"It will he observed that having tied off the main blood vessel supplying this loop there will he little or no hemorrhage and no pain in this resection; and there is no danger of peritoneal infection, as this cavity will have been closed off after the first five or six hours. Four or five days, almost a week, should elapse before the clamps are put in to cut away the spurs. I use a Pryor's hysterectomy clamp, and introduce it well down into the two legs of the artificial anus; it takes from three to seven days for this to cut through before the forceps come away; 1 then introduce through the rectum a No. 8 Wyeth modified Wales bogie, passing it up beyond the artificial anus. Its tip will usually come out of the artificial anus, but it can be reintroduced and carried into the upper leg of the spur. Its elasticity will press the spur backward and cause the mouth of the artificial anus to roll inward. This bogie is left in for two hours, three times a day.

until with soft rubber Wales' bogie the wound caused by the cutting away of the spur has healed, thus giving a wide aperture for the passing of fecal material downward.The next step consists of dissecting the edges of the artificial anus away from the skin and the fascia of the abdominal wall down to the peritoneum; the aperture in the gut is then sewed up by one row of through-and-through sutures and one of Alembert’s; these must be carefully placed, the first being of silk and the last of fine chronic gut - this being accomplished the peritoneum is stripped from the abdominal wall for about a half an inch all around the wound; the cicatrice tissue and fascia is trimmed away and three or four double anchor-ING sutures threaded upon agate buttons are passed across the wound and out upon the skin upon either side, to about one inch away from the margin of the wound. The buttons serve as bases for the sutures to rest upon and prevent their cutting into the skin, and render them much less painful than the ordinary sutures; and if the wound should gape one can twist the button like a tourniquet and bring the parts close together. After the sutures have been tightened, an ordinary subcutaneous suture is used to bring the skin together.

Fig. 72. Turtle's three-step operation. Second step -clamp in position to cut away spur.

It is not presumed that every one of these cases will heal perfectly without a small fecal fistula, but in time they will all close up. The operation is not so brilliant as that of end to-end or lateral Anastasia when these succeed by primary union; but it is much safer, in fact, barring some unforeseen accident, I see no reason why we should ever lose a resection by this technical It is slower, to be sure, and the patients chafe under the artificial anus during the first step, but when they learn the conservatism of the method and the great risk avoided, they are well satisfied."

Fig. 73. Tittle’s three-step operation. Crushing spur and widening lumen of gut

Posterior Proctorial is indicated when urgent symptoms of obstruction exist, and may be performed when the growth is located in the lower three inches of the rectum. External or complete proctorial consists in making a complete incision through the growth, sphincters, and all the tissues backward to the coccyx. Internal proctorial is performed with less shock and bleeding if care is exercised to limit the incision. The incision should be made with a probe-pointed knife, which is carried above the mass and afterward drawn down through the growth, cutting deep enough to relieve the obstruction. The growth should never be incised anterior for fear of injuring the adjacent organs. Sometimes, particularly when cutting from within the growth, several incisions may be necessary in the posterior lateral walls. The wound should be packed tightly for at least twenty-four hours to prevent hemorrhage and the lumen kept open by passing a Wales bogie of soft rubber two or three times each week.

Fig. 74. Tittle’s three-step operation. Third step-closure of artificial anus and abdominal wall.

Dilatation by forcible means requires the administration of a general anesthetic. Since the procedure takes very little time, ethyl chloride is very satisfactory for this purpose. The fingers make the best and safest dilators, as the condition of the growth is easily recognized and large tears avoided. Dilatation will also necessitate the after-treatment with bogies and the careful regulation of the bowel movements to a soft consistent mass. Impaction very quickly follows the smallest arrest of fecal matter.

Radical Treatment. The radical treatment aims to remove the growth and involved structures in their entirety. This procedure is the only one which offers the patient any hope of permanent cure and should be advocated at the earliest possible time. Statistics lead us to believe that one out of every five cases survive time limit for recurrences, and when we consider that death eventuates in every case unless operated upon, it seems that the chance should be advised. The radical operation deals with those cases involving the mucous membrane of the anal canal and rectum and which do-not include the skin of the anal margin. The operations for the radical removal of malignant growths of the rectum are almost innumerable and history covers the gradual involvement of our modern operations for this purpose.

The Krasnodar and Disfranchise operations for the radical removal of rectal cancer have been modified to meet modern ideas since their originators first described them, so that all our present day operations still bear a great resemblance to either or both.