the literature of this subject we find great diversity of opinion. This, as Torkel says, is due partly to the character of the individual investigator's practice and partly to his personal view of the pathology. To exemplify the first case, Kisch, with a clientèle of Marienbad patients, cites 58 cases in which he attributes sterility to fat. Treub, on the contrary, out of 138 cases of sterility, considers 99 due to myoma. To exemplify the second case, one man attributes the condition to retroverted uterus, another to the accompanying endometritis; one to a narrow cervix, another to the accompanying endocervicitis.

The pathological findings fall into four categories: (1) Abnormalities of the generative apparatus, whether malformation or disease existing in the female previous to marriage. (2) Pathological states of the genitalia developing after marriage, but not attributable to it. (3) Constitutional conditions not in direct connection with the reproductive system. (4) Pathological conditions resulting from sexual intercourse, pregnancy or parturition.

In the first three cases the woman is anatomically

or physiologically directly to blame; in the fourth class, which is a large one, she is usually only indirectly at fault, and the real blame must be attributed to the husband. Pinard makes the sensational statement that of one thousand women with normal menstrual history 999 are capable of being impregnated, and that women have been blamed too much for sterility, especially if gonorrhea, which they acquire from their husbands, is taken into account. Lier and Ascher state that two-thirds of primarily sterile women, and four-fifths of secondarily sterile, owe their condition to their marriage. Grünewald made some very interesting observations in this connection. He examined five hundred sterile married women of child-bearing age, and found that about two hundred were sterile from congenital causes; in nearly all the remainder the sterility was acquired. Thus, in over 50 per cent. of the cases the sterility was caused by disease of the sexual sphere. He further states that of three women thus affected after having borne children, one becomes sterile. The proportion of women sterile from acquired disease to those congenitally so, is variously stated. Kleinwachter gives 255 to 238; Kisch 213 to 180; Chrobak 72 to 36.

We consider first the causes of sterility which cannot be referred to the husband or to the marriage, but which must be laid at the door of the woman herself. These include malformations and tumors, malpositions, stenosis of the cervical canal, constitutional conditions and many other miscellaneous minor causes. As might be expected, authors differ markedly in their estimation of the importance of these conditions in the etiology of sterility. Ward quotes Bowman as saying that in two-thirds of the cases where the woman is at fault there is defective development of the genitalia. In 261 similar cases Kleinwachter attributes the sterility to tumors and malformations in 190, Chrobak in 36 cases to these causes in 16. Uncomplicated cases of malposition and stenosis are not often asserted as causes in the more extensive statistics. Considering the voluminous literature on these subjects and the innumerable appliances for their treatment one would expect differently (Torkel). The rank and file of the profession consider them fruitful sources of the condition, but it must be remembered that they are generally complicated with catarrh of the endometrium.

For reproduction to occur we must have a normal spermatozoën and a normal ovum, there must be a union of the two and the resulting cell must be provided with a nidus adapted to its growth and development. The inherent energy of the spermatozoën must be such that it can reach the ovum, the passageways must be patent and their secretions must be practically normal in character and chemical reaction. A normal ovulation is essential, but, even supposing this process to be normal, we are not sure that all ova are capable of growth. Cohnstein thinks there are Prädilectionszeiten, i.e., times