that they had at some time a pelvic peritonitis. If, upon examination of smears from such cases the gonococci are not demonstrable and that they do not yield to treatment and remain well, but are attended by relapses, it is fair to assume that we are dealing with a gonorrheal inflammation. In order that pregnancy may not take place, it is essential that the disease be bilateral. We may not be obliged to look as far back as the tubes and ovaries to account for the sterility. Chronic inflammation of the otsium uteri, or endometrium producing a chronic catarrh may, and, in my experience often does, effect a complete impediment to the entrance of the spermatozoa. Polypi in the cervix, or growths within the uterus afford obvious and more easily demonstrated causes of sterility. The uterus itself may, upon examination, be found to be a probable cause, especially when found to be undersize, as in infantile uteri. While this condition if appreciated might readily be ascribed as a cause, we must advert to the fact that the true condition is easily overlooked, for the reason that the cervix presents to the examining finger often a practically normal size, which if alone taken into account would not reveal the true condition. Bimanual examination might aid and suggest the sounding of its depth, which would be found shallow, with thin walls. The endometrium is thin and unsuitable for impregnation. With this condition is usually found an imperfect development of all of the genital organs, which may be early suggestive of an infantile uterus. Atrophy of the uterus, simulating the infantile, may result following a pregnancy in which some infective trouble has been experienced, and from which the patient may recover. Displacements and flexions of the uterus have been considered by some as prolific causes of sterility. My observation has led me to regard them as merely factors not acting per se in any very pronounced degree. The conical os has seemed to be often a causative factor, especially when we had a socalled pinhole os. According to Sims 85 per cent of all cases of "natural sterility" have a conical cervix.

It is well recognized that long standing catarrhal conditions of the cervix will lead to a stenosis of the canal and must be differentiated from the above lesions. Young women are frequently neglected who suffer for years with a chronic catarrh of the cervix and remain childless after marriage, often charging it to the husband, sometimes properly so.

At this juncture we may profit in pausing

to consider the reasons why we are forced to charge such tremendous responsibility to gonorrhea and its results. To properly appeciate the merits of the situation, we must needs be very plain. In the first place, parents are often to blame for allowing children to grow up ignorant of the nature of the disease, its frequency and results. And here perhaps we should not exact of the parent that of which they may know little or nothing, but shift the responsibility to the family physician and expect him to give the necessary information, acting, as he should, not only as adviser in time of need, but as a protector of those in whom he should have an interest. Too little is known of the nature and harm arising from gonorrheal infection. This is a condition that may be trifled with so long as it is limited to the male, for they can be cured, but it is not so with the female to the same degree.

In the second place, physicians who treat or are consulted in relation to the results of treatment are not painstaking enough to be sure that all danger from inoculation has been eliminated before marriage is permissible. It is known that men capable of inoculation have married and had children with no serious results to the mother, but this is the exception. Some women are more susceptible than others, so frequently is this the case and so disastrous may it become to them that no small number are unsexed by operations thereby made neces

sary.

We are not prepared to accept the Negorath theory-gonorrhea once, gonorrhea always-in the male; in the female it may be true, but we do subscribe to the belief that all cases can and should be cured before marital vows are taken. It has been claimed that a large per cent of married women applying for local treatment, are suffering from a mild form of gonorrhea. Such being found to be the case, should suggest and exact an examination of the husband, and if he is found to be possessed of the exciting gonococci, as one in six are, he should also be subjected to treatment and quarantine.

The credulity and innate goodness of women has made it possible for men to impose upon and endanger their lives without turning upon them the inexorable eye of investigation. When once they shall become aroused to the full meaning of this situation, they will, as in other matters, rise up in righteous indignation and demand a better and more wholesome state of things before they surrender their bodies to the slaughter. Were the condition reversed,

legislative halls would be crying for legal protection and a higher morality with popular acclaim.

Perhaps no symptom has been so frequently charged with being the cause of sterility as dysmenorrhea, being encouraged largely by no less an authority than Sims, and yet it has been proven that a large per cent of dysmenorrheas are unexplainable and are often associated with conditions which when relieved and fertility established, still suffer from a dysmenorrhea. Not all dysmenorrheas, as was thought by Sims, are due to a stenosis of the cervix; indeed, a large per cent are never understood. The reaction of the vaginal secretion is of considerable importance in reaching a diagnosis or the cause of sterility. The normal vaginal secretion is faintly acid, if it should from any cause become strongly acid, the life and movement of the spermatozoa are jeopardized and sterility. results. The cervical mucus is alkaline naturally, and favors the inward movement of the spermatozoa, but if from catarrhal processes it becomes acid, it, too, checks all likelihood of impregnation.

