vent conception. The condition of the thyroid glands, and of the breasts, is important, since both a lack, or an increase of the secretions of these glands is found associated with sterility. Anemia must be eliminated as a possible etiological factor, since we all know that clorosis tends to prevent conception by causing marked menstrual disturbances. The examination of the pelvis is the most important, however, and for the sake of simplifying this part of the paper, I have arranged the pelvic pathology in separate groups, discussing both etiology and treatment of each group.

1. Malformations. Absolute sterility is found in those patients who lack either a uterus or the ovaries, or in whom the uterus is markedly deformed. Unfortunately, neither medicine nor surgery can help these unfortunate

women.

Relative sterility is caused by imperforate hymen, an absent vagina, an infantile uterus or an abnormally small opening in the cervix. The hymen may readily be opened, a vagina may be made from a loop of ilium, and the cervical canal dilated and kept open by the use of a stem pessary. The infantile uterus may be developed by the administration of thyroid, mammary and ovarian extracts, and the use of the galvanic current introduced by the means of uterine sounds. The treatment may take a year or more, but with persistent efforts the uterus will gradually become nearly normal jin size, and menstruation is re-established. General hygienic measures must be employed at the same time, and tonics of iron and arsenic prescribed.

2. Malpositions. Acute anteflexions are best treated by dilatation and the insertion of a stem pessary. The dilatation may be done forcibly, under a general anesthetic, or gradually by the use of the negative pole of the galvanic current transmitted through graduated uterine sounds passed into

the uterus well above the point of constriction. I prefer the gradual dilatation, necessitating from ten to twenty treatments, because it does not traumatize the muscle fibers and does not cause scar tissue formation with its subsequent contraction which tends to increase the flexion.

Retroversions and retroflexions, without the presence of inflammatory changes, in nulliparous women are best treated by a reposition of the uterus and the insertion of a properly fitting pessary. This pessary should be worn until the third month of pregnancy is passed to prevent a possible abortion as the result of an incarcerated uterus. In multipara, retroversions are usually associated with lacerations of the perineum. If the laceration is slight, a pessary may be used; if the tear is marked, the uterus will not remain in its normal position unless the perineum is first repaired. Where the relaxation following the lacation is very pronounced, a round ligament operation must be performed as well as a perineorrhaphy, in order to insure a permanent result.

It is well to remember that a leucorrheal discharge is always found associated with retroversions due to the improper drainage of the normal uterine secretions. This lack of proper drainage causes a chronic passive congestion of the uterus which is followed by a low-grade infection. After the uterus is replaced, local treatments must be instituted.

gonorrheal infection or follow as the result of a septic abortion or labor. If the gonorrheal infection is limited to the vagina and cervix, vigorous treatment by the application of silver or iodine, together with astringent douches, will cure the patient. Unfortunately, most of our cases come to us after the gonococcus has already invaded the uterus, and I seriously doubt whether any one can completely cure a case of this kind. My experience is that the tubes are infected sooner than is suspected, and that all these cases will sooner or later need an extensive laparotomy. Prophylaxis is the only sure cure for gonorrhea.

Septic abortions, if treated expectantly, will seldom cause sterility. It is the currette which is responsible for the extension of the infection into adjacent tissues, and the day is near when the simple currettage will be recognized as a major operation which few surgeons are going to perform. The high death rate reported year by year following septic abortions should be enough proof to convince even the most stubborn that the currette should no longer be used.

a

4. Tumors. Fibroids and ovarian cysts are the two most common types of tumors associated with sterility. The removal of sub-mucous fibroid is usually sufficient to insure a pregnancy in the near future. The sub-serous variety is followed by conception if the growth has not been of too many year's standing. Myomectomy for the intra-mural type, however, is seldom of any value, because the tumor has usually invaded the uterine mucosa and caused permanent changes. Personally. I refuse to remove a tumor of this type, since the mortality following myomectomy is higher than that following hysterectomy, and even if pregnancy occurred there would be danger of a ruptured uterus unless ja Caesarian section were performed at the onset of labor.

