The symptoms at times may be grouped together, as they are almost constant accompaniments of this disease and one might easily make a partial diagnosis by discovering a fissure or prurient an and leave the ulcer undiscovered. This point will emphasize the necessity for the introduction of the finger or proctorial, to exclude the presence of the ulcer. A fissure in anew or prurient an, in many instances, is secondary to an irritation of the rectum, sigmoid or colon, so that a fissure would simply be one of the indications for a more thorough examination and study of the disease. Pain shooting down the legs is very often associated with rectal diseases, and coccyx is often the reflected irritation of a hypertrophy catarrh proctorial.

Symptoms. Diseases of the colon, sigmoid and rectum are, as a rule, manifested by the presence of indigestion, flatulence, loss of appetite, irregularities of the bowels or protracted constipation. Each of these disorders produce characteristic symptoms of disturbed physiological balance, as well as local manifestations in the form of the mucous crisis, of mucous colitis, or a weak and dyspeptic condition, the result of an strophic catarrh condition in whom the assimilation of food results in emaciation and weakness, aggravated by severe constipation.

The presence of spasmodic or periodic dyslexia in the genitourinary tract without an apparent cause, may indicate the presence of a disordered digestive apparatus associated with a catarrh condition which brings about auto-intoxication and irritation. The presence of mucus, blood, or pus in the fecal discharge should in all instances indicate a spectroscopic or kaleidoscope examination. A tendency to diarrhea, and in fact the regular movements of the bowels before breakfast. will indicate irritation of the sigmoid and warrant an examination.

Sensations of constrictions or weight in and about the pelvis, particularly in male subjects, would warrant investigate sons. An examination should be made of the heart, chest, kidneys, and the urine in all instances of protracted colitis.

Sometimes the amelioration of either form of a colitis is dependent upon the rectification of a physiological disorder in either of these organs. Kidney and heart disease, in my experience, have been the underlying cause in a few cases.

One should question the patient as to the state of the bowels, getting accurate information as to whether the bowels are regular, and whether this regularity is disturbed by a periodical diarrhea, which would indicate a catarrh condition. Pain varies with the different affections in this region, from the sharp pain of the fissure brought on at stool to the less severe pain of an ulcer high up. The pain may be described as acute, cutting, burning or a dull ache. If one remembers that acute pain is seldom found higher up than the much-cutaneous junction, its location can be fairly made as a disease of the rectum, rather than the anal canal.

Special Preparation. The special preparation of the patient in most instances is not necessary for an examination which is not intended to include the rectum and sigmoid. Ordinarily, the separation of the buttocks will reveal diseases affecting the anal ring. When an examination of the rectum, colon and sigmoid is intended, the patient should be directed to avoid taking a laxative on the day of examination. It is a better plan to instruct him to move the bowels with an enema an hour or two before examination, the idea being to offset the loose, wide-spread liquid movements which follow the administration of a laxative. A simple enema ordinarily cleanses out the lower portion of the bowel very much more effectively than laxatives.

A Simple Enema. An enema to be most effective should be not less than two quarts of fluid, either plain water or soapsuds, and the patient should be directed to lie upon the right side or in the knee-chest position when it proves very effectual. The fountain syringe should not be elevated more than two or three feet above the body so as to avoid too great force. Various devices have been made for this purpose, but the ordinary fountain syringe serves every purpose for giving rectal irrigation or enema ta. It is provided with tips which are most suitable for the purpose. An enema may be given through a medium-sized, soft-rubber catheter or a Wales bogie.

Fig. 6. Sims's position with patient assisting in exposure of anal ring.

The question as to the use of long rectal tubes or catheters for the purpose of giving colonic or sigmoid irrigation is probably settled as being unsatisfactory, for the long tube or catheter in almost every instance curls upon itself in the rectum and is of no more service than the short tip of the fountain syringe which reaches beyond the sphincter muscle. The position of the patient makes the thorough cleansing of the entire large colon an easy matter when no obstruction exists

Resinous cathartics and glycerin act as irritants to the mucous membrane of the rectum and should never be administered prior to examination, as they often exaggerate the condition. Glycerin, on account of this irritating property, is of service when the protrusion of the hemorrhoid area is desired prior to an operation in the office under local anesthesia.

The Position of the patient will depend upon the condition of the disease in most instances. Affections of the anal orifice can be determined in the knee-chest position, or Sims's position, most easily.

Sims's Position (left lateral) is best suited for the examination of the colon, sigmoid, or rectum with the kaleidoscope but is varied according to the individual idea of the examiner. The patient is probably more comfortable and less embarrassed in the Sims's position than in any of the other positions.