The regular quarterly meeting of the Hillsdale County Medical Society, was held at the court house, Hillsdale, Tuesday, October 10, at 7:30 p. m., the president, Dr. Hanke, in the chair.

Dr. Charles W. Hitchcock of Detroit, favored the society with an interesting and instructive paper, "Some Practical Lessons from Psychiatric Cases," from the case notes of the author. He called especial attention to the danger of trusting patients suffering from melancholic dementia for a moment, no matter how earnest their promises of good behavior. The paper was discussed by Dr. Sawyer and others and Dr. Hitchcock answered a number of questions by Doctors Green, Sawyer, Barnes and others.

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The society then listened to a charming paper by Dr. Jas. M. Barnes of Waldron, "The Physician or Doctor," which was forceful plea for a re-establishment between the doctors of today and their patrons of the old-time relationship and a depreciation of the commercial spirit that seems to be creeping into certain portions of the profession. Also the danger of trying to be too much of a "good fellow" with the "bunch," and the importance of the doctor spending his spare time in trying to learn more about his profession instead of in the pool room or hotel lobby.

The discussion of this paper was general and it was greatly appreciated.

Adjourned until the annual meeting.

D. W. FENTON, Secretary-Treasurer.

MONROE COUNTY

The Monroe County Medical Society held their fall meeting at the Monroe club, Tuesday afternoon, October 17, at 2:00 p. m.

The main business of the afternoon was the election of officers for the coming year. Those elected were: President, Dr. J. J. Siffin, Monroe; Vice President, Dr. S. U. Dussean, Erie; Secretary-Treasurer, Dr. H. W. Sandon, Monroe; Corresponding Secretary to State Journal, Dr. F. C. Thiede, Monroe; Member Medicine Defense Committee, Dr. C. T. Southworth, Monroe; Dele

gate to State Convention, Dr. J. A. Humphrey, Monroe; Alternate, Dr. W. F. Acken, Monroe; Program Committee for year, Drs. A. W. Karch, W. F. Acken, and H. W. London, Monroe.

One new member was voted in the society, Dr. C. J. Golinvaux, who has recently located in Monroe.

We also had a very interesting paper and lantern slide demonstration of X-ray plates, showing numerous fractures and their complications, by Dr. A. M. Unger of Toledo, Ohio.

It was decided to continue the regular monthly meeting and luncheon at the Park Hotel, the coming winter. They will be held every third Tuesday of the month and the program committee, Drs. Karch, Acken and Landon promising us some very interesting papers for the coming year. Last year we had some very good meetings and the attendance was fair, but this year we want even better. All members are urged to appoint themselves as a committee of one and attend every meeting this coming winter, it is only one day a month and we are sure you can tear yourself away for one afternoon. We promise you the "eats" will be as good as ever. Remember they start at 12 noon, the third Tuesday of each month, you will be notified by card.

The following members were present at this meeting: Doctors Acken, Siffin, Southworth, Miller, Hathaway, Karch, Thiede, Humphrey, Landon and Golinvaux, all of Monroe and Dr. S. V. Dussean of Erie and Dr. O. M. Unger of Toledo.

ACADEMY OF SURGERY OF DETROIT

The regular meeting of the Academy of Surgery of Detroit was held at the office of Dr. Max Ballin, 269 Rowena street, Friday evening, Oct. 13, at 8 o'clock.

The program for the evening was as follows: 1-Gastric Fibroma Meningocele....Dr. N. M. Allen 2-Syphilis of the Stomach...

.....Drs. R. C. Moehlig and E. G. Minor 3-Blood Counts in Goitre......Dr. David Kallman 4-Anterior Abdominal Tenderness in Sacro

Iliac Strain............Dr. H. C. Saltzstein 5-Remarks of Interest to the Society.. Dr. M. Ballin DR. MAX BALLIN,

President. WYMAN W. BARRETT, Secretary.

