cornual resection. Mother and child made good recoveries.

5. Mental diseases.

Primary sterilization for these conditions has already been considered and the conclusion arrived at is that the operation cannot be often performed on account of the uncertainty of existing laws. This is not absolute and under certain conditions I would not refuse to do primary sterilization, but I would want to be certain that the facts in the case warranted the operation beyond any shadow of a doubt. My reasons for this hesitancy are based upon the changing opinions of the alienists themselves regarding the prognosis of many of the mental diseases. The worse or hopeless cases are carefully guarded in places where pregnancy is not apt to occur. Recovery may take place in the other class of cases and the surgeon confronted under these circumstances by a woman justly indignant at being deprived of the possibilities of becoming a mother, absolutely without her consent.

I would look upon the question a little differently in mentally deranged women who had to be operated upon for some other condition, although even here the surgeon must be doubly. careful since he is dealing with a patient whose competency to consent to the operation may always be questioned.

Some of the patients have been subjected to incidental sterilization in the clinic but only upon the advice of alienists and those most concerned with the patient. The following is an illustrative case:

Case III, No. 10,120, age 34, married, two children 5 and 1 year old. Has suffered from a mild form of manic depressive insanity since birth of last child. Family surroundings very bad. On February 15, 1919, the uterus was dilated and curetted and an extensive colporrhaphy for rectocele performed. The abdomen was then opened and a diseased appendix removed which was followed by a shortening of the round ligaments for marked retrodisplacement. Cornual resection of the tubes was performed upon the advice of Dr. Barrett who had given a careful consideration to all aspects of the case. Patient made an uninterrupted convalescence and has improved greatly mentally and physically.

6. Pelvic contraction.

At the present time an otherwise healthy woman with obvious pelvic contraction has no right to demand primary sterilization to prevent pregnancy, if she has never borne a child. Presumably she knew her condition and assumed the risks when she married. Furthermore, the risks of elective Cesarean section at term are not

much more than primary sterilization. Theoretically in this class of cases sterilization incidental to the Cesarean section is not warranted, no matter how many sections may be performed. Practically, however, common sense leads us to accede to the wishes of the patient and her husband if she has risked her life twice and does not care to assume the risk again. The following is an illustrative case:

Case IV, No. 1373, age 20, married, slightly, generally contracted pelvis, large child. Test of labor, no progress after 24 hours of labor. Delivered of male child weighing 10 pounds and 7 ounces, May 16, 1916. Mother and child made excellent recoveries. The second pregnancy differed from the first in that the patient suffered a great deal from nausea and vomiting and edema of the feet and ankles. Female child weighing 61⁄2 pounds was delivered by abdominal Cesarean section May 6, 1918. At the request of the patient who claimed that she did not want to take the chances of a third pregnancy and operation and with the consent of the husband, sterilization was brought about by cornual resection. Mother and child made good recoveries.

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

There may exist certain defects in the uterus or its appendages or in the birth canal which render delivery by the natural passages extremely hazardous and undesirable. Time does not permit of the consideration of all the possibilities along this line. I will merely illustrate by the following cases:

Case V, No. 1518, age 37, married, housewife. Personal history negative, married and has three children aged, 8, 11 and 14; labors normal. For the past two years has known she had a fibroid tumor. Examination showed a large uterus with a fibroid nodule the size of a lemon on the anterior surface of the uterus and slightly to the left of the median line. As the patient had lost considerable weight and strength from excessive flowing, an operation was decided upon. April 21, 1919, the abdomen was opened and a club shaped adherent appendix removed after the fibroid nodule had been enucleated. The nodule occupied the entire anterior uterine wall and the uterine mucosa was exposed after the enucleation. The cavity was filled in by interrupted catgut sutures and the peritoneal edges brought together.

The case had been discussed prior to the operation with the physician in charge, with the patient and with the husband, and it had been agreed that it was inadvisable to take any chances in case of a myomectomy of a rupture of the uterus at a subsequent labor. Hence, it was deemed best at the operation to sterilize the patient by cornual resection which was done. tient made a good recovery.

Pa

Case VI, No. 858, age 27, married, was operated upon for a complete tear of the perineum resulting from a protracted labor in a funnel pel

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 7 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

for uterine prolapse February 1, 1919. The interposition 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 sterilization 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 completed by an extensive flap splitting perineorrhaphy 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.