Atrophied conditions of the ovaries, resultant upon such diseases as rickets, phthisis, diabetes, syphilis, tuberculosis, or other toxic affections, should not be forgotten. The long continued use of morphine lessens the probability of fecundation, as also does quinine, in the opinion of some. Repeated ovarian congestions at the time of puberty from various causes, now well appreciated results in follicular cysts of the ovary and sterility.

While we have essayed to indicate some of the etiological factors in the production of sterility suggestive of the necessity for a painstaking consideration in order that we may the more intelligently deal with such cases, we are not unmindful of the fact that we are not fully clear in regard to all the intricacies of fertility. We must admit that not every case of sterility will reveal a cause, however carefully we may work to elicit it. On the other hand, we have, with apparent reason, given an unfavorable prognosis, to be in due time greatly surprised, if not chargined. We feel constrained to caution gynecologists against a preformed notion as to the usual cause of sterility, as was Sims when he claimed that the majority were due to mechanical causes, or of others who claim that it was due to a functional defect of the uterus, although it will be admitted that it may be either or a combination of both. Matthews Duncan brought out the theory that sterility was due to a "deficient reproductive energy."

"That it was an imperfection devoid of all perceptible, measurable characteristics." Placing sterility, as he did, as a law of nature, it failed to gain any lasting hold upon the profession.

After a careful review of the subject, and bringing it down to date, we are forced more and more to recognize the most potent cause to lie in the results of a gonorrheal infection, either in the male or female. Rougy, in the Medical Record of February 18, 1911, reports 120 cases of sterility seen in which the husbands were also examined and found 70 per cent due to gonorrheal inflammation. Dysmenorrhea was present in 84 per cent. Displacements not a great factor, nor does obstruction seem to be a frequent cause. Leucorrhea in 95 per cent. Acid reaction in 20 per cent, all of which is in full accord with our observations as herein set forth.

It is not necessary to advert to the treatment, as that must conform to the findings. The sole object of this paper was to attract the attention of the physician to a closer observation of these unfortunate patients.

819 Gloyd Building.

DISCUSSION.

DR. LESTER HALL: Dr. Crowell's paper treats the subject thoroughly and leaves little to be added to what has been said. Personally I find most of my cases due to obstruction. By repeated dilation until the os becomes patulent, many of these cases become pregnant. The part that gonorrhea plays is recognized yet the gonococcus travels so slowly that the disease is often cured before the infecting organism reaches the endometrium.

In

I have dealt with a class of women not exposed to gonorrhea and have had good results as mentioned. Gonorrhea may be a remote cause. clinical practice it may be the most potential cause, but I doubt if it is in the general practice of most physicians.

I would rather think the habit of not having babies is a more potential cause, fighting against conception for years for a more suitable time to have their children. This brings on nervous disturbances and a sympathetic endometritis results from cheating nature. There are many ways this is done and the fact that men often withdraw from the copulation act before the woman has experienced her orgasm may be a potent cause. True, many times, the man is at fault rather than the woman. There are many of the modern ways of cheating nature out of her just reward and, it seems to me, are more potential in causing sterility even than gonorrhea.

DR. GEO. M. GRAY: Sterile women often are desirous of having children, but are unable to do So. I cannot agree with Dr. Hall that the majority of these cases are due to stenosis of the cervix. In most of them the uterine sound passes easily. Many of them have an inflammation of the cervical endometrium, causing a mucous plug to obstruct the canal very often. I think we are justified in assuming that there is some obstruct

anemic, shows a loss of weight and some atrophy of leg muscles, especially on the left side. He is clear mentally. Pupils respond sluggishly to light and accommodation. Tongue has slight fibrillary tre mor. Motor power generally impaired. Rhombreg sign marked. Ataxia well developed. Intention tremor slight. Babin. ski and Oppenheim's signs positive. All tendon reflexes increased. Abdominal and skin reflexes absent. Cremasteric reflexes sluggish. Tactile sense normal. Lymphocytes, uncentrifuged specimen, 70 to cu. mm. Wasserman reaction negative. Noguchi butyric acid reaction prompt and positive. Nonne-Aplet test prompt, clouding and curding. Luetin test mildly positive.

