median line, which in our experience is very indefinite. Palpation is also of less importance and value for the diagnosis.

The percussion of the region of the stomach with short, sharp taps of the hammer, as described by Mendel, was sensitive only when there is an ulcer of the stomach or duodenum; in other diseases this mode of percussion does not cause pain.

In differentiating doubtful diseases of the stomach the X-ray is by far the most reliable aid at our disposal. Bier considers it of the greatest value in cases of hour-glass stomach and cancer of the stomach, especially, when there is a beginning stenosis of the pylorus; but in cases of duodenal ulcer the X-ray does not offer the same advantage for diagnosis. Many shadows in the X-ray plate have been designated and found to be duodenal ulcer; nevertheless, it has not yet been shown that they are really characteristic for this disease. In the opinion of Barcley an ulcer of the duodenum excites more frequent and stronger peristalsis of the stomach with a correspondingly more frequent opening of the pylorus and a consequent quicker propulsion of the stomach contents into the bowel. The tonus of the stomach is mostly increased.

Kreuzfuchs claims, that the emptying of the stomach is only increased during the first period after taking a meal. This increased and more frequent peristalsis of the stomach is a constant finding in duodenal ulcer, but loses its importance as a characteristic symptom, because it is also found in achylia, icterus caterhalis, pancreatic tumors, etc.

The bismuth spot remaining in the duodenum is a true sign of ulcer according to Moynihan and Barcley, when it can be demonstrated after the stomach contents have been discharged and that it is located in the most proximal part of the duodenum. The sacculation of the scar of the ulcer is claimed to be the cause of the bismuth shadow. In one of our cases this bismuth shadow was clearly shown in the X-ray picture, but upon opening the abdomen no ulcer of the duodenum could be demonstrated.

anamnesis, advises the most careful study of stenosis in the X-ray picture, as they are very deceiving.

Aside from the history, blood in the vomitus and stool and occult blood is a most important diagnostic sign. Occult blood in the stool together with Moynihan's anemnesis, makes the diagnosis positive. In doubtful cases repeated

and careful examinations for occult blood should be made, with the exclusion of blood from food and bleeding from mechanical irritation of other parts.

Most surgeons agree that the chemical analysis of the stomach secretions is of little diagnostic value.

Several errors in the differential diagnosis between ulcer of the stomach and duodenal ulcer had to be recorded, because we accepted the history as sufficient and the differentiation simple. The anamnesis alone may be easily misleading. The indication for operation in most cases is of greater importance than the differential diagnosis, and consequently, if a mistake is made in locating the ulcer in the organs, the same can be rectified at the time of the operation without any detriment to the patient. The operation is indicated in either case.

The differentiation between cholithiasis and ulcer of the duodenum may at times be difficult, but a carefully taken history will clear up the doubt. Care must be taken that a possible gallstone shadow in the X-ray picture is not mistaken for a bismuth spot on the ulcer.

Constipation is usually found associated with gastric and duodenal ulcer. In infections of the biliary tract and gall-stones there is usually no constipation.

Infections of the biliary tract are a center for the distribution of infection; such patients usually give a history to that effect. Ulcer of the duodenum and stomach are the end results of infection and the patient gives no history of infection. Ulcer of the stomach and duodenum is therefore not accompanied by headache, rise of temperature, infections of the joints, coated tongue, or any signs of sepsis, unless complications have occurred.

Icterus being absent may be differential. Many diseases of the biliary tract do not entail icterus, but its absence together with the other symptoms may be an aid in diagnosis.

Loss of weight in gastric and duodenal ulcer is due to starvation, either voluntary or forced, or by lack of assimilation.

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JOUR. M. S. M. S.

Duodenal ulcer symptoms are "clearcut."
Pain to the right of epigastrium.

Pain comes on one or two hours after meals and is relieved by taking food.

Gastric ulcer developing when a duodenal ulcer is present disguises the symptoms of duodenal ulcer.

Pain comes on immediately after eating and merges with the pain of duodenal ulcer that comes on one or two hours later. Prolonged pain may therefore be suggestive of the presence of duodenal and gastric ulcer at the same time. Vomiting or regurgitation may then disguise the duodenal ulcer. Constipation is prominent in both diseases.

Relief upon taking food in duodenal ulcer does not take place, if a gastric ulcer is present. The symptomatology of gastric ulcer covers the symptomatology of duodenal ulcer.

If a clear history of duodenal ulcer is given, that later gives place to symptoms of gastric ulcer, a diagnosis of both conditions can be made.

But if a gastric ulcer develops first and is followed by duodenal ulcer it is impossible to make a double diagnosis. The only possibility of discovering the presence of a duodenal ulcer would be an examination of the duodenal cap by X-ray.

