open are often extensive and formidable; no chance whatever should be taken. If the surgeon is not most thorough, radical and painstaking, the operation might better not have been done, since recurrence is almost inevitable.

With this technic, multiple fistulae can be successfully operated, though the results of the operation are often spoiled by inexpert and careless after-treatment. Bridging over of the tracts during granulation is a great source of danger; the smallest healed-in pocket means recurrence. Examine the cases during the course of healing frequently, to avoid bridging.

The simpler varieties such as the muco-cutaneous, sub-mucous, simple complete, the blind external and blind internal are amenable to successful treatment in one's office, using a local anesthetic.

In operating on blind internal fistula, in which the indurated abscess cavity is easily palpated outside, and with internal opening in the anal canal, it has been found by the writer desirable to first cut into the abscess cavity from without, thus making a simple complete fistula to deal with; when the abscess cavity is more palpable inside the rectum, the free incision should be made at the site of the internal opening, laying the cavity fully open, and thus avoiding a complete fistula.

At the close of operation, tags, and free ends of skin are cut away, and the open surfaces and cavities packed with gauze moistened in Dakin's solution; packed to control hemorrhage, which at times is annoying, but which has never been found alarming. A perineal binder is tightly applied, and the patient sent to his bed; the attending nurse inspects, and if necessary, changes the outer dressings every hour for three or four hours. The patient is then allowed to thoroughly react, and at the end of twenty-four hours, all gauze packing is removed; a hot sitz bath given and the parts irrigated with Dakin's solution, every three hours-day and night. It is permissible to adhere to the strict Carrol-Dakin technic if it can be applied. A hot sitz bath precedes a change of dressings night and morning. The bowels are moved by castor oil or other suitable cathartics on the fourth or fifth day, and kept open by a daily enema given before the morning bath.

In six or seven days, infection will have become so inactive, that in the deep extensive wounds and broad uncovered areas it has been found desirable to place flaps of skin into the depths of the wounds where they become adherent within thirty-six to forty-eight hours. The application of this method partially covers the area with skin, thus greatly hastening recovery, since in the older technic the deep parts must fill by granulation first, necessitating a much longer time to heal. The technic of this operation is simple, and by its use it is possible to shorten convalescence following extensive fistulae often by several weeks.

Along the edge of a wound to be treated, a strip of skin is marked off by two parallel incisions made with a keen-edged knife; the proximal incision is extended-the width of the proposed flap-longer, at the end which is to remain permanently attached; a narrow margin of skin is left between the proposed flap or strip of skin and this wound; the width and length of the flap is determined by the shape and size of the raw surface on which it is to be used; the flap is undercut as near the true skin, and as free of fat as possible; its attachement at one end is severed as illustrated and the two edges of the now uncovered raw

surface, beneath the flap, are brought together and sutured with cat-gut, starting suture at the angle of the attached end; we have now a pointed strip of skin attached at one end and turned down into and partly across the open fistulous tract; this necessarily crosses a section of the narrow margin of skin mentioned, this section is cut out, thus allowing the plastic flap to contact with uncovered tissue in its entirety; this plastic flap can usually be kept in place by a careful pressure-dressing for forty-eight hours, which is sufficient for attachment, though a stay suture is permissible. Bismuth paste is applied at this time with the pressure-dressing.

This plastic operation may be carried as far around a wound as seems desirable by repeating the procedure, described. It must be understood that the intention is not to cover the entire area at once, but furnish large healthy flaps of skin to follow the contour of the area at intervals for subsequent joining by skin proliferation.

It is very desirable at this secondary operation after the use of Dakin's solution, to close the distal (from the anus) ends of these open tracts by suture, thus, is combined secondary suture with the plastic skin-flap operation.

The daily baths and earlier treatment with Dakin's solution are resumed after the fortyeight hours have elapsed, as a prophylactic and cleanly measure.

The writer wishes it understood that in this essay he has simply tried to point out the application of some rather recent and proven methods in a new field, and his experience with the plastic skin-flap in a comparatively small series, should be considered more in the nature of a preliminary report at this time.

REPORT OF CASE HISTORIES.

A resume of twenty-six consecutive case histories of fistulae from among the writer's personal cases in Harper Hospital prior to January 1, 1919, and covering a period of about twelve months, are here recorded.

The average number of days spent in the hospital before discharge is thirteen days; the least number of hospital days was two, and the greatest number was forty-two. The average duration of the fistulae prior to operation was fifty

seven and one-half weeks, as near as it was possible to ascertain from the histories; the least number of weeks duration was two, the greatest number two hundred and sixty. From the twenty-six cases, there were five which gave a positive Wassermann reaction, and there were five positive tubercular findings. The results show twenty-three to have recovered, two to have shown marked improvement, and one to have died after six months from pulmonary tuberculosis. There were three recurrences requiring a second operation, all of which are now recovered. The two cases recorded as "improved" were tubercular cases.

