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The Shape of Things
Presidential Address
The Shape of Things DAVID N. DANFORTH, Ph.D., M.D.
I
to express my grateful appreciation for the honor done me by my election to the presidency of this distinguished society. Certainly one's first reaction to this office, and it is an abiding one, is that he is at once both intensely pleased and awed by his new responsibility. After the initial uncertainties are arranged in their proper perspective, one settles down to the ordinary work of the society, which, in the case of most medical organizations requires great personal effort, heavy correspondence, and the making of many important decisions. Happily we are blessed with a secretary who has for the past 12 years devoted his great talents and enormous energies to the service of our society. It is not possible for me to outline the countless ways in which our continuity and strength have been secured through the devotion and effort of Dr. Herbert Thomas. Accordingly, although there are indeed a few details that remain, a major concern of the president is the preparation of the remarks that are referred to as "The Presidental Address." This is something of a responsibility, but it is also a great privilege, since by precedent the president may talk about almost anything he chooses. He may speak of the past, the present, or the future. He may disapprove of the profession at large (the present company of course being excepted) or he may prophesy, or he may merely take stock. Perhaps I shall do all of these in the time allotted me. But remember that this rare privilege is given to a president only once, never to return again. This particular occasion marks the conclusion of the scientific sessions of our twentieth annual meeting. To some of us the span of 20 years seems an increasingly short time. But many things have happened, not only around us but also within the structure of our society. Within this time, the jet plane, the atomic age, the cold war, and the PILL have all come upon us. WISH FIRST
From the Department of Obstetrics and Gynecology, Northwestern University Medical School, Chicago, and The Evanston Hospital Association, Evanston, Ill. Presidential address, 20th Annual Meeting of the American Society for the Study of Sterility, Miami Beach, Fla., May 17, 1964.
471
472
DANFORTH
FERTILITY
& STERILITY
The first annual meeting of the Society was held June 12 and 13, 1944, at the Morrison Hotel in Chicago. Twenty-one of the 30 charter members were present, and the meeting took the form of round-tables organized not according to modem concepts of the round-table but rather as free discussion groups. The first of these discussions was on general infertility problems and was under the chairmanship of Dr. Abner Weisman of New York. The discussion was lively and had to do with such problems as the cervical and vaginal factors in infertility, psychosomatic effects, sperm reactions to cervical mucus, and the pros and cons of artificial insemination. Dr. Weiss made several interesting comments regarding the effect of Rh incompatibility, suggesting the need for investigation of the influence of both Rh and blood-group incompatibilities on infertility. Specific reference was made to ABO incompatibility, which now arouses much interest in connection with planned conception. The second symposium, on ovulation timing, was under the chairmanship of Dr. John Haman. Dr. Haman presented a short but nevertheless inclusive paper on the means then available for detecting ovulation. He reviewed the work of Rubinstein and expressed his belief that basal body temperatures will in fact indicate the approximate time of ovulation. He commented that "the methods most adaptable to the average physician and patient are basal body temperatures, endometrial biopsies, vaginal smears, and changes in the cervical mucus." This is of special interest, since the last 20 years have turned up little else that is of general use. Considerable discussion of each of these methods followed. One point, on which there appeared to be no agreement, was the proper timing of the endometrial biopsy. Some believed that it should be done prior to the onset of bleeding in order to avoid the dehydration and thinning that may cause difficulty in interpreting the histologic picture; others preferred to do the test after the onset of menstruation lest a new pregnancy be interrupted. Dr. Lyman Mason was a strong supporter of the second group, and 1 suspect that his comment may give us some insight into one of the ways in which medicine has changed. Said Dr. Mason, "I have had my patients call me practically at any hour of the day or night so that I can get these biopsies within an hour after the onset of bleeding." How many of us would welcome a 2 A.M. telephone call announcing the onset of a menstrual period? The final symposium, under the chairmanship of Dr. Fred A. Simmons, concerned semen examination and evaluation. There was much discussion of the manner of collection and the morphology of the sperm and also a most interesting evaluation of the effects of hormones on sperm production. The emphasis at this session was on the effort to improve the quality of the semen. The term "population explosion" had not been coined, and our preoccupation with artificially ruining a perfectly normal sperm count was for the future. The following charter members comprised the American Society for the Study of Sterility in 1944:
VOL.