The presence of a gastric and a duodenal ulcer in the same patient is common.

The differentiation between appendicitis and duodenal ulcer does not present any special

difficulties.

A gastro-enterostomy should not be performed, when there is no ulcer of the duodenum.

Stretching the duodenum gives an anemic white spot near the pylorus, as described by the Mayos, which must not be confounded with ulcer. In doubtful cases an incision transversely into the bowel or stomach may be warranted and an exploration made from the inside with the finger, if necessary inspected with the eye.

The author has come to the conclusion, that the diagnosis of duodenal ulcer sometimes presents many difficulties, and that a diagnostic fallacy may easily be the outcome, if all the aids of diagnosis are not employed to reinforce the diagnostic structure. Acute appendicitis usually is not a diagnostic engima. Nevertheless, this very simplicity has often been the scapegoat of error, because it gives the surgeon an unwarranted sense of positive assurance. Com

complicity and simplicity are not synonymous. On the surface all may seem serene and simple; where the eye and hand do not penetrate, conditions may be very complex. A rapid conclusion, based solely upon the history of the patient may easily cause the chagrined surgeon to blush with diagnostic embarrassment. The diagnosis of duodenal ulcer requires time and study.

WHEN IS STERILIZATION OF WOMEN JUSTIFIABLE?

REUBEN PETERSON, M.D.

ANN ARBOR, MICH.

It has long been an accepted rule of obstetrics that pregnancy may not be interrupted except on the ground that such interruption be necessary to save or prolong the life of the mother or to preserve the life of the fetus. Another rule is that pregnancy shall not be interrupted on the judgment of one physician alone, but, except where circumstances render this impossible, only after deliberate consultation with one or more physicians of recognized standing. Moreover, from the physician's standpoint there is no debatable time during pregnancy when these rules do not apply. Scientifically and practically the rights of the fetus are the same from the moment of conception to the hour when natural labor begins. A physician has no more right to empty the uterus after the skipping of one menstrual period than he has to interrupt pregnancy at a later date, the only difference being that his opinion as to when pregnancy shall be interrupted in the event of the mother's life being endangered may be influenced by the effect of such interruption upon the chances of the fetus for extrauterine existence. For instance, in a case of a woman with cardiac decompensation with small chances of the pregnancy continuing up to the point when the child would be viable, it would obviously be the part of wisdom immediately to empty the uterus in the interests of the mother if in a case of marked cardiac decompensation whose life is endangered. On the other hand, pregnancy has advanced to the sixth month, the physician naturally in the interests of the fetus soon to reach the age of viability will not be in favor of the immediate interruption of pregnancy if the mother's chances are not markedly diminished by such delay.

I trust I may be pardoned for setting forth these rather trite and generally accepted obstetric rules of procedure, but it seemed a necessary preliminary to the consideration of the question of the sterilization of women. Although there exists quite a literature on artificial sterilization, it must be acknowledged that the profession is not nearly as conversant with the rules governing this procedure as is the case with the artificial interruption of pregnancy. This is explainable on the ground that the interruption of pregnancy being a safer procedure has been performed since the beginning of obstetrics while artificial sterilization has only been safe and practicable since the advent of antiseptic and aseptic surgery.

Only those having to do with large public and private clinics have any realization of the number of women which for one reason or the other has been rendered incapable of reproduction. Much of this work has been performed for disease and is justifiable in that it restores the woman to health. It must be confessed, however, that in many cases the woman was sterilized through inexcusable errors of diagnosis and upon insufficient pathological grounds. It is not the purpose of this paper to deal with the class of cases where sterilization resulted from the removal of the diseased female organs of generation but to confine it to the indications for the artificial sterilization of women, either with or without a coincident operation, when the purpose of the procedure is to prevent future conception.

It will be at once apparent why the question of interruption of pregnancy is exceedingly

valuable to a consideration of the indications for the artificial sterilization of women, for both have grounds in common although they differ in other respects. Stated generally, bearing in mind the interests of the State, fetal life should not be destroyed or conception prevented except on the ground that the mother's life be endangered by the continuance of the pregnancy or by the advent of future conception. In other words, the same rules ought to govern both procedures with this difference; in pregnancy at all stages there is another life to be considered, such life to be sacrificed only to preserve the mother's, while in the other class of cases, sterilization is performed entirely in the interests of the woman, for only a possible future life need be considered.

