The differential features of adenoid, papillary, and cancer are briefly enumerated as follows:

An exploratory tracheotomy is often justifiable in cases of cancerous involvement of the upper portion of the rectum or sigmoid for the purpose of ascertaining the nature of the growth or the possibility of its removal. The practice of introducing the entire hand within the rectum to discover the size, limitation, or fixation of such growths is not justifiable in view of the fact that modern instruments for the examination of this organ have proved most perfect.

When the abdomen is opened a knowledge of the possible involvement of other organs should be attained at the same time. The liver, uterus and the lymphatic glands should be carefully examined. The incision for an exploratory tracheotomy in all instances should be made in the same locality as for a colostomy, so that, should it be found necessary from the conditions of either of these organs, an artificial anus may be made at once.

By such means the uselessness of any attempt at removal of the growth in the rectum or sigmoid may be positively determined and relief afforded at once. This procedure is practically without danger.

Treatment. Malignant growths of the rectum and anus require radical treatment at the earliest possible moment as the safest line upon which the surgeon may direct his effort for permanent cure. There is no doubt that as our diagnostic ability improves results will be more gratifying. The radical operation for these cases should in all instances be advocated at the earliest possible moment to give these patients the one chance for enjoying the ordinary five-year limit. Cases that have extensively involved surrounding organs, making it very evident that an operation to remove these would sacrifice life, are not included in operable cases and are only subject to amelioration of their sufferings.

The treatment of cancer in other portions of the body by sear and violet rays has not proved satisfactory in cases of rectal malignancy, and it is with great expectation the surgeon is awaiting developments in this field that such treatment may be applied to these cases.

Chemical Caustics. The application of chemical caustics and thermocouple in this region are of little value, as the great pain which follows such treatment make it inadvisable A curettage will sometimes relieve the bowels by removing the necrotic tissue, but it does not in any way help to relieve the character of the growth and. therefore, is only temporary in its relief.

Inoperable Cases. Cases that are inoperable for radical methods can be made more comfortable by a left inguinal colostomy, as the irritation to the parts is relieved by turning aside the intestinal current, giving relief from the pain, diarrhea, fecal impaction and obstruction, besides affording an opportunity to irrigate the diseased intestine. The operation is attended with little danger and the patient is allowed several months of quite comfortable existence.

Forcible dilatation or revulsion requires a general anesthetic: is performed, as a rule, to relieve impaction and permit, for a short while, regular evacuations of the intestine, but it is attended with so little comfort and danger of rupturing the bowel, that it is not recommended excepting when the growth is in the anal canal.

Extirpation is indicated generally when the growth is movable and does not involve other organs, if no ganglionic involvement and metastasis has occurred, and when the patient's condition can withstand the surgical shock.

When the remote lymphatics and other organs and the pelvic bony structure are involved with low physical condition, rapid pulse, cachepot and fever, the extirpation of the growth is contraindicated. When the digestive apparatus is markedly disturbed, recovery after extirpation is greatly interfered with, due to the continued low vitality and the inability to assimilate blood.

In some instances, however, the liver or other organs may be diseased from some other cause; the growth may be adherent to adjacent organs or the lymphatics enlarged as the result of a simple inflammation and not involved in the malignant disease. When the growth is adherent to the prostate gland or seminal vesicular, an extirpation of part of these organs with the growth can be made, with expectations of radical cure.

The prognosis is much more favorable in adenoid and cirrhosis csrcinoma than in the medulla and squamous varieties. The question of informing the patient as to the true nature of the growth is probably best decided by the physician as circumstances and the mental stamina of the individual are to be considered. When the chances are greatly against a successful termination and palliative measures, such as a colostomy, are rejected, it then becomes almost our duty to inform the patient as to the nature of the disease. It gives the only chance for a prolongation of life, which otherwise may terminate after a long period of misery and suffering.

Palliative Treatment consists of antiseptic and astringent irrigation, cauterization, drugs, curettage, and surgical procedures for the escape of the bowel contents.

The diet should consist of beef, lamb, chicken, eggs, milk, broths and cereals. Sugars, fibrous vegetables and uncooked stsrches should not be given later in the disease, as the undigested residue of this class of foods act as irritants. Milk diet alone causes hard, irritating, fecal masses and for that reason should not be advised.

Irrigation of the diseased area, particularly when the growth has undergone ulceration, becomes an absolute necessity, on account of the odor, for the patient as well as those in attendance. The irrigation relieves the hard fecal accumulation above the mass and the irritation due to the diarrhea. Solutions of five per cent. Doric acid: Hydras, one per cent.; aqueous fluid extract Kramer five per cent.; dichloride mercury i-indoor or carbolic acid one to one hundred, are most satisfactory for this purpose. The solution may be sprayed upon the site of the growth, when low down, or when higher up the double current irrigation may be used, with the patient lying upon the side, or in the knee-chest position. Should the fluid not empty the bowel with the aid of the ordinary rectal irrigation, a small Wales bogie may be introduced through the constricting band and the small nozzle of a fountain syringe inserted into the hollow of the bogie to carry the irrigation to the desired point. The bogie should be introduced by the physician or an expert nurse so as to avoid the danger of rupturing the bowel at the site of the growth. Patients often gain flesh and strength under this diet and antiseptic treatment, and are certainly made much more comfortable.