About 40 per cent. of the cases have been treated with Dakin solution, and 25 per cent. with the plastic skin flap. The period of convalescence following operation has seemed to have been much shortened by this method. One case of five years standing with positive tubercular findings, and the most extensive case in the writer's series, had been previously operated upon; she remained in the hospital forty-two days, with a recovery complete in eight weeks. In this case the plastic skin-flap was used twice following the original operation.

Eighteen less severe cases, and not included in this series were operated by the writer in his office under local anesthesia with but one recurrence. Approximately twenty cases have been operated in the Out-Patient Department under local anesthesia, with no recurrence as far as can be ascertained.

Percentage of recoveries in the series of hospital cases is 88.4 per cent. Percentage of those showing tuberculosis is 19.2 per cent. The percentage giving a positive Wassermann is 19.2 per cent. Percentage of recurrences in major cases is 11.5 per cent. and in the whole group of sixty-four-the percentage is 6.5 per cent. Eleven and five-tenths per cent. recurrence, or three out of twenty-six major cases may seem too many, but when it is considered that we are dealing with infected multiple tracts, many of which are very minute and in an area very subject to contamination, an occasional recurrence is to be, at least tolerated. 1447 David Whitney Bldg.

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December.

Editorials

GREETINGS.

The season of the year is once more here when the decrees of custom call for the extending of Holiday Greetings. In the past in each December issue we have proffered to all our members, advertisers and readers the Journal's good wishes for a Merry Christmas and a Happy Prosperous New Year. In doing so we endeavored to cause that greeting to include more than a perfunctory expression-we were sincere in our intent that each one reading our editorial greeting would perceive it to be a personal message and not an observance of a custom that was being complied with.

And so again, this season, we extend to all our members, advertisers and readers, the personal greetings of The Journal for a Merry Christmas and a Happy Prosperous New Year. Merry in the sense that the holiday season will be filled with cheer that rejuvenates and begets contentment. Happy and Prosperous in their fullest meaning for each who enters upon 1920, a year that is frought with so much that is for good and evil.

We sincerely hope that to each there will acrue that measure of prosperity that will enable

us all, individually and collectively, to reap a full measure of friendship from all with whom we come in contact in addition to financial gain.

THE VENEREAL DISEASE LAW.

Last month we published the text of the Venereal Disease law that was enacted by our last State Legislature. Since then we have heard of some discussion on the part of the profession, some criticism, some threats of rebellion and in certain instances open declaration of intention of not complying with the provision of this act.

We cannot quite conceive how or why any of the profession should attempt, at this late date, to refute the purposes of this law or assume antagonistic and belligerent attitude. The law is a distinct step in advance and commendable asset in the fight to eradicate the "black plague." It is conceded that the reporting of tuberculosis, and thus gaining information as to the extent of the disease, enabled our tuberculosis organizations to combat that disease in the successful manner in which it has been done. The same object will be attained in regard to venereal disease.

The day is past when we are to look upon the venereal disease problem as a social or moral problem. It's a problem of fact that must be combated by facts and infected carriers restrained by quarantine and treatment. Segregation is recognized a failure; moral preaching is ineffective and accomplishes naught. Its prevalence and spread cannot be limited without waging war upon it according to methods that have been demonstrated to attain results in combating other infective and pestilential diseases. This law enables the employment of public health eradication and prevention methods to be instituted. It prepares the way and provides a means. While it is true it will work a hardship on some, nevertheless, its beneficial results will exceed any temporary discomforts.

The time consumed in reporting the cases is negligible-no more so than in tuberculosis, smallpox, typhoid or the other reportable diseases. If the great objection is that one is not renumerated for making this report we dare say the Board of Health will provide a fee. The prohibition of dispensing by physicians is not worthy of argument for it is vastly recompensed by the prohibiting of counter prescribing and dispensing by drug stores. The "C. V. D." on

prescription blanks and the name, address of patient and date is a trivial time consuming requirement. So what is there to "kick" about or object to?

We recommend that the objectors inform themselves of the plans that are being made by the U. S. Public Health Service and the work that that service is already doing to limit the spread of venereal disease. We urge that they familiarize themselves with what was done in the army and navy and the ends that were attained. We urge that they write Dr. Byington of our State Health Commission and secure informative data as to the work that has been done in Michigan in the past two years. Then, if after digesting that information one still remains antagonistic, we recommend that a visit be made to the quarantine wards of several hospitals. We are sure that a change of heart will occur and cause for objection will disappear.

