Drugs can do no more than add to the comfort of these sufferers. Intestinal antiseptics which control digestive disturbances, and stimulation in the form of strychnine are indicated. Morphine or opium should not be employed until the patient suffers from severe pain, as the diarrhea can be as easily controlled with the irrigation. Opium will disturb the digestion and interfere with excretions.

A curettage is indicated when the growth is soft and situated upon the posterior wall of the rectum, and particularly when the loss of blood is a constant drain upon the system. The wound should be irrigated with hot or cold water after the curettage and a drainage tube inserted and retained for a few days. This procedure will accomplish quite as much in some cases as an artificial anus. When the growth involves the anterior walls of the rectum there is great danger of penetrating the peritoneal cavity while curettage Chloroform gauze to control the bleeding is likely to cause toxic symptoms when left in the rectum.

Cauterization for controlling the bleeding and to enlarge the lumen of the bowel at the site of the growth is likely to cause peritonitis through radiation of heat or the actual penetration of the bowel wall. It is much better, when possible, to clamp the excrescences with the ordinary hemorrhoid clamp, then cauterize with the Jacqueline cattery Chemical cauterizes are dangerous because of our inability to definitely control their action.

The surgical palliative procedures are intended to serve the same purpose as colostomy, relieving the bowel of its contents without helping to interfere with the progress of the growth.

An end-to-end Anastasia may be performed when the diseased mass is located in the sigmoid flexible, which permits enough free gut to be brought out of the abdomen to properly manipulate it in making the Anastasia The operator intentionally leaves the diseased segment with its presenter attachment in sit, and anatomizes the two free ends of healthy gut.

Lateral Anastasia may be employed in cases where the tumor is situated high up in the rectum, above the elevators an, or in the sigmoid flexible There must be sufficient healthy gut to permit an Anastasia below the growth.

The Threes-Step operation in tumors of the sigmoid colon, originated within the past year by the late James P. Cuttle of New York, is a most ingenious and safe procedure for the extra-peritoneal excision of neoplasms and tight strictures of the sigmoid, or to effectively treat a severe case of diverticulitis. He emphasizes the great danger of infection and death from resection by end-to-end or lateral Anastasia, and claims to have had no deaths in four cases operated upon by him by this method.

He assumes that the growth is above the recto-sigmoid junction and movable, otherwise the operation is impracticable from the present standpoint of his experience. The technique written by Cuttle in the Parasitologist of September, 1912, is as follows: "The incision is made through the outer margin of the left rectums muscle; we make this incision because if it proves impossible to remove the growth it is one of the best incisions for the exit of an artificial anus. Care should be avoided not to wound any of the large veins that run along this region. The abdomen having been opened by an incision three or four inches long in order to give plenty of working space, the patient is placed in Trendiness’s posture, and the small intestines are lifted out of the pelvis and packed up as high in the abdomen as possible. The sigmoid is then caught and pulled out of the abdomen; the peritoneal covering of mes-sigmoid is slit along for a distance well above and below the tumor (Fig. 71); this incision should be made on each side and rather close to the gut itself; the peritoneum is then peeled back to the posterior abdominal wall or rather to the crest of the ilium.

Fig. 71. Turtle's three-step operation. Sigmoid with tumor on abdominal surface. Shows peritoneal layers of mes-sigmoid cut and sutured over leaving no raw surface in abdominal cavity. Two layers of sutures are used to bring the two legs of the sigmoid into apposition.

"The blood vessels and their containing cellular tissues and glands are exposed, and the loosening of the peritoneal bands will allow the gut to be brought out upon the abdominal wall. All glands and fatty material around the blood vessels supplying the part of the gut which is involved in the growth are pulled or milked away toward the gut. thus exposing the blood vessels. The artery and veins can then be clearly seen, and the main vessel supplying the involved portion is cut and tied in two places, as will be seen in Fig. 71.

The gut is thus loosened and can be pulled out of the abdominal cavity. The stump of the blood vessels is pushed back between the two peritoneal layers of the mes-sigmoid; these two layers are stitched together, thus covering up all the nude surface in the peritoneal cavity. The two legs of the loop of the sigmoid are now brought together by one row of sutures running along the border of the dysentery, well down to the peritoneal cavity; they are then rotated on themselves and another row of sutures is run the same level along through the long muscular bands of either leg down to the peritoneum as before, thus bringing the flat surfaces of the gut together.

"The peritoneum is now stitched around the two legs, with the tumor brought well outside the abdominal cavity, and after this the gut is stitched to the skin; it is then covered with rubber tissue and left in sit from 24 to 72 hours, according to the condition of the patient. If there is any indication of obstruction a puncture can be made in the upper loop allowing the gas to escape, or, if gangrene should be imminent in the loop exposed, there is no reason why it should not be execised any time after 18 hours or less. In my second last case I excised the growth in 20 hours after the operation, without any complications. When the gut is excised it should he done by a V-shaped incision, as in Fig. 72, in order that there may he abundant material for bringing the ends together at a later period.