15, No.5, 1964 ACTIVE
Abarbanel, A. R. Dabney, M. Y. Davis, M. Edward Dickinson, R. L. Douglas, Gilbert F. Durfee, H. A. Greenhill, J. P. Haman, John O. Hamblen, E. C. Lawrence, Charles H.
473
SHAPE OF THINGS
Mason, Lyman Mazer, Charles Meigs, Joe V. Michelson, Lewis Robertson, Edwin M. Rock, John Rubin, I. C. Shute, Evan Simmons, Fred Stein, Irving F. Tompkins, Pendleton Weinstein, B. B.
Weisman, Abner I. Williams, Walter W. Ziegler, Floyd H. ASSOCIATE
Beacham, W. D. Johnson, C. Gordon MacLeod, John Pollak, O. J. HONORARY
Papanicolaou, George N.
I have spoken with several who attended this first meeting. Although it is clear that the experience was a thrilling one, nevertheless there was a question as to how long the Society would survive and, if it did, what proportions it would take or what influence it might exert. Its first name, The Society for Study of Human Sterility, was changed to the present name in 1946. Not only did the Society survive, but we have in fact experienced our own version of the population explosion. The following table shows that, during the span of 20 years, our total membership has increased more than sixtyfold: Year
:ftfembers
Year
:ftfembers
Year
Members
1944 1951 1952 1953 1954
30 150 236 379 425
1955 19.56 1957 1958 1959
500 686 775 840 893
1960 1961 1962 1963 1964
989 1006 1082 1624 1951
The Society's official journal, FERTILITY AND STERILITY, was started in 1950, and this too has shown progressive growth. In 1958 there were 3,400 subscriptions, and in 1963, 5 years later, there were 4500 subscriptions. This journal, under the distinguished editorship of Dr. M. Edward Davis, has now established itself as one of the leading journals of its type in the world literature of obstetrics and gynecology. We may now inquire what, in addition to extraordinary growth and the publication of an outstanding journal, we have accomplished. At the outset, it should be recognized that our society is in fact unique, not only by reason of its size but also of its membership. The only qualification for membership that we have imposed is that the applicant be ethically engaged in professional work that is related directly or indirectly to the field of fertility and infertility. Last year among our members were 98 urolog-ists, 45 whose interest is pure research in reproduction, and 2 doctors of veterinary medicine. Only 64 of our members limited their work to fertility and infertility. All the rest are listed as gynecologists, obstetricians, or both. Each of the minority groups has much to contribute to our total knowledge of reproduc-
474
DANFORTH
FERTILITY
&
STERILITY
tion, and it has been in an effort to establish this broad base for discussion that all individuals in allied fields have been welcomed. Through the years we have provided for our membership an organized meeting of extraordinary quality and an important journal whose purpose has been to disseminate the newer knowledge that relates to our particular field of interest. We have assisted in the establishment of proper standards for the diagnosis and study of infertility and we have been effective in publicizing them; what a pity they are not followed more generally. How frequently do we see an infertile couple who have carefully followed the physician's orders by collecting dozens of sheets of basal body temperatures, and whose only work-up was an inconclusive Rubin test or salpingogram? At the opposite extreme, not long ago I saw an infertility patient who had visited her gynecologist, by actual count, 40 times during the course of 1 year. One may speculate what the doctor could possibly have found to do at all of these visits. Be this as it may, the case illustrates the desperation of these patients and the unique cooperation that can be wrenched from them. We must continue our efforts to publicize the minimal standards for infertility evaluation, and the work-up must be within reach of the average practitioner. The need for simplicity is emphasized by the fact that within our own organization are listed only 64 physicians whose work is limited to infertility. Hence, our standards, the country over, must be designed to produce the basic information in the shortest reasonable time. Also, the couple should understand at the outset the nature of the information that is needed and should be told that the study is to have a definite beginning and a definite end. If no pregnancy occurs within 6 months after the study is concluded, and no treatable abnormalities have been found, adoption should be discussed. We still have much to contribute by repeatedly stressing these principles. In addition to our meetings, our Journal, and certain standards, the Society has sponsored certain awards for outstanding work in our field of interest. The first of these, the Rubin