Symptoms. At first the patient complains of weight and fullness in the rectum or pelvis when the growth is high up, associated as a rule with very little pain; but if the growth is situated low down in the anal canal the pain is an early symptom, undoubtedly caused by the abundant nerve supply of that region. The involvement of the sphincter muscles causes a tenements as the disease progresses. There is a frequent desire to expel the mass. Constipation is a marked symptom when the growth is high up. Blood, pus, and mucus are found in the stool when the ulceration is marked. Stricture of the rectum from carcinoma will sometimes produce the only symptoms of any disorder in that region.

During the early stages of malignant disease of the rectum the symptoms are usually attributed to some ordinary disturbances of the intestinal tract in the form of a diarrhea or constipation, as there is apt to be no pain, bleeding or discharge of mucus and the only symptom is that of a sensation of a fullness in the rectum which interferes to a slight degree with the normal evacuation of the bowel. As the disease progresses a feeling of fullness and weight at the location of the growth or in the pelvis becomes more pronounced. Pain which is referred to the sacrum, coccyx, or radiating down the limbs becomes constant in character. Later the patient complains of hemorrhoids, fissure, ulcer, a discharge of mucus or blood and a desire to empty the bowel at more frequent intervals. Constipation supervenes, alternated with diarrhea during the same day or at intervals of several days. The sufferer may begin the habit of emptying the bowel during the period of constipation with enema ta The mucus discharge, with blood, becomes more frequent and profuse, almost invariably causing alarm sufficient to warrant seeking medical advice at this late period of the disease. The discharge has a foul odor characteristic of the disease. The anal margin may become so irritated from the discharges that vegetation, excoriations and elongated tags of skin cause an intense prurient

The pain from cancer of the rectum which exists high up seldom causes much suffering until the growth encroaches upon the nerves located in the pelvis, and when it has assumed such a size as to cause obstruction. Disturbances of the bladder and involvement of the nerves supplying the pelvic organs and the legs are constant symptoms. The retention of fecal matter and gases above the obstruction cause symptoms of colic. Tenements is almost a constant symptom of the disease, when located around the anal margin, on account of the direct involvement of the sphincter muscles. Edema of the legs, as cites, intestinal obstruction, fecal vomiting and rupture of the intestine above the obstruction are common symptoms during the latter stages of the disease. The involvement of the uterus, vagina, and the destruction of all the surrounding tissue becomes almost inevitable as the disease progresses.

Diagnosis. The proctorial and kaleidoscope may be of service in these cases, but should be used with the greatest care and by an experienced person only for fear of rupturing the bowel. This disease illustrates most emphatically the necessity ≪>f an early examination by the physician. Cases in adult life presenting themselves for the treatment of chronic diarrhea associated with the discharge of pus. blood, or mucus from the rectum, or those giving the symptoms of rectal obstruction associated with pain or a sense of fullness in that region, are referred to the surgeon, as a rule, only after the disease has progressed so far as to make the chance of radical cure very uncertain should the diagnosis show cancer or sarcoma. The great mortality after operations for cancer and sarcoma of the rectum will continue until the chances for early operation are afforded more often.

Carcinoma is most likely to be confused with sarcoma for the reason that it extends over a long period and appears chronic in its course. One fully realizes that the patient is suffering from a disease that has been irresponsible to treatment.

Sarcoma occurs quite often in children, but cancer is a disease of adult life, with few exceptions-. Cancer tends to ulcerate early and involves the surrounding tissue, making its outlines very much less definable. Sarcomas metastases in some instances occur early, but the tumor does not involve the surrounding tissue as would occur at a corresponding stage with cancer. Cancer of the rectum in the majority of cases presents a circular, ulcerated, annular stricture at the time of examination. The examiner may easily determine the shape and the ulcerated condition of the growth, but attribute the condition to an ordinary catarrh stricture of the rectum and hesitate about a microscopic examination of the tissue for diagnosis. One should remember that stricture from any other cause, unless associated with an abscess or fistula from an inflammation, does not undergo ulceration and that the intestine may be almost completely obstructed before there would be sufficient traumatize to cause ulceration and degeneration of the constricting band.

Myxomatosis and fibroblasts tumors of the rectum are slow in their growth and do not produce systemic disturbance-, as cachepot or metastasis. They can hardly be confused with sarcoma or carcinoma of the rectum. Tuberculosis and inflammatory deposits are more apt to confuse one in the diagnosis of malignant growths of the rectum than any other disease, and a specimen of the tissue should always be promptly subjected to microscopic examination for diagnosis. Examination of the feces in growths of the upper intestine infrequently prove of value.

The disease may be confounded with proliferating proctorial (syphilis), sarcoma, papillary, multiple adenoidal and fibrous stricture of the rectum or sigmoid. Multiple adenoidal and papillary are very prone to a malignant transformation and are wisely treated from the beginning as carcinomas The same may be said for sarcoma, being malignant in character the prognosis is quite as bad. Syphilis should be differentiated from this group of diseases by microscopic examination of the tissue involved. This disease is generally manifested by syphilitic disease at some other portion of the body. It usually appears in the form of a proliferating disease of the entire rectum with the discharge of pus and mucus in great abundance. The protruding granulation are not inaugurated and are soft to the touch. The pathogenic odor of cancerous discharges from the bowel may further aid in distinguishing the disease from syphilis. A specimen of the growth may be obtained by means of the nasal scissors or with the specimen forceps. The latter cuts out a piece of the tissue with the two elliptical spoons which form its cutting ends. A piece of tissue may be obtained through the kaleidoscope at a height of twelve inches with this instrument.