OFFICIAL MINUTES OF THE JOINT COMMITTEE ON PUBLIC EDUCATION. OCTOBER 9, 1922

The meeting of the Joint Committee on Public Education was held in the Michigan Union at Ann Arbor at 12:0 p. m., October 9, 1922. President Burton presiding and the following members present: Burton, Kay, Olin, Cabot, McCracken, Sundwall, Dodge, Henderson, Storey, Frothingham, Huber, Biddle and Warnshuis.

The minutes of the last meeting were approved as read.

Professor Henderson, chairman of the sub-committee on speakers and topics reported that 10,000 copies of the University Bulletin had been printed. That 8,000 copies had been given state-wide dis

tribution. That twenty-five lectures had been given and that since the opening of the University for its 1922-23 session, 36 requests had been received for speakers. He further reported that these requests were coming in rapidly and that the extension committee was arranging for a large number of meetings to be held during the fall and winter months.

Dr. Storey, Chairman of the Committee on Public Education of the Wayne County Medical Society, addressed the committee regarding the plans of the committee of Wayne County. The committee engaged in a discussion of plans of co-operation with the Wayne County Committee and it was moved by Dr. Olin, supported by Dr. Dodge, that the chairman of our committee on Topics and Speakers co-operate with Dr. Storey in planning the meetings for Detroit and that a close laison be maintained by our committee on Speakers and Topics with Dr. Storey so that there would be no duplication of the lectures or conflict with the work that is being done by the two committees.

It was moved by Dr. Dodge and supported by Dr. McCracken that the Committee of Wayne County nominate ten names from Detroit for our Speakers' Bulletin and that these men be available for lectures throughout the state.

Because of removal from the state or for other reasons, the Committee on Speakers and Topics was directed to remove from the Speakers list the following names: Harriet Leck, C. W. Edmunds, Professor Warthin.

On motion of Dr. Dodge, supported by Dr. Cabot, it was moved that the Chairman of the Committee on Speakers and Topics eliminate the names of lay speakers unless said lay speakers understand that they are to pay their own expenses, since the committee has no funds for this purpose. That their names may be retained upon the list if these speakers understand that they are to pay their own expenses.

Upon motion of Dr. Dodge, supported by Dr. Huber, it was moved that the name of every member of the Joint Committee be added to the list of speakers and that they be requested to submit the topics of their lectures.

Moved by Dr. Biddle, supported by Dr. Dodge that Dr. Henderson communicate with the listed speakers and secure from them a new acceptance Further, that Dr. and the topic of their lectures. Henderson Storey, Chairman ask Dr. of the Wayne County Committee to submit an amended list of speakers. Carried.

Moved by Dr. Biddle and supported by Dr. Kay that the Sub-Committee on Speakers and Topics be authorized to select speakers in counties that have not submitted lists of speakers. Carried.

Moved by Dr. Biddle, supported by Dr. Kay, that the Deans of the Medical Schools be au thorized to submit supplemental lists of speakers. Carried.

tures in the colleges of Michigan for the benefit of the students attending these colleges was referred to President Burton for investigation and recommendation.

Upon motion of Dr. Cabot, supported by Dr. Dodge, the special committee on Speakers and Topics was authorized to compile and issue a second edition of the Bulletin for state-wide distribution.

Upon motion of Dr. Huber, supported by Dr. Kay, the Committee on Speakers and Topics was authorized to aid the State Commissioner of Health to the extent of supplying his department with speakers at the roundup meetings of the public health weeks that the department is conducting throughout the state.

Upon motion of Dr. Dodge, supported by Dr. Cabot, the meeting adjourned to meet in Ann Arbor at 12 noon, January 16, 1923. F. C. WARNSHUIS,

Book Reviews

Secretary.

OPHTHALMOSCOPY, RETINOSCOPY AND REFRACTION. W. A. Fisher, M. D., F. A. C. S., Professor of Ophthalmology, Chicago Eye, Ear, Nose and Throat College. Cloth, 217 pp. 248 illustrations. Published by author, 31 N. State St., Chicago, Ill.

Ophthalmoscopy is generally considered as a di cult subject. It is one that is not taught either practically or successfully in medical colleges, with the result that scarcely two per cent. of practitioners coming to the author for postgraduate teaching know how to use the

ophthalmoscope.