Award, was established by a generous donation in recognition of our distinguished member's classic contributions to the study of infertility. In addition the generous awards of the Ortho Research Foundation and of the Ayerst Laboratories have done much not only in the recognition of accomplished work, but in stimulating new work. We have accomplished much and contributed much, and have taken our place among the established societies of our discipline. As we have matured, we have also gained in strength. And we have assumed increasing responsibilities on the world scene of fertility and infertility. Is it now proper merely for us to congratulate ourselves, or must we at once take steps to avoid the senility which so often follows upon maturity? Certainly we have outgrown many of the technics that were so effective in holding our Society together in past years, and much thought has been given to our organizational plan and to promoting the continuity of office of those responsible
VOL.
15,No.5,1964
SHAPE OF THINGS
475
for carrying out the Society's objectives. In any society, the secretary is of transcendent importance, since his relatively long tenure is the only real bridge in the affairs of the society. When one realizes that we are not only the largest of the subspecialty groups but are indeed, except for the College, the largest of any obstetric or gynecologic society in the United States, it requires little imagination to recognize the magnitude of the task of organizing a meeting such as we are about to conclude or the burden this has imposed on one individual. To be sure, all this is not a personal task, since the committees have worked assiduously throughout the year, and credit is due many individuals. The new office of executive secretary (which in my view should be a salaried position) will relieve the secretary of the larger detail of the mailings, the mechanics of the annual meeting, certain facets of the program, and other matters of routine detail that can best be handled from the larger office. The secretary will concern himself exclusively with the parliamentary business of the society. By these changes, and the other new amendments to the bylaws, we are assured of a modern organization that will be effective for the present and the immediate future. If we continue to grow, as we surely will, new adjustments may be necessary. As to our size, the suggestion has been made that our membership should henceforth be limited. I believe this would be an error. On the contrary, in my view greater effort should be made to enlarge our numbers among those disciplines that touch upon, but are not directly a part of, our major field of interest. I refer here principally to the basic sciences, especially reproductive physiology, and to veterinary medicine. Individuals in these and allied groups have much to contribute to our knowledge, and in addition to the programs themselves, the opportunity for all interested workers to visit informally once each year is of inestimable value. At a meeting such as this I have heard it said that one learns as much in the corridors between sessions as in the meeting hall. It would be unfortunate to exclude any who have a genuine interest in anyone of the many facets of our field. With regard to our activity on the scientific scene, I have already detailed the matters that were discussed by the men whose vision established our Society at the time of their first meeting. At that time, our main preoccupation was with occluded tubes, failure of ovulation, the influence of anatomic variations, the effect of thyroid extract or stimulating doses of X-ray to ovary, and the like, as they are concerned in fertility and infertility. How similar in some ways to the subjects we still debate, except that we have achieved an increasing awareness that the field of our particular interest runs the whole gamut of physiology. In addition, our interests have now extended from the simple management and evaluation of infertility to its artificial inducement. We still recognize our primary responsibility to the infertile couple, but we also are causing perfectly normal individuals to become infertile. In recent years the laboratories and, interestingly enough, most particularly the commercial laboratories, have presented us with prep-
476
DANFORTH
FERTILITY & STERILITY
