of the greatest improvements in modern surgery. James Y. Simpson belongs the merit of this invention.

FISSURE OF THE ANUS.

To Sir

This affection is often mistaken for internal piles, and treated as a trivial matter. It is really one of the most important lesions with which the surgeon has to deal. It is often pronounced a simple excoriation or a hæmorrhoidal tumor; it may last for years before its real nature is recognized. It happens in females much more frequently than in males, and may be passed over as a trifling ailment, and even be attributed to hysteria. There is however, no other disease where the surgeon can promise so much from an operation as the one in question.

Within the last four years, I have known of four instances of this complaint in married ladies, where its existence was the cause of sterility. I know of no author, except Dr. Baker Brown, who has given instances confirmatory of my experience. In the cases in question, the patients were subjected to the most agonizing tortures, before, during, and after defecation. Three of these cases I have reported in the forthcoming edition of Dr. Hale's work upon abortion, and I will not therefore speak of them in detail. Suffice it to say a perfect cure followed the operations for fissure, and the patients became pregnant. In the fourth case, the result of which has come under my observation quite recently, the patient, a married lady, had had hypertrophy of the cervix uteri for twelve years, and during this time was not pregnant, although she had previously borne three children. For three years past, she had had, as she supposed, internal piles; upon examination, they proved to be a double fissure of the anus. To relieve her of this, I made two different operations within three weeks of each other. The fissures were perfectly cured, and her health, notwithstanding the hypertrophy of the cervix, was greatly improved. In less than one year after the operations she became pregnant.

Fissure of the anus is, I believe, seldom cured without resorting to the knife. In former years, I have tried every means in our art, not even neglecting the vaunted cucumber ointment emollient and astringent salves, extract of hamamelis, etc., but without effecting a cure. In making the operation, the folds of the anus must be separated, and then just within the margin of the anus, a fissure, crack, or chap will be discovered, which frequently extends up from a half an inch to an inch. This fissure must be freely divided with a sharp-pointed curved bis toury. Formerly it was thought best to divide the sphincter but this is seldom necessary, though in some cases it may be required; it may be divided subcutaneously with a tenotomy knife, as directed by Dr. Warren. If the fissure is of long standing and its walls are callous, or an ulcer is situated upon its anterior part, as sometimes happens, it is then best to seize with forceps the ulcer or callous portion, and carefully excise it from without inwards with a pair of sharp-pointed scissors.

A

The operation for fissure is always followed by relief, and a perfect cure is the result. Baker Brown reports operating in more than one hundred instances, and all were successful. second operation is occasionally necessary, especially if a second fissure should be present, let it be ever so small and insignificant. In a few instances that I have seen, the fine, sharp point of a stick of nitrate of silver effected a cure of a smaller fissure. In the past eleven years, I have had ten or eleven cases where I have operated with a successful result.

That diseases of the rectum and anus, especially prolapsus and fissure, may cause sterility is an interesting fact; and I should be glad to learn the experience of my honored colleagues, members of the Institute, upon this subject.

XVI.

CARIES OF THE ANKLE-JOINT.

BY J. H. MCCLELLAND, M.D., PITTSBURG, Pa.

I WAS called to see James S, aged thirteen, who was suffering with caries of the ankle-joint. The disease commenced about six or eight months before, during which time he had been under allopathic treatment. The ankle presented the usual appearance of caries and necrosis, swelling, pain, distortion, and numer ous fistulous openings. The probe revealed the fact, already apparent, that the ends of the tibia and fibula, and also the astragalus, os calcis, and upper row of the tarsal bones, were involved to such an extent that even excision was not justifiable and the only remedy was amputation. The patient was weak, emaciated, and suffered extremely. He was much improved and relieved by Bell.6 followed by Calc.30 and 200

The leg was amputated at the lower third by the flap operation; the arteries secured with silk ligatures; the wound washed with a weak solution of Calendula, and allowed to remain open for a short time in order to become glazed, and then closed in the usual manner with sutures and adhesive strips; after which a dry dressing was applied.

Arn., Acon., and Bry. were administered at different times, as indicated, during the first two or three days; then he took Calend.3 internally. The wound healed almost by first intention; not more than a tablespoonful of pus came from the stump. All the ligatures but one were removed before the seventh day; this one remained till about the fourteenth day.

At the end of two weeks he walked about on crutches, the wound being almost entirely healed, and the stump firm and round. The boy's health began to improve immediately, and he is now perfectly well.

Drs. Burgher, Hofmann, Willard, and others, were present, and rendered the necessary assistance in the operation.