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to sterilize for the incipient or moderately de- by the advent of pregnancy. This class of cases veloped case. In advanced cases, primary ster- is very well illustrated by the following: ilization will seldom be employed on account of Case I. No. 1516, age 40, married, American, the danger of any operative procedure under housewife. Had scarlet fever at age of ten. Nethese conditions.

phritic symptoms developed at age of 30. Has

two living children, 13 and 10 years old. MiscarIncidental sterilization should be considered

ried during second pregnancy at second month where the woman with advanced tuberculosis due to typhoid fever. Had eclampsia with third must have a laparotomy for other imperative pregnancy at eighth month, in convulsions for conditions. In case the woman has children and

several hours, child removed manually and saved.

About a year later aborted at fourth month on desires future sterility on the ground that preg- account of nephritis. Three years later a vaginal nancy will augment her disease, the operation Cesarean section was performed for nephritic conwould be justifiable and therefore indicated. dition at the seventh month and child died. Had

influenza and active nephritis in October, 1918, 2. Other forms of tuberculosis.

and has had a great deal of headache and backEach case must be judged on its merits but ache since. generally speaking sterilization will rarely be Pelvic examination showed an enlarged, retroindicated except in tuberculosis of the abdom

Aexed uterus, a badly lacerated cervix and a secinal and pelvic organs. In tuberculous peri

ond degree tear of the perineum. The urine was tonitis in the female the genital organs are usu

quite normal showing neither albumen .nor casts.

The patient was operated upon January 11, ally primarily or secondarily involved and when 1919, the series of operation consisting of dilaaffected will be removed.

tation and curettage, bilateral trachelorrhaphy, 3. Disease of the kidneys.

perineorrhaphy and shortening of the round liga

ments. In addition the patient was sterilized Both primary and incidental sterilization may by removal of wedge shaped pieces from each be indicated in chronic disease of the kidneys.

uterine cornua and burying the distal ends of

the tubes between layers of the broad ligaments. Experience has shown that a woman with

Convalescence was normal. chronic nephritis should not marry since the

4. Diseases of the heart. patient's condition is bound to be made worse by pregnancy. Not only is this true but the My own experience has shown that women chances of the pregnancy going to term and a

with organic lesions of the heart where the comhealthy child being delivered are greatly reduced

pensation is even fairly good do remarkably well

during pregnancy. by the presence of the disease.

Where compensation has Each case should be carefully studied as to

about reached its limit or where there is perthe type of severity of the kidney lesion. If a

sistent decompensation with its attendant sympwoman marries against advice she should not toms, edema, ascites and congestion in various be subjected to the dangers of sterilization for

parts of the body, due to a dilated and overfear of pregnancy since this condition may not

loaded right sided heart, and experience has supervene. If she become pregnant and either

shown that the woman will probably become aborts spontaneously or the pregnancy is inter

pregnant if not rendered sterile, primary artirupted to save her life, it is well to consider the

ficial tubal sterilization is indicated. advisability of primary sterilization and to per

Incidental sterilization in this class of cases form the operation if the kidney lesion so war- should not be performed upon insufficient rants, with the idea that future pregnancy is grounds but only after careful study of the paprobable and that in that event her life will be tient's past history in reference to pregnancies endangered. Moreover, under these conditions and labors and after careful estimation of the her chances of going to term and giving birth present and future severity of the heart lesion. to a healthy child are very poor.

The following is illustrative: Under the heading of disease of the kidneys

Case II. No. 1614, age 19. First para. Has should be included those numerous cases where severe mitral and aortic lesions with a greatly the woman has threatened or actual eclampsia hypertrophied heart which is on the border line with each pregnancy although she is in quite

of decompensation. Her condition was such that normal condition with no or very slight urinary

it was thought inadvisable for her to undergo the

strain of labor in a first pregnancy, although as findings when not pregnant. In my experience far as could be judged the pelvic measurements such women have had scarlet fever or some were normal. · Abdominal Cesarean section 'was other contagious or infectious disease when performed August 28. 1917 and a healthy female

child weighing six and one-half pounds delivered. young which has left its mark on the kidneys,

It was deemed advisable to sterilize the patient the lesions being increased to the danger point at the time of the operation which was done by


cornual resection. Mother and child made good much more than primary sterilization. Theorecoveries.

retically in this class of cases sterilization inci5. Mental diseases.

dental to the Cesarean section is not warranted, Primary sterilization for these conditions has

no matter how many sections may be performed. already been considered and the conclusion ar