arations of enormous potency and great clinical value both for the production of ovulation and for its prevention. In the latter area it is estimated that perhaps 3 million women are using these substances to prevent conception. Many studies have attested to their effectiveness, and they are sometimes referred to as an important answer to the population explosion. The Food and Drug Administration has approved their use for up to 4 years. But what do we actually know of these drugs except for their direct effect on the reproductive system? We have not quite nailed down their actual relation to thromboembolic disease. Comments have been made to the effect that liver function may be affected. Results of tests for thyroid function are uniformly altered by them. Certain direct vascular effects have been reported. Although their effect on breast tumors has not been specifically outlined, I am told that despite their high estrogen content, they are sometimes prescribed without preliminary examination of the breasts or pelvis and that continuing prescriptions are written for up to 4 years' use without the requirement of interim examinations. The recent thalidomide tragedy may be a case in point, since it demonstrated so neatly that a drug may have effects in addition to those that were originally intended. It is curious that our horror over this disaster has given way to a certain indifference and that we continue to prescribe drugs of enormous potency without exact knowledge of their possible secondary effects. As our knowledge of the newer progestins increases, we find an increasing number of ways in which their effects resemble those of pregnancy. It is argued that pregnancy is a fine state indeed, perfectly physiologic, and is to be encouraged. But what exactly are the effects of these preparations, and how long do they last? And would a pregnancy have desirable effects if it were to last for 4 years? If this address could be said to contain a message, it must take the form of a plea for caution in the use of new and wonderfully potent preparations that have such apparently desirable effects on the reproductive apparatus. Penetrating inquiry must be made into their exact effects on all systems, and answers must be provided to the question whether all the effects are reversible, and if so, how promptly. When this is done, it may turn out that we have in fact found a reasonable answer to one aspect of the population explosion. But our full acceutance of drugs that are to be prescribed for perfectly normal people with the view to setting up a derangement of function, however small, must beheld in abeyance until we have full knowledge of their entire action. In conclusion, I wish again to express my grateful thanks for the privile2:e of serving the society as president during this past year, and to predict for the society over the course of the next 20 years even greater growth, stature, and success. Evanston Hospital Association 2050 Ridge Ave. Evanston, Ill.
The Shape of Things DAVID N. DANFORTH, Ph.D., M.D.
I
to express my grateful appreciation for the honor done me by my election to the presidency of this distinguished society. Certainly one's first reaction to this office, and it is an abiding one, is that he is at once both intensely pleased and awed by his new responsibility. After the initial uncertainties are arranged in their proper perspective, one settles down to the ordinary work of the society, which, in the case of most medical organizations requires great personal effort, heavy correspondence, and the making of many important decisions. Happily we are blessed with a secretary who has for the past 12 years devoted his great talents and enormous energies to the service of our society. It is not possible for me to outline the countless ways in which our continuity and strength have been secured through the devotion and effort of Dr. Herbert Thomas. Accordingly, although there are indeed a few details that remain, a major concern of the president is the preparation of the remarks that are referred to as "The Presidental Address." This is something of a responsibility, but it is also a great privilege, since by precedent the president may talk about almost anything he chooses. He may speak of the past, the present, or the future. He may disapprove of the profession at large (the present company of course being excepted) or he may prophesy, or he may merely take stock. Perhaps I shall do all of these in the time allotted me. But remember that this rare privilege is given to a president only once, never to return again. This particular occasion marks the conclusion of the scientific sessions of our twentieth annual meeting. To some of us the span of 20 years seems an increasingly short time. But many things have happened, not only around us but also within the structure of our society. Within this time, the jet plane, the atomic age, the cold war, and the PILL have all come upon us. WISH FIRST
From the Department of Obstetrics and Gynecology, Northwestern University Medical School, Chicago, and The Evanston Hospital Association, Evanston, Ill. Presidential address, 20th Annual Meeting of the American Society for the Study of Sterility, Miami Beach, Fla., May 17, 1964.