Differential Diagnosis.-1. From hereditary spastic paraplegia, by lack of history, by ataxia, sphincter and cerebral symptoms. 2. Combined scleroses by vagueness of entity.

3. Diffuse myelitis, by the symptoms referable to the brain.

4. Tabes dorsalis, lack of Argyll-Robertson pupil, by increase of deep reflexes, lack of optic atrophy and crises.

5. Paralytic dementia, lack of characteristic mental disturbances as changes in character, delusions of grandeur, cerebrospinal fluid findings against.

6. Multiple Sclerosis. Of extreme difficulty to differentiate. Against it is age of patient, 52, and the definite history of lues. For such a diagnosis is a mild, not classical intention tremor, a speech defect, hardly scanning, hystagmoid movements with vertigo, spastic weakness, sphincter involvement and lost abdominal reflexes.

Diagnosis. Late cerebrospinal lues, para-specific in type; on history of lues, cerebrospinal fluid findings and reflexes so often found in late specific lesions of the spinal cord; the multiplicity of symptoms and the regions involved; spinal cord, lateral columns, particularly pyramidal tracts, but not the anterior horn cells. The brain changes limited to base, may be meningeal or nuclear changes.

(b) Pathological report, Dr. Skoog.

(Dr. Skoog read notes on pathological specimens from two patients. Then Dr. Skoog showed slides projected.)

DISCUSSION.

S. GROVER BURNETT: There is not much to add to Dr. Skoog's definite, detailed clinical findings, leaving little mystery as to the diagnosis, notwithstanding a negative Wasserman. A negative Wasserman does not exclude syphilis but it does support the doctors contention of a para-specific classi

fication. A positive Wasserman is not only sugges-
tive of syphilis by itself but is suggestive of a slight
activity.
or a considerable degree of a continued syphilitic

Again the high lymphocytosis linked to the clinical history is significant; in this relationship it points to a specific or para-specific pathology. The essayist's statement of the lateral pyramidal tracts being the seat of the lesion is true only in part in as much as his further clinical descriptives indicate even more damage to the ingoing or sensory route. This would indicate a previous or present spinal cord syphilis, leading again to Dr. Skoog's question as to whether we now have a para-specific condition; I think we have.

DR. MILLER: Another point. The Wasserman both in the cerebro-spinal fluid and in the blood was negative, while the Nouguchi test was positive, showing these cases of late syphilis can be detected by the Nouguchi and butyric acid tests; they being of more value than the Wasserman in either blood or spinal fluid.

DR. SOPHIAN: If I may be permitted, I should like to call attention to the cerebro-spinal fluid in, these cases referred to. A lymphocytosis in these cases is not diagnostic of syphilis, because lymphocytosis is commonly seen in other types or conditions. First, tubercular meningitis often shown up to 99 per cent lymphocytes. Another common condition is infantile paralysis, making as high a differential count practically as tubercular meningitis. The other type is syphilis of the central nervous system. A point to bear in mind is that lymphocy tosis is not diagnostic, but only suggestive.

Nouguchi's test referred to also is simply significant of an increased proteid element, which simply means an inflammation in the central nervous system, so I think the only positive examination of the fluid present in syphilis of the central nervous system, not present in other conditions, is the positive Wasserman. The Wasserman in these cases is often negative, but a positive Wasserman is more than suggestive and means something. Increased proteid content only, is what the other tests show. They are not of absolute diagnostic significance. I saw a case several years ago where diagnosis of inpeared. One of the earliest diagnoses was made by fantile paralysis was made before the paralysis apDr. Flexner. Paralysis appeared later, and Dr. Flexner had already predicted infantile paralysis. He found positive Nouguchi test, high lymphocytosis, the inflammation coming on with general constitutional symptoms. With fever and high lymphocytosis, one is warranted in suspicioning infantile paralysis. I saw a case, with acute onset, and with the same picture in the spinal fluid, and I made the diagnosis before the paralysis appeared. In the cases of syphilis of the central nervous system, the Wasserman is necessary it seems to me to make a positive diagnosis.