In the author's opinion ophthalmoscopy and the fitting of glasses belong to the general practitioner, and acquirement of the necessary practical and theoretical knowledge is easy, interesting and within the reach of all.

This book has been written with the intention of teaching medical practitioners and students the practical use of the ophthalmoscope and retinoscope, with easy application of methods of study, to the detection of diseases of the interior of the eye, and for the fitting of glasses when they are indicated.

By mastering the methods here described and equipping himself with the necessary instruments, there is no reason why the general practitioner should not prescribe so as to correct the common errors of refraction and become proficient in the use of the ophthalmoscope.

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Vol. XXI

In patients with absolute contractions of the pelvis our plan of treatment is clear, as in these cases we can anticipate suprapubic delivery and be prepared for operation at the most suitable time. Absolute contractions however are rare.

Most of our dystocias occur in patients with pelves that are relatively contracted, i. e., those with diagonal congugates of from 10 to 101⁄2 cm. As the great majority of these patients may be delivered through the natural passages it would be poor judgment to do cesarean sections on all of them at the onset of labor. On

*Read before Annual Meeting, M. S. M. S., Flint, June, 1922.

No. 12

the other hand if we wait until the patient has had an opportunity to engage the fetal head in her relatively contracted pelvis before we decide that suprapubic delivery is necessary, the oplimum time for cesarean section will have passed. Those of us who are conservative will then hesitate to do this operation because of the greater risk to the mother. We either must do a craniotomy on the patients who fail to deliver after a test of labor or use a cesarean section technic which eliminates most of this added risk.

The great increase in the maternal risk is due to the increasing danger of peritonitis as labor progresses, particularly after the membranes have ruptured and many vaginal examinations have been made. Infection of the peritoneum may result from (a) a break in the operating

room technic; (b) spilling of the amniotic fluid; (c) extension of the infection from a septic uterus through a broken down uterine wound; (d) lymphatic extension, as in the ordinary cases of puerperal infection. The first two of these modes of, infection need not be considered. In our experience they seldom are factors. Most of our fatal cases first showed evidence of peritonitis in from 5 to 7 days after operation and autopsy revealed broken down uterine wounds through which contaminated material from the septic uterine cavity reached the peritoneum, thus causing a fatal peritonitis. We therefore feel that any method which is to reduce the mortality of cesarean section done late in labor must be one that will prevent extension of infection through the wound in the uterus.

Fig. 2

To accomplish this, two plans are possible; first we may do an immediate hysterectomy and thereby remove the wound in the uterus, or sec

ond we may avoid the sacrifice of the reproductive function by choosing the most favorable site for our incision and completely sealing it with peritoneum. At the Long Island College Hospital, we have adopted the latter plan. After trying the several types of low incision cesarean section we chose the Kronig operation as a routine procedure and the technic which I shall show you is a modification of that described in Kronig's text book.

When the incision is made in the lower segment of the uterus the wound sinks into the pelvis as soon as the operation

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Fig. 3

separated bladder as shown in figure 4 and the more firmly attached tissue in the midline is cut. The fingers are then swept from side to side until the bladder is separated for a distance of about three inches below the original transverse incision. In the preparation of the upper flap the dissection should be started at least 1 cm. from the midline on each side, the scissors being passed upward and outward as indicated in figure 5. The more firmly adherent areas which cannot be separated by blunt dissection are cut. Occasionally

it off is thus afforded and a localized pelvic peritonitis rather than infection of the general peritoneal cavity may result. In addition we thoroughly seal the uterine wound with two flaps of peritoneum. Figure 1 shows the site of the incision in the peritoneum which covers the lower segment of the uterus. Late in labor the peritoneum in this region is loosely attached. With the tissue forceps it is picked up and cut at a point about 2 cm. above the upper margin of the bladder. This incision is extended latterly about 21⁄2 inches on each side of the midline. We then pass a pair of blunt scissors underneath the peritoneum and bladder side as shown in figure 2. The scissors are opened and withdrawn thus separating sufficient tissue to permit the introduction of the gloved finger. The dissection is continued by sweeping the finger from side to side in this area. Figure 3. (Little difficulty will be encountered if the operator avoids beginning this dissection in the midline). The opposite side is prepared in a similar manner, care being taken to again avoid the midline. Two fingers are then introduced under the

