RADIOGRAPH OF THE PELVIC COLON after the injection of bismuth emulsion, showing a cancerous stricture at the recto-sigmoidal junction.

(OKINCZYC, Cancer du Côlon: Steinheil, Paris.)

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it should be made into a thick emulsion with olive oil; the quantity required is from 200 to 400 cc.

The patient is placed in the genu-pectoral position during the introduction of the emulsion, and a long rectal tube is passed into the sigmoid flexure by means of the sigmoidoscope, the instrument being afterwards withdrawn over the tube so as to leave the latter in place. Unless the tube is passed through the sigmoidoscope it is impossible to be certain that it is in the

Fig. 22.-X ray photograph of a patient after bismuth emulsion has been injected into the colon. The photograph shows extensive prolapse of the tranverse colon-visceroptosis. (After Schule, from La Presse Médicale.)

sigmoid. By injecting the emulsion through the tube we avoid distending the rectal ampulla and so causing tenesmus, the presence of the emulsion is more easily tolerated, and a larger quantity can be introduced. By placing the patient in the genu-pectoral position the emulsion is enabled to pass up into the higher parts of the colon.

If the patient is unable to remain long enough in this position. the injection should be given in the left Sims' position, and the foot of the couch well raised on blocks. The X-ray examination is made in the same way. The bismuth seems to be well tolerated by the bowel, and does not cause any unpleasant consequences as a rule. A stricture in the bowel is generally indicated by a dense shadow above and below it, but deceptive

Fig. 23.

-X-ray photograph of a patient after the introduction of a long rectal tube. Note that
the tube has curled up in the rectum and not entered the colon.
(After Schule, from La Presse Médicale.)

appearances are liable to occur. These methods of X-ray diagnosis in disease or abnormalities of the colon are comparatively new, and are only of use in certain cases. The results so obtained must not be too implicitly relied on, but used rather as confirmatory evidence.

The X rays are of the greatest value in localizing foreign bodies in the colon, and may also assist in the detection of stercoliths.

Diagnosis by Means of Rectal Bougies and Tubes.The use of rectal bougies for the diagnosis of strictures in the bowel was at one time very popular, but they have now been entirely replaced by the sigmoidoscope and similar instruments. It is well that it is so, for the use of bougies is by no means free from danger, and there have been numerous accidents due to perforation of the bowel wall; moreover, they are of very little value in diagnosis, as the end may easily be arrested by one of the rectal valves, and so give the impression that a stricture exists, when as a matter of fact there is none.

Diagnoses based on the passage of a rectal tube are quite valueless. One not uncommonly hears it stated that a patient in whose colon the presence of a stricture is suspected, has no stricture in the sigmoid flexure, because a rectal tube has easily been passed for two feet. This, however, proves nothing, as the tube usually curls up in the rectum, and although two feet of it have been introduced, the end may lie just within the anus. Any one who doubts this statement has only to examine the patient with X rays, after passing the tube, to be convinced; they will see the tube coiled up in the rectal ampulla (Fig. 23).

The only way in which a long tube can with certainty be introduced into the colon is by passing it through the sigmoidoscope.

It is very doubtful whether a tube can be passed up the bowel for more than six inches once in twenty times, and the so-called high enemas given with a long tube could be just as well administered with an enema nozzle.

Examination Under an Anæsthetic-This is a most valuable aid to diagnosis in difficult cases. With the abdominal muscles well relaxed, the whole colon can be palpated, and if a tumour is present it can usually be felt. A bimanual examination should also be made with two fingers in the rectum. If the sphincters are slightly stretched, the two first fingers of the right hand can easily be passed into the bowel, and this allows one to reach nearly an inch higher than if only one finger is employed. By bimanual examination, growths in the lower third of the sigmoid can usually be felt through the anterior rectal wall. Abscesses in the iliac fossæ can also be felt, and the pelvic organs explored.

The examination should first be made with the patient lying on his back, and he should then be turned over on his side, and