Practically, however, common sense leads us rived at is that the operation cannot be often

to accede to the wishes of the patient and her performed on account of the uncertainty of ex

husband if she has risked her life twice and isting laws. This is not absolute and under

does not care to assume the risk again. The certain conditions I would not refuse to do

following is an illustrative case : primary sterilization, but I would want to be

Case IV, No. 1373, age 20, married, slightly, certain that the facts in the case warranted the generally contracted pelvis, large child. Test of operation beyond any shadow of a doubt. My labor, no progress after 24 hours of labor. Delivreasons for this hesitancy are based upon the

ered of male child weighing 10 pounds and 7

ounces, May 16, 1916. Mother and child made changing opinions of the alienists themselves

excellent recoveries. The second pregnancy difregarding the prognosis of many of the mental

fered from the first in that the patient suffered a diseases. The worse or hopeless cases are care- great deal from nausea and vomiting and edema fully guarded in places where pregnancy is not

of the feet and ankles. Female child weighing

61/2 pounds was delivered by abdominal Cesarean apt to occur. Recovery may take place in the

section May 6, 1918. At the request of the paother class of cases and the surgeon confronted tient who claimed that she did not want to take under these circumstances by a woman justly the chances of a third pregnancy and operation indignant at being deprived of the possibilities and with the consent of the husband, sterilization


was brought about by cornual resection. Mother of becoming a mother, absolutely without her

and child made good recoveries. consent.

7. Defects in the reproductive organs due to I would look upon the question a little differ

previous labors or operations. ently in mentally deranged women who had to

There may exist certain defects in the uterus be operated upon for some other condition, al

or its appendages or in the birth canal which though even here the surgeon must be doubly

render delivery by the natural passages extremecareful since he is dealing with a patient whose ly hazardous and undesirable. Time does not competency to consent to the operation may

permit of the consideration of all the possibilalways be questioned.

ities along this line. I will merely illustrate Some of the patients have been subjected to by the following cases : incidental sterilization in the clinic but only

Case V, No. 1518, age 37, married, housewife. upon the advice of alienists and those most con- Personal history negative, married and has three cerned with the patient. The following is an

children aged, 8, 11 and 14; labors normal. For illustrative case :

the past two years has known she had a fibroid

tumor. Examination showed a large uterus with Case III, No. 10,120, age 34, married, two chil- a fibroid nodule the size of a lemon on the andren 5 and 1 year old. Has suffered from a mild terior surface of the uterus and slightly to the form of manic depressive insanity since birth left of the median line. As the patient had lost of last child. Family surroundings very bad. On considerable weight and strength from excessive February 15, 1919, the uterus was dilated and

flowing, an operation was decided upon. April curetted and an extensive colporrhaphy for rec- 21, 1919, the abdomen was opened and a club tocele performed. The abdomen was then open- shaped adherent appendix removed after the ed and a diseased appendix removed which was

fibroid nodule had been enucleated. The nodule followed by a shortening of the round ligaments occupied the entire anterior uterine wall and the for marked retrodisplacement. Cornual resection uterine mucosa was exposed after the enucleaof the tubes was performed upon the advice oi tion. The cavity was filled in by interrupted catDr. Barrett who had given a careful consideration

gut sutures and the peritoneal edges brought toto all aspects of the case. Patient made an un

gether. interrupted convalescence and has improved

The case had been discussed prior to the opergreatly mentally and physically.

ation with the physician in charge, with the pa6. Pelvic contraction.

tient and with the husband, and it had been At the present time an otherwise healthy agreed that it was inadvisable to take any chances

in case of a myomectomy of a rupture of the woman with obvious pelvic contraction has no

uterus at a subsequent labor. Hence, it was right to demand primary sterilization to prevent deemed best at the operation to sterilize the pa. pregnancy, if she has never borne a child. Pre- tient by cornual resection which was done. Pasumably she knew her condition and assumed

tient made a good recovery. the risks when she married. Furthermore, the

Case VI, No. 858, age 27, married, was oper

ated upon for a complete tear of the perineum risks of elective Cesarean section at term are not resulting from a protracted labor in a funnel pel.

for uterine prolapse February 1, 1919. The inter-
position operation was performed which consists
in separating the anterior vaginal wall from the
bladder and pushing the latter upward separating
it from the uterus. The fundus is delivered .
through the anterior culdesac and tubal steriliza-
tion performed by cornual resection. The fundus
is stitched to the resected vaginal walls thus
holding the bladder upward supported on the
posterior uterine surface. The operation is com-
pleted by an extensive Aap splitting perineor-
rhaphy by which the levator ani muscles are
brought together in the median line.