The physician will be spared much if he agrees to the above statements and acts upon

these rules of procedure. The physician who is not firm in his refusal to interrupt pregnancy except to save or prolong the life of the mother, if he is even willing to discuss the justifiability of interruption in a given case on other grounds, is in a very disagreeable position to say the least. So many apparently good social and economic reasons why particular pregnancies should be ended can be advanced that the minute he makes this debatable ground, his troubles begin. In artificial sterilization this is even more true. The woman dreads to have a child or go through the ordeal of another pregnancy and labor; she has enough children and for social and economic reasons does not desire more; these and many other reasons are advanced and would be given far more frequently than is the case except for one thing. The laity are not as yet so well educated regarding artificial sterilization of women as they are along other physiologic and operative lines. Sterilization of women carries with it in the public mind the loss of the ovaries from which women shrink, since it means diminished or gradual loss of sexual desire. That this is true is demonstrated by the comparatively large number of cases where women refuse certain types of operations necessitating sterilization until they can be assured that their ovaries will not be removed and that tubal sterilization will not interfere with sexual desire or marital relations.

It will be necessary in any consideration of the indications for artificial sterilization to keep in mind two kinds of sterilization, which in lieu of better definitions may be spoken of as, 1. Primary Artificial Sterilization, 2. Incidental

Artificial Sterilization.

1. Primary Artificial Sterilization. Under this classification would come all cases where artificial sterilization is the primary end in view, the patient not being pregnant at the time, and the operation performed solely to prevent future conception.

2. Incidental Artificial Sterilization may be defined as sterilization performed during the course of another operation in the belief that the patient's life or well being would be seriously impaired by. future pregnancies.

Obviously, if artificial sterilization can only be performed on pathological grounds, for serious organic changes in the maternal organism, or because the past history of the individual has shown that pregnancy will bring about changes which will seriously threaten her life, primary sterilization will not often be performed. The

surgeon will hesitate to advise sterilization in the presence of organic disease which renders any kind of operation hazardous, for he will reason correctly that he is not justified in exposing his patient to certain risks in order to safeguard her against a possible additional danger by which she never will be menaced in case she does not become pregnant. For example, a woman with diabetes of a certain grade can never be subjected to operation without considerable risk. Artificial sterilization of such a woman would be subjecting her to certain risks. If the operation be not performed and pregnancy does occur, the latter can be interrupted with minimum risk to the patient. The same line of reasoning will apply to other organic diseases, the indications for primary sterilization depending upon the extent of the disease and the dangers of the operation in each individual case. However, it may be stated in a general way that this careful weighing of the indications and contraindications for primary sterilization is bound to narrow the field of this operative procedure. If the condition of the woman is such that pregnancy would be a serious additional menace to life, her condition would be such as not to warrant the performance of an operation to prevent something which may never occur.

In the second class of cases, incidental artificial sterilization, the situation is entirely different. Another operation must be performed for the safety or comfort of the patient. The puerperal history of the patient may show that her life would be seriously menaced or made so miserable as to be unendurable by another pregnancy. In such a case, since the additional operative risk of coincident tubal sterilization is practically nil and need not be considered, it is not only justifiable but it is the duty of the physician to consider the advisability of sterilization. For example, a woman with chronic nephritis in the child bearing period who must be operated upon for the removal of a pelvic or abdominal tumor should be sterilized as a part of the operative procedure if pregnancy would seriously jeopardize her life and if without sterilization her puerperal history is such as to warrant the assumption that she will become pregnant.

It is important to study each case carefully in order to decide wisely whether or not to sterilize, and the careful study of the patient's Duerperal history is absolutely essential in this connection. While incidental sterilization may

be indicated in a young woman who has had frequent pregnancies during her married life it may perhaps be decided unnecessary in an older woman who has been sterile the entire period of, or a greater part of her married life.

If artificial sterilization can be performed upon pathologic grounds alone, only those cases can be judged suitable for the procedure where the organs or organism of the woman is so impaired as to render future pregnancies extremely dangerous, or parts of the birth canal may be in such condition as to make it necessary to provide against future conception. In any case there should be definite reasons for sterilization which time can not change except to make them more urgent. If this be true, there is no place for temporary artificial sterilization and all operations with this end in view are based upon false premises and need not be considered.

A woman never should be sterilized without the knowledge and approval of the patient herself, that of her husband and the family or another physician. This applies not only to the removal of diseased tubes or ovaries or both but to artificial sterilization as well. It is the custom in the University Clinic for the husband or the woman herself if she be of age, unmarried, widow or divorced to sign a paper before operation authorizing the surgeon to perform such operation as he may deem necessary. It would seem advisable to be even more explicit when artificial sterilization is contemplated, for it is an extremely serious thing to deprive a woman of her capacity for reproduction. That is why, personally, I am not enthusiastic over primary sterilization of the insane, or those who are defective mentally, since they are incapable of giving assent to the operation. I would not refuse to perform incidental artificial sterilization on people of this class when the operation is advised by an alienist of high standing but I certainly would hesitate under the existing laws of the State to perform the primary operation. Most of the sterilization laws passed by many states have been declared unconstitutional, showing that it is a debatable question and that one should not lightly perform such operations upon this class of people.