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 organic 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

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 tuberculosis, 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 a 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 remoru. She had a badly lacerated cervix and I advised her have that repaired and see if she could not go through a pregnancy. She wants children, 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 if 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 inadvisable for that woman to have any more chlidren, or to have 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 prohibited 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 experience 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

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 prevention 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 Some to the uterus, but that also has been proved a failure. 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 tuberculosis incipient tuberculosis and moderately advanced 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 spyhilis, 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 sterilized. If her abdomen was opened and it was decided or proved that her life would be saved by cornual resection, I think the question should be considered.

SEROLOGIC EXAMINATIONS IN EYE 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

*Read before the Detroit Ophthalmic and Otologic Club.

transitional or adventitious type. 5. Urinary analysis, including other things than the presence or absence of albumen or sugar.

The latter, of course, is not a serologic test, but must be here considered in order to complete the diagnostic picture.

The Wassermann and allied reactions for lues is of so common occurrence and of such evident utility that not much need be said of its great value from a diagnostic, prognostic and therapeutic viewpoint. The blood Wassermann when negative, should be repeated after provocative doses of potassium iodide or very small doses of neo-salvarsan, to get accurate data.

It would seem advisable, however, to refer to the value of the Wassermann reaction in connection with a condition in the eye with which it is not perhaps so often associated. I refer to traumatism, in which the constitutional condition revealed by a positive Wassermann reaction not infrequently gives a new viewpoint on the prognosis and therapeutic management of the case.

A mental review of the disastrous traumatisms of the pre-Wassermann period as contrasted with equally severely injured eyes in which a positive Wassermann pointed the way to a more successful therapy is quite striking in some cases. The following brief history illustrates this point:

M. L., age 36, male, metal worker, received a severe contused wound of the cornea of the right eye, the missile being a large piece of metal hur'ed with great force from a machine.

The vision was reduced to good perception of light and good projection. The cornea was found bruised and the epithelial layers desquamated over the central area. X-ray examination negative. Tension normal. A good prognosis seemed justified provided a choroidal rupture through the macula had not occurred

For five days after the injured eye progress was very satisfactory. The blood in the anterior chamber cleared so the pupil became visible. The lens was not dislocated.

The eye then became very painful. Irido-cycli

tis supervened and after a few days the tension rose to 60 mgm. mercury as shown by the Shiotz tonometer. The vision, which heretofore had been rapidly improving. quickly deteriorated, the cornea became hazy, the iris discolored and the ciliary region tender when palpated. A small nodule of a yellowish-gray color began to form in the iris.

The secondary glaucoma was the most disconcerting element. Was it due to a dislocated lens? Or was it due to plastic irido-cyclitis, and what was the cause of the latter? Should we trephine? Or do an iridectomy?

The nodule in the iris suggested lues or tuberculosis. A Wassermann was done and showed a ++++ positive reaction. The case was per

fectly cleared up by bringing the man to the point of salvation by intensive mercurial inunctions.

In the matter of interstitial keratitis the Wassermann reaction has reduced lues as an aetiological factor to well below 50 per cent. In Moorfields, when I was a student there in 188687, Nerthship placed syphilis well up in the 90 per cent. class as a cause of interstitial keretitis.

The same may be said of choroiditis or in fact of uveitis.

There have been several cases of delayed healing of the wounds after enucleation of the tear sac and after mastoid operations which have shown positive Wassermann reactions and thus given information which led to a constitutional therapy, which soon brought about a favorable termination.

THE TUBERCULIN TEST.

Local (1) Calmette; (2) Constitutional as exemplified by temperature variations and the skin reaction of von Priquet have all played a most important role in properly classifying the aetiology of various eye affections. Where syphilis has lost in popularity as a causative factor, tuberculosis has gained, thus many more cases of interstitial keratitis are now recognized as tuberculous in character than was formerly thought possible.

So, too, in the choroidal affections many are now known to be tubercular where formerly they were looked upon as all of luetic origin.

The calmette test is unsuitable and dangerous for use in eyes which are the seat of tuberculous lesions. There is also a danger in such cases of a diagnostic dose producing an undesirable focal reaction in such an eye.

The tuberculin test, which is most reliable as of true diagnostic value, is that by diagnostic doses of tuberculin and observing the reactions produce local, focal and most important of all, constitutional as exemplified by variations in temperature, a record of which must be kept for several days preceding the giving of the diagnostic dose.

The tuberculin test, which is of least inconvenience to the patient and freest from danger to the eye affected with a tuberculous deposit, is the skin test of von Priquet. While it is generally recognized as of but little value as a reliable test for active tuberculosis because a very high percentage of adults will show a positive reaction, nevertheless the test has an extremely important role to play as an indicator