The patient returned home with her prolapse cured and in no danger of becoming pregnant.

In the large majority of these marked cases of prolapse, the women are beyond the menopause. Where they are not and desire more children another type of operation must be utilized.

vis and a large child. Examination showed the soft parts terribly lacerated and the vagina so contracted that the cervix could not be located. There was a complete tear of the perineum, the lower part of the rectovaginal septum being torn upward one inch.

October 2, 1912, the complete tear of the perineum was successfully repaired so that control of the feces and gas resulted. However, there was so much scar tissue in the vagina that the patient was advised in case of another pregnancy to be delivered by Cesarean section. On July 4, 1916, she was delivered by abdominal Cesarean section of a male infant weighing ĭ pounds and 10 ounces. Both mother and child made good recoveries.

This patient was again delivered by abdominal Cesarean section November 29, 1918, of a female infant weighing 7 pounds and 12 ounces. Both she and her husband requested that she be sterilized at the second operation as they did not desire to take any further chances. The request seemed reasonable under the circumstances and tubal sterilization was performed by wedgeshaped cornual incisions. Both mother and child made good recoveries.

Incidental sterilization it seems to me was decidedly indicated in Case V. Here was a woman with an impaired and weakened uterus due to the removal of a large fibroid nodule. The resulting cicatrix was bound to be less firm than that resulting from a clean cut and properly sutured incised uterine wall. It did not seem right, considering the number of her children and their need of her, to let her be subjected to another labor with a uterus which, to say the least, would be handicapped.

In Case VI where there was a contracted outlet and a vagina almost obliterated by scar tissue, another delivery except by Cesarean section would have been not only dangerous but probably impossible. Here abdominal Cesarean section was clearly indicated, as was sterilization at the second section.

8. Operation of such a nature that subsequent pregnancy and labor are rendered dangerous.

Without attempting to enumerate all such operations, suffice it to say, that all abdominal or vaginal uterine fixation operations are contraindicated during the child bearing age unless accompanied by tubal sterilization. The truth of this statement has been borne out by the reports of dystocia and fatalities resulting from a neglect to sterilize, or the employment of the wrong technic with resulting pregnancy. The following is an illustrative case of incidental sterilization for operations of this type:

Case VII, No. 10,080, age 45, married, 2 children 21 and 23 years of age, was operated upon

SUMMARY 1. Fetal life should not be destroyed or conception prevented except on the grounds that the mother's life is endangered by the continuance of the pregnancy or by the advent of future pregnancy.

2. There are two kinds of artificial sterilization of women: 1. Primary artificial sterilization. 2. Incidental artificial sterilization.

3. In primary artificial sterilization, the end in view is solely to prevent future conception.

4. Incidental artificial sterilization means the sterilization of the woman during the course of another operation in the belief that the patient's life or well being would be seriously impaired by future pregnancies.

5. Primary artificial sterilization will be comparatively infrequent, since the organic disease which calls for the operation at the same time renders it hazardous.

6. In the uncertainty of the woman with or. ganic disease requiring sterilization, the physician will hesitate to advise this procedure when the uterus can be emptied with less danger in case pregnancy supervenes.

7. In incidental sterilization, the woman can be rendered sterile by a simple additional operative technic the dangers of which are practically nil.

8. All operations devised for temporary artificial sterilization are based upon wrong premises, since the indications calling for sterilization are bound to grow worse, never better.

9. As a rule a woman should never be sterilized without her consent and that of her husband, and of her family or other physician.

10. Careful study of the history of the patient, especially her puerperal history, her past

and present condition, will enable the physician to decide for or against primary and incidental artificial sterilization in :

1. Pulmonary tuberculosis.
2. Other forms of tuberculosis.
3. Disease of the kidneys.
4. Diseases of the heart.
15. Mental diseases.
6. Pelvic contraction.

7. Defects in the reproductive organs due to previous labors or operations.

8. Operations of such nature that subsequent pregnancy and labor are rendered dangerous.


Cramer (H.) Ueber prophylaktische Sterilisierung der Frau.