Conditions where sterilization may be considered:

1. Pulmonary tuberculosis.

Primary sterilization will rarely be indicated in pulmonary tuberculosis. Great advances have been made in the treatment of this form of tuberculosis, so that it would never be justifiable

to sterilize for the incipient or moderately developed case. In advanced cases, primary sterilization will seldom be employed on account of the danger of any operative procedure under these conditions.

Incidental sterilization should be considered where the woman with advanced tuberculosis must have a laparotomy for other imperative conditions. In case the woman has children and desires future sterility on the ground that pregnancy will augment her disease, the operation would be justifiable and therefore indicated.

Other forms of tuberculosis.

Each case must be judged on its merits but generally speaking sterilization will rarely be indicated except in tuberculosis of the abdominal and pelvic organs. In tuberculous peritonitis in the female the genital organs are usually primarily or secondarily involved and when affected will be removed.

3. Disease of the kidneys.

Both primary and incidental sterilization may be indicated in chronic disease of the kidneys. Experience has shown that a woman with chronic nephritis should not marry since the patient's condition is bound to be made worse by pregnancy. Not only is this true but the chances of the pregnancy going to term and a healthy child being delivered are greatly reduced by the presence of the disease.

Each case should be carefully studied as to the type of severity of the kidney lesion. If a woman marries against advice she should not be subjected to the dangers of sterilization for fear of pregnancy since this condition may not supervene. If she become pregnant and either aborts spontaneously or the pregnancy is interrupted to save her life, it is well to consider the advisability of primary sterilization and to perform the operation if the kidney lesion so warrants, with the idea that future pregnancy is probable and that in that event her life will be endangered. Moreover, under these conditions her chances of going to term and giving birth to a healthy child are very poor.

Under the heading of disease of the kidneys should be included those numerous cases where the woman has threatened or actual eclampsia with each pregnancy although she is in quite normal condition with no or very slight urinary findings when not pregnant. In my experience such women have had scarlet fever or some other contagious or infectious disease when young which has left its mark on the kidneys, the lesions being increased to the danger point

by the advent of pregnancy. This class of cases is very well illustrated by the following:

Case I. No. 1516, age 40, married, American, housewife. Had scarlet fever at age of ten. Nephritic symptoms developed at age of 30. Has two living children, 13 and 10 years old. Miscarried during second pregnancy at second month due to typhoid fever. Had eclampsia with third pregnancy at eighth month, in convulsions for several hours, child removed manually and saved. About a year later aborted at fourth month on account of nephritis. Three years later a vaginal Cesarean section was performed for nephritic condition at the seventh month and child died. Had influenza and active nephritis in October, 1918, and has had a great deal of headache and backache since.

Pelvic examination showed an enlarged, retroflexed uterus, a badly lacerated cervix and a second degree tear of the perineum. The urine was quite normal showing neither albumen nor casts.

The patient was operated upon January 11, 1919, the series of operation consisting of dilatation and curettage, bilateral trachelorrhaphy, perineorrhaphy and shortening of the round ligaments. In addition the patient was sterilized by removal of wedge shaped pieces from each uterine cornua and burying the distal ends of the tubes between layers of the broad ligaments. Convalescence was normal.

4. Diseases of the heart.

My own experience has shown that women with organic lesions of the heart where the compensation is even fairly good do remarkably well during pregnancy. Where compensation has about reached its limit or where there is persistent decompensation with its attendant symptoms, edema, ascites and congestion in various parts of the body, due to a dilated and overloaded right sided heart, and experience has shown that the woman will probably become pregnant if not rendered sterile, primary artificial tubal sterilization is indicated.

Incidental sterilization in this class of cases should not be performed upon insufficient grounds but only after careful study of the patient's past history in reference to pregnancies and labors and after careful estimation of the present and future severity of the heart lesion.

The following is illustrative:

Case II. No. 1614, age 19. First para. Has severe mitral and aortic lesions with a greatly hypertrophied heart which is on the border line of decompensation. Her condition was such that it was thought inadvisable for her to undergo the strain of labor in a first pregnancy, although as far as could be judged the pelvic measurements were normal. Abdominal Cesarean section was performed August 28. 1917 and a healthy female child weighing six and one-half pounds delivered. It was deemed advisable to sterilize the patient at the time of the operation which was done by