The Exaggerated Lithology Position is seldom excepting for fistula which involve the recto-vaginal outlets. This position is one most commonly used by American surgeons when operating under a general anesthetic; the English surgeons prefer the Sims's position.

The Knee-chest Position (gen-pectoral) has been less commonly used since the invention of the pneumatic instruments for the examination of the rectum and sigmoid. With the old instruments the inflation of the bowel had to be brought about by assuming this position. When the patient is put in the knee-chest position, the abdominal organs readily fall towards the diaphragm, not only permitting the entrance of air, but straightening the rectum and part of the sigmoid. When one has only the old-fashioned instruments for the examination of these patients this position will be found quite satisfactory.

The Brandenburg Position is of service in operating under a general anesthetic, when the abdomen is opened for the extirpation of a malignant growth or any surgical procedure necessitating the exposure of the rectum and the adjacent organs. This position of the patient under such circumstances is readily indicated and the surgeon is usually forced to an appreciation of its value.

Office Arrangement. Physicians who intend to give their conscientious attention to rectal diseases should provide such surroundings as will afford an opportunity to carry out the work properly.If possible the location and arrangement of offices should provide for a reception, a consultation, an ex ambling or operating, and a recovery room. The recovery room is an absolute necessity in the treatment of rectal diseases, gynecology, or any surgical treatment that causes the patient pain or weakness. The recovery room will not only prove valuable for the rest and comfort of patients, but will afford an opportunity for the treatment of another subject during the time that might otherwise be spent with a patient after operation.

The operating and consulting rooms should be, if possible, somewhat away from the reception room. The operating room, for rectal work, should be patterned after those adopted by hospitals and sanitariums and provided with tiled or enameled ceilings and walls, lavage and a sewer connection just under the operating table. The latter will allow irrigation to be carried from the operating table to the sewer without flooding the floor. The location of the operating and examining rooms should be one that will provide the best light during the office hours in the afternoon or morning. A white interior with as little wood work as possible will give the patient the impression of cleanliness and make cleanliness necessary, as any slight soiling will be conspicuous. The furniture necessarily consists of a surgical table, sterilizer stand and other requisites which may be added according to the ideas of the physician.

The Examining Table. An examining table is preferable to the surgical chair. There is no doubt but the patient is much more comfortable when examined upon the table, not only from the advantage to the examiner, but from the sense of greater security. The chair in which the patient is placed, put into the recumbent position by means of a crank, then turned on the side or in the knee-chest position, is very confusing, embarrassing, and intimidating to many persons. It seems that the simpler and stronger the examining table can be made the more reassured the patient is of getting through the ordeal without pain.

Fig. 7. Knee-chest position.

It must be remembered that many individuals have never undergone an examination for rectal troubles and they are exceedingly awkward in assuming even the simplest position. Often patients will turn on the abdomen when instructed to turn on the back, or become confused as to the right or left side, and there is a certain amount of danger of having them roll off the table before they have assumed the proper position. They are all more or less nervous and excited and in fear of pain. Should an ordinary kitchen table be used a cushion should be provided to counteract the hardness of the table and at the same time protect the patient's buttocks. The tables built by W. W. Allison and Clark & Roberts Co. have all these requirements, and can be used for minor operations if necessary, by simply protecting the cushions with the Kelly pad.

The Light. A suitable light for illuminating the rectum, either by the aid of a head mirror or the spectroscopic instruments, should be provided. A most satisfactory light which may be reflected by the head mirror can be provided with the Welshman burner and ordinary illuminating gas. Acetylene gas, used in specially designed lamps, is a most satisfactory light where circumstances force one to put up with the annoyances of these devices.

A gas bracket lamp provided with a number of joints which can be turned into almost any desired position for external examination, fitted with a strong magnifying glass and reflector, makes a very useful device. Head and reflecting mirrors are especially useful in the examination of the rectum and for locating fistula and fissure of the anal ring. The reflecting mirrors used by the throat specialists, with the long handle bent at right angles to not obstruct the view, can be introduced into the proctorial.

Specular. The choice of a speculum for rectal examination is ordinarily a matter of much concern to the inexperienced examiner for fissures, fistula, prurient an and hemorrhoids, but the use of the speculum is often unnecessary as either the sight or sense of touch is sufficient to make a diagnosis. Ulcerations higher than the external sphincter may have to be examined with the speculum. The ordinary Sims's speculum, used by the gynecologist, is a most practical instrument for prognosticating ulcers in the lower part of the rectum and anal canal. Bivalve specular such as the Sims's rectal speculum.