471
472
DANFORTH
FERTILITY
& STERILITY
The first annual meeting of the Society was held June 12 and 13, 1944, at the Morrison Hotel in Chicago. Twenty-one of the 30 charter members were present, and the meeting took the form of round-tables organized not according to modem concepts of the round-table but rather as free discussion groups. The first of these discussions was on general infertility problems and was under the chairmanship of Dr. Abner Weisman of New York. The discussion was lively and had to do with such problems as the cervical and vaginal factors in infertility, psychosomatic effects, sperm reactions to cervical mucus, and the pros and cons of artificial insemination. Dr. Weiss made several interesting comments regarding the effect of Rh incompatibility, suggesting the need for investigation of the influence of both Rh and blood-group incompatibilities on infertility. Specific reference was made to ABO incompatibility, which now arouses much interest in connection with planned conception. The second symposium, on ovulation timing, was under the chairmanship of Dr. John Haman. Dr. Haman presented a short but nevertheless inclusive paper on the means then available for detecting ovulation. He reviewed the work of Rubinstein and expressed his belief that basal body temperatures will in fact indicate the approximate time of ovulation. He commented that "the methods most adaptable to the average physician and patient are basal body temperatures, endometrial biopsies, vaginal smears, and changes in the cervical mucus." This is of special interest, since the last 20 years have turned up little else that is of general use. Considerable discussion of each of these methods followed. One point, on which there appeared to be no agreement, was the proper timing of the endometrial biopsy. Some believed that it should be done prior to the onset of bleeding in order to avoid the dehydration and thinning that may cause difficulty in interpreting the histologic picture; others preferred to do the test after the onset of menstruation lest a new pregnancy be interrupted. Dr. Lyman Mason was a strong supporter of the second group, and 1 suspect that his comment may give us some insight into one of the ways in which medicine has changed. Said Dr. Mason, "I have had my patients call me practically at any hour of the day or night so that I can get these biopsies within an hour after the onset of bleeding." How many of us would welcome a 2 A.M. telephone call announcing the onset of a menstrual period? The final symposium, under the chairmanship of Dr. Fred A. Simmons, concerned semen examination and evaluation. There was much discussion of the manner of collection and the morphology of the sperm and also a most interesting evaluation of the effects of hormones on sperm production. The emphasis at this session was on the effort to improve the quality of the semen. The term "population explosion" had not been coined, and our preoccupation with artificially ruining a perfectly normal sperm count was for the future. The following charter members comprised the American Society for the Study of Sterility in 1944:
VOL.
15, No.5, 1964 ACTIVE
Abarbanel, A. R. Dabney, M. Y. Davis, M. Edward Dickinson, R. L. Douglas, Gilbert F. Durfee, H. A. Greenhill, J. P. Haman, John O. Hamblen, E. C. Lawrence, Charles H.
473
SHAPE OF THINGS
Mason, Lyman Mazer, Charles Meigs, Joe V. Michelson, Lewis Robertson, Edwin M. Rock, John Rubin, I. C. Shute, Evan Simmons, Fred Stein, Irving F. Tompkins, Pendleton Weinstein, B. B.
Weisman, Abner I. Williams, Walter W. Ziegler, Floyd H. ASSOCIATE
Beacham, W. D. Johnson, C. Gordon MacLeod, John Pollak, O. J. HONORARY
Papanicolaou, George N.
