When the tumor is low down and less than two inches from the anal opening the perinea operation is advocated. But if it be found that there is too great tension on the superior hemorrhoid arteries, interfering with a good circulation, the field of operation should be packed with gauze and the abdomen opened to relieve the tension by freeing the sigmoid and blood vessels in the manner described above. An assistant should then pull the gut down the required extent. After this is done and the distance measured, one can then proceed to repair the peritoneal floor of the pelvis and close the abdominal wound. The gut should then be sutured at the anal opening. This method affords one the opportunity of relieving the strain upon the superior hemorrhoid artery by the abdominal route, as suggested by Shallot This procedure may be reversed in the manner practiced by Hartman, by going through the abdominal cavity first, freeing the blood vessels, closing the peritoneal floor and restoring the mes-sigmoid prior to pulling the gut down to the required extent from the perinea end. When the tumor is low down the perinea nucleation of the mass should be tried first as it offers the possible avoidance of opening the abdomen in many instances where the tension upon the gut does not interfere with the circulation.

Objections against the combined operation. The extremely high mortality associated with the performance of the combined operation for the removal of malignant growths of the rectum is probably due to a lack of technical knowledge and dexterity in its performance, when we look at the subject from a clear honest viewpoint. The mortality is decreasing as our technique and experience improves in the thorough preparation of the patient before operation, combined with that necessary anatomical knowledge of the structures which surround the rectum and its blood supply.

Shock is probably one of the most frequent causes of death within the first few days after this operation, resulting probably from the prolonged anesthesia and the traumatize to the abdominal viscera. Some surgeons advocate as a preliminary measure to offset sepsis, the establishment of an artificial anus in all cases, whether the perinea method alone is the choice, or the combined abdominal-perinea operation is to be performed.

An artificial anus does not permit more radical surgery or add to the safety of the patient only when the growth has assumed the proportions of a stricture, causing partial or complete obstruction. When obstruction exists to such a degree that the patient suffers from a chronic or prolonged debilitating auto-intoxication, it is our duty to relieve the condition some weeks prior to the operation, so as to allow him to recuperate sufficiently to withstand the intended operative procedure. The absorption of the retained intestinal contents and the septic material at the site of the broken-down cancerous tissue is the cause of much of the patient's suffering. When a colostomy is done and a temporary artificial anus established we are put to the necessity of again operating upon the patient to close it, though this may be postponed until conditions are auspicious for its performance.

The exact amount of gut which can he measured to reach the anal opening by the abdominal method is in itself one of the strongest points in favor of this procedure, as when operating by the perinea route upon a growth high up one can never tell the exact degree of tension put upon the blood vessels at the time of operation and cause later destruction of the gut by a circulatory failure.

The danger of septic infection of the peritoneal cavity should not he greater than when performing any of our abdominal operations for the removal of the ovaries, uterus or the appendix, if the technique is carried out in the manner described,-restoring the peritoneal floor, suturing the reflected dysentery in its place, and closing the abdominal wound before proceeding further with the perinea nucleation

Inferior Proctorial is performed when the growth is located in the lower three inches of the rectum and when the gut can he pulled down without overstretching the dysentery or blood vessels, which would interfere with the circulation and cause retraction of the rectum after fixation to the anal margin.

The operation is known as Disfranchise, or the perinea excision of the rectum, and is modified by different surgeons to meet the circumstances prompted by their own ideas. The technique is as follows: The patient is prepared and placed in the lithology position with the limbs well flexed upon the abdomen and held in position with leg holders so that the buttocks extend well over the end of the table. A catheter or sound is introduced into the bladder as a guide against injuring the urethra. The sphincters are stretched with the thumb or the dilator, and to prevent inadvertent injury of the rectum itself during its nucleation from the surrounding tissues and organs it is a wise plan to lightly pack it with gauze so that one can easily recognize it during the entire operative reduce. A circular incision is made superficially to the external sphincter, deep enough to permit grasping the rectal mucous membrane with T-shaped forceps, which are held by an assistant.

The sepsis of this operation may be greatly improved at this step by tying off the freed end immediately after sufficient of the rectum is nucleated to permit doing so. The freed end should be then cauterized with the Jacqueline cattery and all the instruments used and the hands again sterilized. In order to facilitate operative procedure, an incision is made without injury to the rectal mucous membrane, through both sphincters as far back as the coccyx.