Muenchen. med. Wchnschr., 1904, LI, pt. 1, 605. Editorial New York Med. J., 1899, LXIX, 127. Hauch (E.) Avortement et stérilisation combinés et simultanés,

Arch. mens, d'obst., 1916, VIII, 267. Hedges (E. W.) Physical conditions in women warranting ster.

ilization. Am. J. Obst., 1917, LXXVI, 745. Heineberg (A.) Tubal sterilization. Pregnancy following bilat

eral salpingectomy. A report of two cases and a complete review of the literature, New York Med. J., 1916, CIV,

107-11. Huebl (Hugo) Ueber kuenstliche Sterilisierung des Welbes.

Monatschr. f. Geburtsh. u. Gynaek., 1902, XVI, 82; 237. Kehrer (F. A.) Sterilisation mittels Tubendurchschneidung nach

vorderem Scheidenschnitt. Centralbl. f. Gynaek., 1897,

XXI, 961-965. Kehrer (F. A.) Veber tubare Sterilisation. Beitr. 2. Geburtsh.

u. Gynaek., 1901, V, 188. Leonard (V. N.) The difficulty of producing sterility by opera

tions on the Fallopian tubes. Am. J. Obst., 1913, LXVII,

443. Offergeld (H.) l'eber die tubare Sterilisation der Frau. Arch.

f. Gynaek.. 1910, XCI. 1. Polak (J. 0.) Sterilization in Cesarean section. Tr. Am. Gynec.

Soc., 1909, XXXIV, 73. Rose (H.) Sterilisierung mit Erhaltung der Menstruation. Cen

tralbl. f. Gynaek., 1898, XXII, 689. Sullivan (Robert Y.) The indications for and advisability of

artificial sterilization. Am. J. Obst., 1916, LXXIV, 458-466.

is toward insanity, and where the woman has had trouble witb the first child or the second child, it would be a good idea for that kind of people not to survive. I think we have enough of them to take care of. To support them is the "white man's burden," and I think we are better off without them.

In tuberculous peritonitis I object to removing the womb, the tubes and ovaries. Why? Because they are always young women and you sterilize them and ruin them for their lives. You operate for tubercular peritonitis and you cure them, and those women can be married and have children and bave no future trouble. To remove the tubes and sterilize those women because there are a few tubercles on the tubes, I think is bad practice. Because there are thousands and thousands of tubercles around on the peritoneum everywhere you can put your finger, but those tubercles are going to be absorbed and disappear, and those on the tubes will disappear too. There is no doubt at all. We think the tubercles can come up through the uterus and infect the tubes, but they do not come up in that way at all, They come through the lymph channels. NObody here has ever seen such a case. I have seen only one and I have probably seen more cases than any of the rest of you. I saw one case where there was a tubercle in the uterus, but they have no bearing at all as a rule. If the tube is destroyed, you have to remove the tube just as it she had no tubercular peritonitis, but there is no use to remove the tube because there are tubercles around on the tube the same as on the peritoneum otherwise.

The point about bringing on a premature labor in these cases I think is perfectly right in certain cases, but still I am the last one who does it. I do not like to interrupt pregnancy. but once in a while I have to do it to save a woman's life, Here comes the question of Caesarean section. A way back when we made abdominal section and it was a dangerous operation, cases away back in the days when no single case recor. ered, when for a hundred years in Vienna they did the Caesarean section and never a case recovered, an Italian said to take out the whole uterus and thus avoid Infection. So we did the Porro operation and I did some of those, One case was a young woman and the child afterward died, and for Fears afterward that woman cried every time she met me and said, "Oh! if only you had not removed my womb, I could have another child," and that was a lesson to me and never after that did I do such an operation unless some other complication made it absolutely necessary. One patient I operated on four or five times by Caesarean section and after the third I sug gested that she ought to be sterilized, but she was a good ('atholic and wanted to keep on having children by Caesarean section.

So far as the consent of the woman's husband and family is concerned, that is a matter of fact. We must have a thor. ough understanding and they must understand the case. I think we ought to try and prevent pregnancy in those cases.

The great thing is we talk a lot about pregnancy, but we do not know absolutely how to prevent it. There are all kinds of means employed and they are all more or less successful, and in those cases of the women who ought not to have children we ought to find a means to prevent pregnancy and then if they do become pregnant, we can interrupt the pregnancy and thus avoid the dire consequences of the continuation of the pregnancy.

DR. JOSEPH E. KING, Detroit: I would like to know what the opinion would be about the use of radium to etrect ster ilization in those individuals who are afficted with nephritis, or for the purpose of producing temporary sterilization in the cases of women who may recover and eventually have children.