I have spoken with several who attended this first meeting. Although it is clear that the experience was a thrilling one, nevertheless there was a question as to how long the Society would survive and, if it did, what proportions it would take or what influence it might exert. Its first name, The Society for Study of Human Sterility, was changed to the present name in 1946. Not only did the Society survive, but we have in fact experienced our own version of the population explosion. The following table shows that, during the span of 20 years, our total membership has increased more than sixtyfold: Year
:ftfembers
Year
:ftfembers
Year
Members
1944 1951 1952 1953 1954
30 150 236 379 425
1955 19.56 1957 1958 1959
500 686 775 840 893
1960 1961 1962 1963 1964
989 1006 1082 1624 1951
The Society's official journal, FERTILITY AND STERILITY, was started in 1950, and this too has shown progressive growth. In 1958 there were 3,400 subscriptions, and in 1963, 5 years later, there were 4500 subscriptions. This journal, under the distinguished editorship of Dr. M. Edward Davis, has now established itself as one of the leading journals of its type in the world literature of obstetrics and gynecology. We may now inquire what, in addition to extraordinary growth and the publication of an outstanding journal, we have accomplished. At the outset, it should be recognized that our society is in fact unique, not only by reason of its size but also of its membership. The only qualification for membership that we have imposed is that the applicant be ethically engaged in professional work that is related directly or indirectly to the field of fertility and infertility. Last year among our members were 98 urolog-ists, 45 whose interest is pure research in reproduction, and 2 doctors of veterinary medicine. Only 64 of our members limited their work to fertility and infertility. All the rest are listed as gynecologists, obstetricians, or both. Each of the minority groups has much to contribute to our total knowledge of reproduc-
474
DANFORTH
FERTILITY
&
STERILITY
tion, and it has been in an effort to establish this broad base for discussion that all individuals in allied fields have been welcomed. Through the years we have provided for our membership an organized meeting of extraordinary quality and an important journal whose purpose has been to disseminate the newer knowledge that relates to our particular field of interest. We have assisted in the establishment of proper standards for the diagnosis and study of infertility and we have been effective in publicizing them; what a pity they are not followed more generally. How frequently do we see an infertile couple who have carefully followed the physician's orders by collecting dozens of sheets of basal body temperatures, and whose only work-up was an inconclusive Rubin test or salpingogram? At the opposite extreme, not long ago I saw an infertility patient who had visited her gynecologist, by actual count, 40 times during the course of 1 year. One may speculate what the doctor could possibly have found to do at all of these visits. Be this as it may, the case illustrates the desperation of these patients and the unique cooperation that can be wrenched from them. We must continue our efforts to publicize the minimal standards for infertility evaluation, and the work-up must be within reach of the average practitioner. The need for simplicity is emphasized by the fact that within our own organization are listed only 64 physicians whose work is limited to infertility. Hence, our standards, the country over, must be designed to produce the basic information in the shortest reasonable time. Also, the couple should understand at the outset the nature of the information that is needed and should be told that the study is to have a definite beginning and a definite end. If no pregnancy occurs within 6 months after the study is concluded, and no treatable abnormalities have been found, adoption should be discussed. We still have much to contribute by repeatedly stressing these principles. In addition to our meetings, our Journal, and certain standards, the Society has sponsored certain awards for outstanding work in our field of interest. The first of these, the Rubin Award, was established by a generous donation in recognition of our distinguished member's classic contributions to the study of infertility. In addition the generous awards of the Ortho Research Foundation and of the Ayerst Laboratories have done much not only in the recognition of accomplished work, but in stimulating new work. We have accomplished much and contributed much, and have taken our place among the established societies of our discipline. As we have matured, we have also gained in strength. And we have assumed increasing responsibilities on the world scene of fertility and infertility. Is it now proper merely for us to congratulate ourselves, or must we at once take steps to avoid the senility which so often follows upon maturity? Certainly we have outgrown many of the technics that were so effective in holding our Society together in past years, and much thought has been given to our organizational plan and to promoting the continuity of office of those responsible
VOL.