Fig. 4

on one

Fig. 5

is not a serious accident, as the perforation can easily be closed later in the operation. If a little care is used in the preparation of these flaps, excellent cleavage planes will be found and little or no hemorrhage will take place. The inferior flap is now retracted, care being taken to pass a retractor to the lowermost portion of the dissected area. To accomplish this, one must use a Deaver retractor or some similar instrument. The uterine incision itself is made vertically in the midline. After making a stab wound in the region shown in figure 6, the lower two-thirds of the incision is completed by cutting with a straight pair of scissors. Frequently the flow of blood and aminotic fluid obscures the field of operation. When this occurs, the operator need have no hesitancy in deliberately though blindly, continuing as the bladder is held out of the field by the

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the presenting part and the assistant, by making pressure on the fundus forces the presenting part through the uterine wound. If any difficulty is encountered in the extraction, forceps may be applied to the sides of the head. Many of the men who favor this operation, prefer to deliver the head with forceps. For a long time I have been able to accomplish the delivery without the use of these instruments. Pituitrin should not be given until the child is delivered,

Fig. 7

as the contracting uterus may force the head against the brim and thus greatly interfere with the extraction. If the presenting part is firmly fixed in the brim before operation, it should be dislodged by the finger introduced into the rectum or vagina, prior to the starting of the anesthetic. There is no need for haste and if any difficulty in extraction is encountered, several minutes may with safety be consumed by this step of the operation. Immediately after the delivery of the child, pituitrin is given and a traction suture is introduced at each angle of the uterine incision. See figure 7. By pulling on these sutures, the assistant brings the uterine incision into the abdominal wound, thus protecting the peritoneal cavity from further contamination. Deep, interrupted catgut sutures are placed at intervals of 1 cm. These pass through the muscle wall down to the endometrium. They are not tied at this time, but the ends are clamped with hemostats. After the introduction of these deep sutures, the hand is again passed into the uterus, between two of them, and the placenta is separated and removed. By following this technic we wait for the uterus to contract well before

Fig. 8

separating the placenta. If hemorrhage from the placental site should occur, the wound may be closed in a few seconds, as all of the deep sutures have already been placed. See figure 7. While hemorrhage from the placental site seldom occurs in a classical cesarean section done early in labor, the opposite occasionally is true when the operation is performed late in labor, and the uterus is fatigued. A second series of interrupted sutures completes

the closure of the uterine incision. These are inserted midway between the deep ones and pass through only about half the thickness of the uterine wall. Figure 8. The upper flap is now brought down and anchored by several catgut sutures. Figure 9. The bladder reflection or lower flap is then brought up over the upper one as shown in figure 10, thus completely peritonealizing the wound in the uterus. In a short time these flaps become adherent and our wound is perfectly sealed.

To my knowledge, this operation has been done 150 times by a number of different men throughout the country. I have studied the detailed records of more than 100 of these cases and shall give you a synopsis of this study. In somewhat more than two-thirds of the patients, the elective time for operation had passed and the classical procedure therefore was contraindicated either because the patients had been too long in labor or the membranes had been ruptured a long time or many vaginal examinations had been made. In spite of this fact only four of the mothers were lost. A mortality of slightly under three per cent.

doubt

Fig. 9

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The post-operative convalescence in most of these cases was accompanied by somewhat more morbidity than is usually observed after an elective classical cesarean section. The increased temperature no was due to the fact that our dissection in the twoflap, low incision cesarean section is more extensive and leaves a much greater area for absorption. In these patients who were infected, the clinical course was similar to that of an ordinary puerpral infection, a marked improvement frequently being observed about the seventh day after operation when pus usually was observed in the lochia or draining from the lower angle of the abdominal incision. Our explanation of this occurance is that the infected uterine wound breaks open at this time and instead of draining into the peritoneal cavity, discharges the puerulent material either through the cervix and vagina or through the lower angle of the abdominal incision. One of the

Fig. 10