Affections of the Sigmoid Flexible are characterized by pain in the left inguinal region of the abdomen. Pain in this region is quite as significant of sigmoid disease, as pain occurring in the right inguinal region is of appendicitis, only not as frequently involved. Affections of the sigmoid may be mistaken for ovarian disease or a left-sided appendicitis. The inaugurated sigmoid. "ilia roll," or "sausage shaped" roll are indicative of the chronic affections. Periodontists is an acute suppuration affection, characterized by symptoms resembling appendicitis which demand immediate operation.

Constipation and Fecal Impaction are interchangeable terms used to denote the complete or partial arrest of the regular fecal movements usual to the individual. The condition arises when there exists some growth, deformity or narrowing of the intestinal canal that causes a mechanical interference with the contents of the bowels. Impaction is generally understood to be an accumulation of hard fecal material at some particular point, by organic narrowing or spasmodic contraction of the intestinal canal. Either constipation or fecal impaction indicate a partial intestinal obstruction and give rise to symptoms similar in severe neglected cases.

Prolapse of the Rectum, as observed in the incomplete variety, suggests the picture of large swollen hemorrhoids, which it resembles pathologically as it is simply an exaggerated protrusion of the normal mucous membrane. Hemorrhoids are tabulated and usually bilateral. Polyp are easily recognized by the finger as a peculated mass.

An imagination of the upper part of the rectum, or third degree prolapse, may be distinguished by the concentric rings, cone-shaped, and the distinct space which exists between the wall of the anal canal and the protruding mass. The finger may be easily introduced and passed around the entire circumference of the in-paginated mass while in the other forms of rectal prolapse the mucous membrane is continuous with the skin of the anal margin. Rectal hernia may complicate insusceptible of the rectum, and can usually be recognized by the gurgling due to the contained gases.

Malignant Growths are diagnostician by being hard, nodular masses, or of cauliflower shape, and only protrude when forced downward by a large fecal mass. A fecal impaction producing this effect upon the growth can usually be felt through the abdominal wall. Patients are, as a rule, emaciated at this period of malignancy.

Stricture of the Rectum is easily diagnostician when located within the range of the finger tip, but when higher up the diagnosis becomes more difficult and the aid of the kaleidoscope is necessary. Many cases have been treated for stricture when later examination showed only hypertrophy-pied Houston's valves.

In examining for stricture the bogie is of very uncertain value as it is very apt to bend upon itself when it comes in contact with the stricture and confirm the belief that no constriction exists. The chief symptoms of stricture of the rectum are constipation, constipation and fecal impaction. It may be spasmodic which is very unlikely or due to a malignant or non-malignant growth.

Malignant and Non-Malignant growths may be differentiated by the following points:

Non- Malignant

1. A disease of adult life, but may occur in children.

2. The tissue feels like a hard ridge or a polypeptide growth, peculated.

Malignant

1. A disease of advanced life usually.

2. New growth masses feel like distinct tumors or as flat plates, within mucous membrane.

Non-Malignant

3. Ulceration when present does not greatly obdurate the edges.

4. The constriction includes the entire circumference.

5. Pain due to fecal impaction complained of during defecation only.

6. No glandular involvement.

Malignant

3. Ulceration evident when growth is breaking down.

4. Involves one side of the circumference more than the other.

5. Pain is the result of involvement of the sensory branches of sacral nerves.

6. The sacral lymphatics are enlarged and hard late in the disease with cancer, and early with sarcoma.

These growths are hard, nodular masses or of the cauliflower shape which protrude from the anal orifice only when forced out by a fecal impaction. The impaction can usually be felt through the abdominal wall in these emaciated subjects.

Fissure in No. Syphilitic fissures are usually situated laterally, and are multiple in the form of several small and a single large one. The lymphatics of the inguinal and femoral region may be enlarged. A blind internal fistula may be mistaken for a fissure, as both are attended with pain and tenements. The blind internal fistula pain is constant and exaggerated at time of defalcation; and is continuous until the discharge of pus from the fistulous tract; afterward, there is little pain for a variable time excepting when the bowels move. This cycle of pain recurs again within a period of a week or two and repeats the same symptoms. On digital examination a small amount of pus may be squeezed out, and found on the surface of the fingers, after withdrawal. The untrained finger cannot easily detect the edges of a fissure unless greatly inaugurated, but the localized pimple or inaugurated tissue about the orifice of the fistula may be distinguished between the index finger in the rectum and the thumb outside.

This inaugurated surface is never so sensitive as the floor of a fissure. It is possible to insert a small probe into the fistulous opening, but, as a rule, considerable dexterity is required to accomplish its introduction and withdrawal without causing great pain to the patient.

A fissure is simply a longitudinal ulcer extending from the much-cutaneous junction upward, and it is quite unnecessary to see its upper limit to make a positive diagnosis. Retraction of the skin about the anal orifice with the fingers suffices in the majority of cases to reveal the fissure. A fissure is usually so sensitive to the touch, and manipulation of the parts is so apt to excite spasm of the sphincter muscles, that the quicker the examination is made, the more likely the patient is to return for further treatment. It is a common experience to have sufferers refuse the completion of the examination. Such patients are the hardest to control under these circumstances, and will try one's patience and skill in the endeavor to make a satisfactory exploration of the lower rectum, when the co-existence of a fistula is suspected. Both lesions may be present at the same time, in which case the internal opening will be found in the floor of the fissure.