15,No.5,1964
SHAPE OF THINGS
475
for carrying out the Society's objectives. In any society, the secretary is of transcendent importance, since his relatively long tenure is the only real bridge in the affairs of the society. When one realizes that we are not only the largest of the subspecialty groups but are indeed, except for the College, the largest of any obstetric or gynecologic society in the United States, it requires little imagination to recognize the magnitude of the task of organizing a meeting such as we are about to conclude or the burden this has imposed on one individual. To be sure, all this is not a personal task, since the committees have worked assiduously throughout the year, and credit is due many individuals. The new office of executive secretary (which in my view should be a salaried position) will relieve the secretary of the larger detail of the mailings, the mechanics of the annual meeting, certain facets of the program, and other matters of routine detail that can best be handled from the larger office. The secretary will concern himself exclusively with the parliamentary business of the society. By these changes, and the other new amendments to the bylaws, we are assured of a modern organization that will be effective for the present and the immediate future. If we continue to grow, as we surely will, new adjustments may be necessary. As to our size, the suggestion has been made that our membership should henceforth be limited. I believe this would be an error. On the contrary, in my view greater effort should be made to enlarge our numbers among those disciplines that touch upon, but are not directly a part of, our major field of interest. I refer here principally to the basic sciences, especially reproductive physiology, and to veterinary medicine. Individuals in these and allied groups have much to contribute to our knowledge, and in addition to the programs themselves, the opportunity for all interested workers to visit informally once each year is of inestimable value. At a meeting such as this I have heard it said that one learns as much in the corridors between sessions as in the meeting hall. It would be unfortunate to exclude any who have a genuine interest in anyone of the many facets of our field. With regard to our activity on the scientific scene, I have already detailed the matters that were discussed by the men whose vision established our Society at the time of their first meeting. At that time, our main preoccupation was with occluded tubes, failure of ovulation, the influence of anatomic variations, the effect of thyroid extract or stimulating doses of X-ray to ovary, and the like, as they are concerned in fertility and infertility. How similar in some ways to the subjects we still debate, except that we have achieved an increasing awareness that the field of our particular interest runs the whole gamut of physiology. In addition, our interests have now extended from the simple management and evaluation of infertility to its artificial inducement. We still recognize our primary responsibility to the infertile couple, but we also are causing perfectly normal individuals to become infertile. In recent years the laboratories and, interestingly enough, most particularly the commercial laboratories, have presented us with prep-
476
DANFORTH
FERTILITY & STERILITY
arations of enormous potency and great clinical value both for the production of ovulation and for its prevention. In the latter area it is estimated that perhaps 3 million women are using these substances to prevent conception. Many studies have attested to their effectiveness, and they are sometimes referred to as an important answer to the population explosion. The Food and Drug Administration has approved their use for up to 4 years. But what do we actually know of these drugs except for their direct effect on the reproductive system? We have not quite nailed down their actual relation to thromboembolic disease. Comments have been made to the effect that liver function may be affected. Results of tests for thyroid function are uniformly altered by them. Certain direct vascular effects have been reported. Although their effect on breast tumors has not been specifically outlined, I am told that despite their high estrogen content, they are sometimes prescribed without preliminary examination of the breasts or pelvis and that continuing prescriptions are written for up to 4 years' use without the requirement of interim examinations. The recent thalidomide tragedy may be a case in point, since it demonstrated so neatly that a drug may have effects in addition to those that were originally intended. It is curious that our horror over this disaster has given way to a certain indifference and that we continue to prescribe drugs of enormous potency without exact knowledge of their possible secondary effects. As our knowledge of the newer progestins increases, we find an increasing number of ways in which their effects resemble those of pregnancy. It is argued that pregnancy is a fine state indeed, perfectly physiologic, and is to be encouraged. But what exactly are the effects of these preparations, and how long do they last? And would a pregnancy have desirable effects if it were to last for 4 years? If this address could be said to contain a message, it must take the form of a plea for caution in the use of new and wonderfully potent preparations that have such apparently desirable effects on the reproductive apparatus. Penetrating inquiry must be made into their exact effects on all systems, and answers must be provided to the question whether all the effects are reversible, and if so, how promptly. When this is done, it may turn out that we have in fact found a reasonable answer to one aspect of the population explosion. But our full acceutance of drugs that are to be prescribed for perfectly normal people with the view to setting up a derangement of function, however small, must beheld in abeyance until we have full knowledge of their entire action. In conclusion, I wish again to express my grateful thanks for the privile2:e of serving the society as president during this past year, and to predict for the society over the course of the next 20 years even greater growth, stature, and success. Evanston Hospital Association 2050 Ridge Ave. Evanston, Ill.