DR. JOHN N. BELL, Detroit: Mr. Chairman: I recall a case seen several years ago, a good Catholic woman with four or five children, and she and her husband requested sterilization. The operation was done and she afterwards was, I presume, chastized by the priest for having this done, and she became temporarily unbalanced from worry over the sin she had committed. However, later on she was restored to a normal condition by forgiveness and assurance that she had been forgiven for the act. It was a well-defined mental condition due entirely, I believe, to worry because of having the sterilization done. I think we ought to be very careful about sterilizing a woman without good reason.

DR. C. E. BOYS, Kalamazoo: Mr. Chairman: I endorse very heartily the points made by the essayist this morning, but I have a little stronger conviction about tuberculosis than Dr. Peterson suggested. I am intimately associated with Dr. Shepard of our city and he sees a great many of these cases. One woman became pregnant and it took three and a half years for her to be restored to her usual health. She became pregnant again and that time it took two years for her to be


DR. J. H. CARSTENS, Detroit: It seems to me there is nothing to discuss. The paper so thoroughly covers the ground in every direction that I cannot find anything really to discuss. Some of the little details we may have different views on, but the one general principle laid down is the most valuable of all, and that is, that each case must be considered individually. They are all different, and you cannot lay down any absolute rule. If we start with that, we will probably all agree.

In pulmonary tuberculosis I think it is a good rule that women should be sterilized. In cardiac trouble I do not think it is needed. Those women have children and get along fine. In kidney trouble I think it is more serious again.

As to the woman's consent, the woman's opinion is not a great thing. I do not care much what a woman tells me about what she wants or what she does not want. I know what is good and I'm the best judge of that job. Perhaps a woman comes to me and says, "I want to be sterilized, will you do this operation and make me sterile ?" That woman does not know what I know. I can see into the future. She may have two children, but I have seen those children die and she would give anything in the world to bave another child. Or 1 have seen this woman's husband die and she would marry again, or would be in a position to marry again if it were not for the fact that she was sterile. I have seen many of these cases. In the woman who has three or five or six children and is about the age where she will cease to have children, I think you are more justified in sterilizing that woman.

In the cases of insanity the Doctor talked of, I believe I am a little inclined the other way. I believe in eugenics and I think where anybody with those defects, where the tendency

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and found tuberculosis, the curetting of the uterus has shown tuberculosis present. In my experience many cases come from below upwards and infect the tubes. His statement that the tubercles are scattered around on the tubes and are of no particular significance is perfectly true, but in my opinion, the tubercles do come from below upward and infect the tubes.

In regard to Dr. King's inquiry, the paper was simply one on indications for sterilization and I did not take up the operative part of the question. The use of the X-ray and radium may be considered an operative means for the preven. tion of pregnancy. In my review of the literature I found that both X-rays and radium would produce temporary sterilization and permanent sterilization was not at all conclusive from the use of both these agents. Consequently, I would consider the use of these two agents as not at all proved as regards permanent sterilization, The literature is very unsatisfactory in that it shows all kinds of operations for sterilization and all of them have failed, even the resection of the cornua of the uterus and the burying under the peritoneum of a wedge-shaped piece from the uterus has failed. The tying off of the tubes and the resection of the tubes is a failure. Some men have devised means of shutting off and confining the tubes anterior to the uterus, but that also has been proved a failure. Some men have gone so far as to take the tubes and put them up in the inguinal canal and that has failed. All kinds of technic for sterilization has failed, but the cornual of the tubes has proved most successful.

As regards Dr. Boys' part of the discussion, here again I would fall back on my opinion that sterilization must be determined upon pathological grounds only. I contend that incipient tuberculosis and moderately advanced tuberculosis have no part in sterilization, If it proves necessary,

the uterus can be emptied at any time. Where a woman has such advanced tuberculosis that her life would be seriously endangered by pregnancy, the mere operative procedure of sterilization would be dangerous.

In regard to the question of Dr. Williams, I should want to know definitely about the cause of the repeated abortions. IS it spybilis, is it the cervix, or what are the causes ? Is her life seriously menaced by future pregnancies? According to her testimony I should say it was not seriously menaced and that the woman could not justifiably be sterllized. It her abdomen was opened and it was decided or proved that her life would be sa ved by cornual resection, I think the question should be considered,


AND EAR CASES.* Don. M. CAMPBELL, M.D., L.R.C.S. (Edin.)

