Kramer’s operation and operations which advise the removal of portions of the sacrum are less frequently advised. It has been found that the rectum and an operable cancer can ordinarily be nucleated by means of an anterior and posterior proctorial as readily as with the removal of a portion of the sacrum, unless the hand of the operator is very large. When we consider the advantages of the combined operation even the modified Krasnodar operation seems to be useless, unless one is forced to make a sacral anus.

The combined operation for the removal of malignant growths of the rectum is probably the best. This procedure includes an abdominal route which allows one to nucleate a part or the entire mass; permits the descent of the rectum to the desired depth by detaching all of its dysentery; safeguards the circulation above the growth by cutting the superior hemorrhoid artery, and also allows the descent of the rectum without overstretching the sigmoid. The perinea route is then made use of for the final extirpation of the growth.

Hartman points out that there is a space just above the recto-sigmoid junction poorly supplied with blood vessels. These vessels are apparently without any anatomizing branches. This space seems isolated, as the gut below this area is supplied by the superior hemorrhoid and above by the lower sigmoid arteries. The superior hemorrhoid artery sends its terminal branches directly downward, anatomizing with one another but not with the branches of the lower sigmoid from above. Therefore, if the superior hemorrhoid is cut above its distribution to the rectum, the amputated gut between that part formally supplied by it and the portion above, so sparsely supplied by the sigmoid artery, will have an insufficient blood supply, which is very likely to result in a slough and retraction of the gut. This deficiency may, in other instances, terminate in suppuration, with death. due to infection of the peritoneal cavity.

The question arises in every instance where cancer is located above the floor of the pouch of Douglas as to how we may provide for proper circulation in that section of the rectum intended to take the place of the cancerous portion removed. The perinea route confines one to the sense of feeling in distinguishing the pulsating arteries. Therefore it is almost impossible to avoid tearing off the superior hemorrhoid artery while nucleating the rectum, when the growth is situated higher than three inches from the anus.

This study of the circulation explains some of the disastrous results obtained after the most careful technique in the operative procedure following amputation within this segment of the gut by the abdominal route; or when the rectum is pulled upon to such an extent as to interfere with the proper blood supply from the superior hemorrhoid artery in performing the perinea excision. The combined operation offers through the abdomen a clearer conception as to the limit of the perinea work, and, at the same time, discloses the extent of gut involved in the growth, in order that the amputation be made with a degree of assurance as to its nutrient blood supply. To sum up the advantages: It affords an opportunity to examine the adjacent organs, glands, and the metastases; allows a possible curettage; removal of glands; permits one to tie the superior hemorrhoid artery above its junction with the sigmoid artery, and permits stretching of the gut below this point to prevent strangulation from tension. Finally it allows the surgeon to cover up all the denuded surfaces; restore the mes-sigmoid to prevent retraction and prolapse; and to close the peritoneal cavity before beginning a perinea nucleation

The abdominal incision also permits one to resort to an artificial anus, if the growth presents such conditions as to not warrant total extirpation, or if the sigmoid attachments will not permit it to be carried down to be sutured at the normal position of the rectum.

It is very probable that many failures have resulted in death or stricture after the perinea excision from the tearing offshore blood vessels; or if by the abdominal route, from tying off a number of blood vessels within the dysentery as the gut is loosened from its attachments to the sacrum, without regard to the loss of blood supply.

The combined operation was first suggested by Counselor in [892, but literature does not give us any account of any effort on his part to safeguard the circulation. He simply loosened the peritoneal attachments of the gut above and below the growth and then passed a tape around the mass, through the gut and out through the anal opening, which permitted him to pull the neoplasm out by this route.

Weir modified this method because the forcible traction upon the tape spread the opening in the bowel through which it passed and allowed the fecal matter to escape into the peritoneal cavity. He ties the inferior dysentery artery at the promontory of the sacrum, frees the rectum and sigmoid down to the tip of the coccyx posterior and to the lower border of the prostate anterior Below the tumor two chloroform tapes are tied around the gut at a distance of about one inch apart and the gut cut between them. The neoplasm and the upper portion is drawn out through the abdominal wound and the growth is removed. The rectal end of the gut is then reverted through the anus by an assistant with forceps. Through this reverted portion of the rectum a long forceps is carried into the pelvis, and the upper bowel grasped and drawn down through the reverted rectum. Both ends of the lower and upper segment of the gut are then sutured together. To hold the parts from retracting, fixation needles should be passed through the paginated ends before beginning to completely suture these ends. The parts are then restored to their position after the removal of the needles reverted rectum.