Dermoid cysts of the ovary, if unilateral, are removed and often followed by conception. The ordinary cystic ovaries do not cause sterility, and the puncture of the cysts, or the removal of parts of both ovaries, do not effect pregnancy in any way.

5. Chemical Changes. If the vaginal secretions are too highly acid, they will kill the spermatazoa before they reach the cervix. I believe that the pernicious habit of many women to take daily douches as a matter of cleanliness has much to do with the chemical changes of the normal secretions. To determine the hyper-acidity of the secretions, smears are taken from the cervix from one to six hours after coitus. If the secretions are normal, the spermatazoa will be found alive from twelve to twenty-four hours after coitus. The best treatment for this hyper-acidity consists in the use of weak sodium bicarbonate douches, together with the administration of alkalis and restrictions in diet.

In conclusion, let me say that the causitive factors producing sterility may not be discovered during a short office call. A diagnosis requires both time and patience. Husband and wife must both be subjected to complete physical and laboratory examinations. It is only after careful and deliberate study of a case of sterility in the female that a diagnosis can be made; an absolute diagnosis is positively essential before any therapeutic, particularly operative measures, are advised

If we, as doctors, can realize the seriousness of the condition, from the viewpoint of the patient-realize, that to a woman maternity means the culmination of all the dreams and hopes formulated from childhood, the time and energy expended in the gratification of these maternal instincts will be deemed well spent, both for the personal satisfaction it gives us as well as the reputation we gain in the community.

We must remember, too, that the birth of a baby has great importance besides merely satisfying the maternal instincts of an individual woman. To some races, as the Jews, a woman is practically an outcast if she remains barren after marriage. To the husband it means the continuation of his family name and the assurance of a happy married life. To society, it means the continuation and progress of the race. In view of all these facts, does it not behoove us, as physicians, to be more careful in our diagnoses, and more scientific in our treatment of these women?

Parke, Davis & Company's InfluenzaPneumonia Vaccine is prepared essentially in accordance with the original formula and method of Dr. Rosenow. It is administered in three injections, at intervals of six or seven days.

What about the treatment of influenza and influenzal pneumonia?

Physicians who employed Pneumonia Phylacogen last winter with the most striking results gave an initial injection of 16 minims immediately to every patient who came down with influenza. The second day the dose was increased to 32 minims, the third day to 48 minims, and so on until convalescence was established.

When pneumonia had already developed, 16 minims of Pneumonia Phylacogen was administered immediately. Twelve hours later 32 minims was injected, and the dose was gradually increased every twelve hours until the critical period had been passed.

Parke, Davis & Company, Detroit, will be pleased to send a copy of a new booklet, "Prophylaxis and Treatment of Influenza and Influenzal Pneumonia," to any physician requesting it.

CARBOLIC ACID TO BURN. Before the war, this country's consumption of phenol was about 9,000,000 pounds per year. The bulk of it came from England, and was obtained from coal tar distillates directly. A small part was synthetized from benzol. The general impression here is that this synthetic phenol was made in German plants, subsidized and kept in existence by the government for war purposes.

The production in the United States during the war continually increased. At the time of our entry into the struggle it amounted to 75,000,000 pounds per year, and, after that time, plants were erected so that, at the end, we had capacity to produce more than 150,000,000 pounds. Of this, not more than 2,000,000 pounds were obtained directly from coal-tar distillates by extraction with caustic soda.

At the present time, the consumption in this country is not much greater than 6,000,000 pounds per year, about equally divided between the drug and disinfectant, the dyestuff and the synthetic resin industries. This means that there was, at the time of the armistice, a sudden cessation of manufacture and use on a comparatively huge scale, and stocks on hand altogether out of proportion to the possibility of use in times of peace. In private and government hands today there are, at the very least, 30,000,000 pounds of phenol. The government wants to know what to do with it.

and Arizona.

1414 South Hope Street, Los Angeles, Cal.

PROHIBITION AND THE HOSPITALS.