We would regret sincerely any obstructive methods from the organized profession of Michigan. We bespeak whole-hearted co-operation to Health Authorities in their administration of this law.

We append a concise statement of the law, extracted from the Bulletin of the Wayne County Medical Society.

C. V. D.

The editor is indebted to Dr. Don M. Griswold, Director of Medical Service, Board of Health, for the following excellent abstract of the recent venereal law. Learn it and file it for reference.

It is hoped that all the members of the W. C. M. S. will co-operate and abide by the law, thereby helping to reduce the number of syphilities in Detroit to below 100,000.

Section 1-Syphilis, gonorrhea and chancroid are infectious diseases.

Section 2-(a) The State Department of Health will make rules and regulations to prevent the spread of these diseases.

(b) Blanks for reporting cases will be furnished to physicians upon request.

(c) All cases of the diseases must be reported. These reports are not to be public records.

Section 3 (a) The State Department of Health is to provide treatment in proper institutions for such cases.

(b) Cases under treatment in institutions shall be deemed to be in quarantine.

Section 4-(a) A physician who fails to report a case is subject to a fine of $1,000.00 or

5. The letters "C. V. D."

(c) These prescriptions shall be numbered consecutively and shall be kept on file for at least two years.

(d) This file of prescriptions shall be subject to inspection by the

Prosecuting Attorney;
Commissioner of Police;
Commissioner of Health;

or their authorized representatives.

(e) Druggists must make detailed monthly reports to the State Department of Health of all such prescriptions.

(f) No person shall treat another for syphilis, gonorrhea, or chancroid except that duly registered physicians may give office treatments.

(g) Violations of this section by druggist or physician may be sufficient reason to revoke their license and impose a fine of $1,000.00 and imprisonment for one year in the county jail.

Bristles.

The world at large has just been let in on the secret that the 8 hour day is too long and will soon be a thing of the past and it has even been doped out that production will not only NOT suffer thereby but increase.

We merely mention the above to bring to your attention the extremes to which "organization" can be carried, for the little old law of average tells us that it can't be done. Aside from this, we all must admit that the organization of labor is so nearly perfected that they can almost put over anything and get away with it.

Don't think that we advocate any radical movements by the medical profession, a body that stands "head and shoulders" above any other class of professional or vocational men. What we do mean, though, is, if "day labor" can secure the "Life of Reilly" for its cohorts, then the medical profession, co-operatively, can, at least, get to the point where they can command their own self-respect and make humanity recognize them as men and not as a necessary evil.

This can't be done by thinking, wishing or grouching, but it can be accomplished by one grand "get together" policy. We can't hope to promulgate the eighth wonder by lining up the physicians nationally but we can give them a wonderful start by putting Michigan out in front in the getaway.

The first horse under the barrier always has the choice of the rail and with any kind of leadership continues to show the way.

It may be wrong to try to create a simile between the question that is as vital to us as life itself and a horse race, for victory won't come in one lone heat, but we can by concerted effort raise a cloud of dust that will make the has beens anxious to find out the cause of it.

Get your bet on the rail horse and back him to the limit.

Rome wasn't made in a day but the Bolsheviks put in their appearance soon afterwards.

The Boston police, in their recent strike, evidently overlooked the fact, that few people, in the present reign of old H. C. L., consider a "copper" seriously.

The conclusion seems to have been reached by the coal miners that it is better to suffer with the suffering, than have the comforts with the comfortable.

The "Sky Pilot," who recently won the transcontinental aero race, proved beyond a doubt, that the best of preachers must come down to earth occasionally.

The Peace Treaty, ratified by a sufficient number of European powers, became effective last month. Who said anything about a "Scrap of Paper?"

We are in receipt of a communication from the Secretary of the American Medical Association requesting information as to what was being done in Michigan in the movement that is being developed to provide opportunity for medical extension among our members. We were compelled to reply that up to now Michigan had given no consideration to the subject. The need of undertaking such work is apparent and should be discussed and plans developed without further delay.

Illinois, Ohio, Wisconsin and several other states have such courses. The general plan being to hold one, two or three day meetings and clinics in several localities in a state. Definite subjects are covered-fractures, obstetrics, physical diagnosis, heart and kidney diseases, etc. In selecting lecturers care is exercised to designate men who are known and who possess specialized information on the branches they cover.

We all are aware that the scientific practice of medicine today requires constant study. We also know many doctors find it impossible to devote the time or to assume the expense entailed in studying at a clinic or medical center. As a result the percentage is small of those who avail themselves of the opportunity of becoming familiar with scientific development. With a view of bringing such opportunity to all these extension courses are provided.

We do not hesitate in stating that such a plan should be developed in Michigan. Tentatively