DR. LYLE: Notwithstanding the results of these tests in diagnosis, their reliability, etc., I would like to ask what are we to do with these cases? One we see treated with 606 may make a recovery, another, treated with mercury makes a recovery, while in other cases, both fail. What are we to go by? What is the general practitioner going to do? Are we to use the arsenical preparation to treat these. or should we use the old mercury treatment, and hope for results? These are some of the things I would like to be enlightened on.

DR. SKOOG (closing): I did not rely on any of these things as diagnostic. We have to consider every factor, and that is what I tried to do here. I am cognizant of the fact that we have lymphocytosis

in other things than syphilis of the nervous system. For instance in infantile paralysis before paralysis appears, in tuberculosis and I had one case of multiple sclerosis with active lymphocytosis.

I have classified this man as a para-syphilitic. While we so classify tabes and paretics it is a question of whether we have a right to do it here, or is this a plain case of syphilis. Some rely too much, I think on 606 for these cases. This patient has never had 606. He is better today than six to eight weeks ago. He received mercury, and is now on an iodid preparation.

SOME CHILDLESS WIVES.

SECOND PAPER.

G. HENRI BOGART, M. D., Paris, Ill. Barrenness was once woman's most dreadful fate, back in those days when "Go ye forth and replenish the earth" was spoken, and thence to the pioneer days when the family greeting to the bride and groom, as they turned from the altar was "May you live long, prosper, and have big babies." And the big babies were an elemental part of the prosperity, for each boy and girl was a valuable asset in the earlier days of the pioneer. It was a disgrace, or at least a misfortune, not to have children. But the old order changeth, and instead of a dozen or more olive branches the family of one and two became more frequent than greater numbers.

At the same time the long rows of tiny tombstones in family burial lots are no longer common.

Prevention of pregnancy became more common and by the crudest methods. Va ginas were tanned into leather by astringent douches and washes. Fallopian section as a preparation for marriage was resorted to. It was to this illicit operation, indeed, that the world is indebted for the boon of sterilization by vasectomy.

Thus was repeated the truth of that age old truism told in Samson's riddle, "Out of the eater came forth meat, but of the strong came forth sweetness." Some of these women have later come to know the holy desire for maternity, and have come begging oh, so piteously that the severed tubes be reunited, but I have never known the operation successfully performed, either in the male or the female.

There are some of these women who had contracted loveless marriages, mere sexual partnerships for reasons of finance, social position, or other conventional cause, who have later developed love and affection strong as their nature will admit. These women, invariably desire to bear a child for the husband who later became a lover.

The relation between love and sexual desire is dual and in its better phase is little understood. Sexual desire does lead to attachments between man and woman. On the other hand, love for a man instinctively prompts a normal woman to wish to mother his child.

From all this generalization I desire to report a case of an entirely different kind, one in which the woman desired motherhood for financial reasons. After correspondence I met her at a hotel in Indianapolis. She had written for me to meet her at a certain date, in her home city, but had fixed a time when I would be in attendance on a convention, and I so wrote her. The morning of the convention, I had not been in the lobby of the hotel where our association foregathered, for fifteen minutes until I was paged out. She was in the city, waiting me at another hotel. Angered, I sent her messenger back with a note making an appoinment for 8:30 in the evening. My cavalier treatment resulted partly from resentment that she had presumed to come on for consultation regardless of my convenience, and partly because of disgust for her mercenary reasons for desiring maternity.

A childless uncle wished to make her husband his heir, provided there were children to perpetuate the family, otherwise another nephew was to inherit it. She was anxious that the money should come to her husband. When I came to her room. I found her a magnificent jewess married at sixteen and now thirty. She had brought written reports from examinations of both herself and her husband.

A careful reading of these reports convinced me that neither partner should be sterile.

For a long time I talked with her hoping to stumble on to a solution. Finally I learned that orgasm occurred much more quickly and forcibly with her than with the husband. This, with a sharply acid reaction of the vaginal secretions offered a pos sible answer. At orgasm the uterus after its usual suction action, would close firmly and exclude the semen ejaculated later, while the acid secretions would kill the spermatozoa, before admission to the uterus was possible.

I explained this to her and advised that she procure a bivalve speculum and a long smooth syringe. Before coition thoroughly cleanse the vagina with borax solution. Then after intercourse the speculum was to be introduced, the semen taken up in the syringe then injected into the uterus. I insisted upon the speculum, and also that in the first instance the husband should have