The under surface of the blades are grooved to a depth even with the upper surface of the slots. This groove is wide enough to exert no pressure of consequence on the base of the tumor. The under surfaces of the blades are rounded to facilitate suturing and the heel of the instrument is properly smoothed off. The upper portion of the clamp blades above the slots and the groove come together with serrated edges which will give as firm grasp of the tissues as is needed. A-Clamp edge which exerts its pressure outside the line of incision The use of the instrument is simple. The usual preliminaries of stretching the sphincters and cleansing the field are attended to; the tumors are brought down to suit the operator's convenience; the clamp is applied parallel to the long axis of the gut and with the heel of the instrument toward the center of the anal orifice; proper pressure is made by the clamp blades; sutures are then passed under the instrument, its rounded under surface facilitating this procedure; a blunt-pointed bistoury or thin scalpel is inserted in the slots and the hemorrhoidal area separated thereby. The clamp with the hemorrhoid is removed and the sutures tied. Either continuous or interrupted sutures are used, usually of catgut of a size suited to the exigencies of a given case. The idea in this instrument is that the lips of the cut surface have not been injured by the crushing of the clamp blades, consequently if proper sterilization of the field has been carried out we may as well expect primary union here as in any part of the body; and if primary union fails to result, there is no sloughing mass which has to be cared for and healing is advanced by just so much. Some surgeons advise to cut off a hemorrhoidal mass and suture it as we do in any other wound, but there is danger of the incised base of the tumor retracting up into the bowel before sutures can be applied, and sometimes the hemorrhage from such an accident might easily reach the danger point. The operation with this clamp has all the advantages of clean cut surgery and brings the field of operation always under the operator's control. Curts, Norris & Co., 31 West Mound street, made the instru ment. JACKSON ON THE SKIN. A ready reference hand-book on diseases of the skin. By George Thomas Jackson, M. D. Chief of Clinic Instructor in Dermatology, College of Physicians and Surgeons (Columbia University), New York. Fifth edition, enlarged and thoroughly revised. In one 12mo volume of 676 pages, with 91 engravings and three colored plates. Cloth, $2.75, net. Lea Brothers & Co., Publishers, Philadelphia and New York, 1905. The great value of this new (5th) edition lies in the clearness of its symptomatology and diagnosis, and the excellent judgment used in its therapeutic recommendations. The demand for five large editions is ample evidence of the popularity of the book. The present revision has been particularly searching, and the subject matter has been brought up to date. THE PROCTOSCOPE AND COLONOSCOPE IN THE DIAGNOSIS AND TREATMENT OF DISEASES OF THE LARGE INTESTINES. BY WELLS TEACHNOR, M. D., COLUMBUS, OHIO. The proctoscope and colonoscope are tubular specula designed for the purpose of viewing the interior of the rectum signomid and descending colon. The essential adjuncts for their proper application are the Sims or knee-chest posture for which especially devised tables have been constructed for the purpose of making the patient comfortable in this position for prolonged examination and operation. This, however, is not absolutely necessary, as the patient can assume the posture on any solid, flat table for sufficient length of time for ordinary examination. Ballooning of the rectum by atmospheric pressure. This merely requires under normal conditions of the rectum the removal of the obturator from the scope after it has been introduced a sufficient distance to clear the sphincter muscles, and light to illuminate the now smooth and cylindrical canal. This may be either natural or artificial in a majority of rectal cases, the former if it can be received in generous quantities will be found quite satisfactory, but for high examination reflected artificial light from a head mirror or an electric light contained in the instrument with battery attachment which gives a general illumination of the gut, will be found absolutely necessary. In the absence of either one of these agents a successful examination will be out of the question. Their development was the result of the principle demonstrated by J. Marion Sims, in 1845, that a hollow viscera would inflate by atmospheric pressure if the orifice was open at a time when the hips were elevated above the chest. Many surgeons of note took this suggestion and began to make application of the same principle in the examination and treatment of the rectum. As a result, many instruments of this character were devised which gave very satisfactory results in examination of this organ, but it remained for Howard Kelley to systematize the method and arrange a complete outfit of tubular instruments. His efforts cleared the way and established a rational method of intestinal investigation. By their means, accurate diagnosis and exact location of the disease within the canal can be readily made. In fact, their perfection has established a new era in diagnosis of intestinal diseases, and has made possible a rational method of local treatment which is far superior to the older methods of irrigation and sounding without the sense of vision. He, therefore, may be rightly called the father of proctoscopy, and due credit should be given for his efforts in this line. Prior to the introduction of these instruments, exploration of the upper rectum and colon for the purpose of diagnosing and treating disease was practically an unheard of procedure. The rectal speculum which gives a limited view of the first three or four inches of the bowel was the only means in our possession for making such investigation. However, a great variety of specula were devised. There are by-valves, conical and fenstrated, all serving their purpose in a circumscribed way. Their construction does not conform to anatomical relations of the part, and their introduction and manipulation are so painful that examination by this means has become so unpopular that a great indifference is shown by the physician to individuals suffering from disease of this region, and at the same time the patient receives the impression that such examination means pain, and often defers treatment until disease, oftentimes readily curable, does irreparable damage. The construction of the proctoscope being complete it was not long, however, until the fact became known that under certain conditions as chronic inflammation of the mucus membrane and hypertrophy of the rectal valve, the gut would fail to inflate to a degree sufficient to make vision perfect. This lead to the construction of a pneumatic attachment, which consists of a cap fitting over the end of the scope after the obdurator has been withdrawn, when it is evident that the gut will not dilate sufficient for inspection. The cap not only prevents the escape of air, but affords means for inspection at the same time. An ordinary hand. bulb is used to pump air into the bowel, or if it should be convenient, the cut-off of a compressed air tank can be attached to the cap in an opening made for the purpose, when the air can be turned on in sufficient quantities for complete dilitation. By this means, intractable cases can be overcome and much higher examination can be made than by natural inflation. With a thirteen-inch scope under high pressure, about eighteen inches of the large bowel can be inspected; beyond this, the instrument will impinge either on the liver or the diaphragm. In connection with this procedure just described, it requires not only practice and a knowledge of the normal anatomy of the part, but tact, in order to bring out the diagnostic value of these instruments. Rectal examinations are decidedly unpopular at the best, so it is necessary to inake a complete and successful examination to have the utmost confidence of the patient. The bowels should be cleaned by a cathartic followed by an enema just before the examination. An unnecessary display of instruments before the examination is liable to have a bad effect on the patient. While they are neither formidable or grewsome, it is hard for the patient to understand that their use will cause little exposure and no pain in the absence of active ulceration in the anal region, such as ulcerated hemerrhoid and fissure. I have had patients say to me that the introduction of such an instrument would be impossible. In a well-appointed examination, there should be no exposure except the interior of the rectum, therefore, your future connection with the case depends largly upon your tact in bringing about such an examination when required and your skill in conducting it without pain or exposure. Of all the essentials for examinations for disease, that of the sense of vision is the most certain method of acquiring the exact nature and location. Many of the local diseases that come under the eye when the anus is exposed to inspection as a patulos condition of the orifice or a pathological discharge are expressions of disease higher in the intestinal canal and should immediately demand a thorough exploration with the colonoscope. I believe the rectum should come in for an examination in all chronic disorders of the intestinal canal whether the symptoms point directly to it or not. To be accurate, the physician must first familiarize himself with the normal appearance of the mucus membrane. He must be able to distinguish between the normal livid color of the anal mucus membrane and the pale anemic appearance of the membrane in the upper chambers in chronic inflammation. When this is accomplished the inflammatory conditions so often affecting the large intestines can be easily observed and made accessible to |