*Dr. Carl Meyer, assistant warden of the Cook County Hospital, Chicago, which has a daily average of 1850 patients, says:

"Since prohibition went into effect there has been a marked decrease in our hospital population. We are running about 500 less than usual, our average at present being around 1300. We are getting very few accident cases, the former record of twenty-five to fifty on Saturday nights having been reduced to one or two. Alcoholics have been almost eliminated, and accidents due to this condition, as well as medical cases growing out of exposure, have been practically nil. In fact, the 'typical bum' who used to make up a large percentage of the hospital is rapidly becoming obsolete."

Dr. Arthur B. Ancker, superintendent of the St. Paul City and County Hospital of 800 beds says:

"It is of record here that there has been a very marked decrease in the number of acute alcoholics, as well as in the number of patients suffering

from other conditions due to alcoholism, since July 1st of this year.".. Dr. Chas. A. Drew, supt. of the City Hospital, Worcester, Mass., says:

"There has been a very great reduction in the number of alcoholics admitted, and there have also been fewer admissions to our public wards since prohibition went into effect.'' Dr. Drew also states that:

“The effect on our hospital has been more marked in regard to male employes. Prior to the coming of prohibition it was a common thing to discharge a man today for intoxication and hire him again day after tomorrow with an increase of salary. For the past four months we have had almost no trouble with the male help because of intoxication, and the number of alcoholics admitted has not been over 10 per cent of the average prior to the coming of prohibition.” *See hospital management.

PROSTITUTION.

A recent number of The Nineteenth Century in speaking of "America and the Social Evil" says:

There are many men and women in England today who, in spite of the findings of scientific experts such as Dr. Abraham Flexner and others, cling to the belief that the adoption of segregrated areas will remove many evils. Segregation of prostitutes, a method which has been so completely shown to be ineffective that it has not even a crutch to stand on, is often regarded as the best solution of the problem. People hesitate to express this belief publicly as in days gone by, yet as many still cherish it I do not hesitate to insert here the two sides of the question as it was stated and, widely circulated by the American government.

The Two Sides.

It is claimed that--
Segregation

1. Concentrates prostitution, thus facilitating control and reduction.

2. Decreases prostitution by regulation.

3. Decreases venereal diseases through medical inspection.

4. Enables control of the liquor traffic in connection with prostitution. 5. Prevents crimes against women. 6. Protects the community from offensive and detrimental proximity of prostitution.

7. Decreases graft in connection with prostitution, and the exploitation of the prostitute.

8. Decreases crime by enabling police supervision of a recognized crime

center.

9. Protects boys and young men from contact with the prostitute by removing temptation from the streets and residence districts.

The truth is that

Segregation

1. Increases prostitution, continually advertising vice by making it familiar. Affords a place of commerce, otherwise uncertain and precarious, to the least competent of prostitutes, mentally and physically.

2. Increases prostitution by increasing the demand, which increases the supply.

3. Increases venereal diseases by deceiving the ignorant into a fancied reliance upon a frequently "faked" and inevitably futile medical inspection.

4. Stimulates an illegal liquor traffic, since commercialized vice fails without liquor.

5. Tends to increase crimes against women by fostering promiscuity and providing a source of sexual brutalization and degeneracy.

6. Exposes the community by advertising vice as a community necessity, making it easily accessible and tolerated, a condition conducive to the moral degradation of the community.

7. Increases graft, by illegal toleration of commercialized vice, tempting the police to exact illegal revenue and confer illegal privilege. Gives free rein to the exploitation of prostitutes.

8. Increases crime by fostering viciousness and disease, providing a meeting place for the idle and vicious with whom the prostitutes sympathize and usually co-operate.

9. Exposes boys and young men to contact with the prostitute by presenting an ever-present opportunity to 'go down the line and see the sights.' Provides a showplace for special obscene and depraved exhibitions to which the youth is lured by "runners" and the sale of lewd pictures.

A conference on Social Hygiene was held in New York last October. It was attended by representatives from England, France, and Canada. It sat for two days, some 200 persons being present. A findings committee was appointed on which sat, amongst others, Dr. Abraham Flexner, Colonel Snow, M.P., of the American Social Hygienic Association, Dr. Exner, Captain Bates, of Canada, Madame Aveil de Sainte Croix, Dr. Katherine Davies, and the present writer. The findings committee unanimously accepted the follow