DETROIT, MICH. The importance, far-reaching influence and significance of information supplied by laboratory diagnosis will be admitted to every one whose experience is at all extensive in the diagnosis and treatment of diseases of the eye and ear. The bacteriology of many diseases of these organs makes of itself an important chapter, but can only be referred to here in passing, fascinating as its study would be.

The phases of the subject to which attention is here directed are: 1. The Wassermann and allied reactions. 2. The tuberculin tests. 3. The complement fixations for various infections other than syphilis and tuberculosis. 4. The blood picture including total and differential blood counts for the white cells; the red count and the condition of the red cells—haemoglobin estimation and the presence of other cells of a

restored on account of the tuberculosis, and because of the third pregnancy she is now down and out. I am of the opinion that that woman should have been sterilized after the first pregnancy. I have a nightmare about tuberculosis, I just abhor It and it always seems to me that whenever anybody has tuber. culosis, even in an incipient form, they have just as big a load as they can carry without adding pregnancy to it, and even though we know that they may get through the pregnancy all right, then comes the real strain, the labor, the loss of blood, the exhaustion incident to the labor and pain, and then added to that, if she tries to nurse her baby, that is the straw that breaks the load and she goes down, often to stay. 1 believe where there is a definite tuberculosis, we have a really definite indication for sterilization. of course, she should understand the situation, I agree with Dr. Peterson about that, but I do feel that if it were my own wife and she had tuberculosis in any form, I should certainly consider it an unwarranted calamity for a pregnancy to ensue.

DR. MARY WILLIAMS, Bay City: Mr. Chairman: I have & case of a woman who has two children and she has had, I think, about four or five miscarriages. Two or three have been in the early months. The two last times she has gone seven months and she came in the other day and said she had been advised to have her uterus remor.. She had a badly lacerated cervix and I advised her to have that repaired and see if she could not go through a pregnancy. She wants chil. dren, has tried in every way to have them. The last miscarriage was in April when she had the Flu, but she has done this every time. She says she simply has some feeling in her side as if something slipped down and then she is in labor. I advised her to have some operation on the cervix and see it that would not remedy the condition.

DR. REUBEN PETERSON, Ann Arbor, (closing): Mr. Chair. man: In regard to Dr. Carstens' discussion, it seems to me that you cannot help bearing particularly upon the pathological grounds for sterilization. We have to continually keep these in mind. As I said in the paper, the minute that we begin to discuss these things with the patient we are lost, because there will be many social and economic reasons why it seems in. advisable for that woman to have any more chlidren, or to bave any child. If we attack it on the strictly pathological grounds, that pregnancy will endanger this woman's life, then the question of whether she should or should not be sterilized will be discussed. I:, C: the other hand, there is no pathological ground for her sterilization, we are just as much probibited from discussing future conception in that woman as we are with the woman who comes to us and says, "Doctor, I am three months' pregnant and I am going to give a series of parties and this pregnancy is going to interfere with those parties," or "My husband is only getting thirty dollars a month and I cannot afford to have a child,” or any of the grounds on which they come to us. We have no right to discuss an interruption of the pregnancy on those grounds. Only when the woman's life is in danger are we justified in discussing the question.

Secondly, Dr. Carstens is right when says he pays no attention at all to the request of the woman, but we can go further and say if there are no pathological grounds. If there are pathological grounds, the woman should be informed of the danger. She has the right to risk her life if she wants to, If the woman says, "That may be true, but I want to have a child and I will not be sterilized" she has that right. That is why I am so opposed to the sterilization of the mentally defective. I do not agree with Dr. Carstens when he says he thinks we have enough of these people and we had better prevent descendents of these peopl as much as possible. The best alienists have said that only about 8 per cent. of Insane women have descendents that are insane, where it can be proved that those descendents are insane. Consequently, we must deal with this question very carefully. It does not necessarily follow that where a woman is insane, she will have an insane child or that the child will become insane. For instance, look at the way we are importuned about epilepsy. Not a year goes by that I do not have women brought to me to have their ovaries removed because of convulsions occurring during the menstrual period. I have gone through that exper. ience and have seen the convulsions occur just the same after the ovaries are removed. I would not sterilize a woman who had epilepsy, because it is by no means proved that a woman with epilepsy will have an epileptic child.

My experience is entirely different from Dr, Carstens in regard to tuberculosis of the uterus. In many cases we have established the diagnosis of tuberculosis of the pelvis and peritoneum from examination of the curetted material. In other cases where we have opened the pelvis without curetting

*Read before the Detroit Ophthalmic and Otologic Club.

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