Fig. 78. Skin incision for perinea mastectomy Birmingham’s method.

Fig. 79. Perinea extirpation of the rectum. Que nus method.

The nucleation of the rectum is now commenced. The T-shaped forceps may be swung from right to left in order to permit access to the attachments to the surrounding tissue and the dissection is ca raid on with the fingers, the knife or the blunt scissors, as necessity demands. The use of the sharp-pointed scissors or the knife is to be condemned during this process of nucleation Only when deemed absolutely necessary should a sharp pointed instrument be used, as the danger of button-holing the bowel, the urethra, or the vagina is very great. The renucleated-ton will be found to be very much easier posterior than anterior on account of the anterior portion being so closely attached to the bladder, urethra, prostate gland or the vagina.

When the nucleation has progressed so far as to allow the growth to be free from its attachments and sufficient of the gut loosened above it to permit it to be drawn down to make the new rectum, the bowel should be amputated an inch above the growth. It is then united to the skin by interrupted catgut or silk sutures passed through the entire thickness of the rectal wall. The ends of the divided sphincters and the elevator an muscles are approximated by buried catgut sutures and a gauze drain is inserted at the coccyx end of the posterior wound. The remainder of the wound is then closed by a continuous suture.

Primary union seldom results, owing to the tension on the gut and blood vessels. In some instances, especially when the growth is large, it is impossible to bring the end of the rectum down far enough to attach it to the anal margin and the wound is permitted to heal by granulation This misfortune seldom happens with the more scientific and safer methods advised by the advocates of the combined operation, as the measurements are most exact and a control of the field of operation almost perfect.

Fig. 80. Perinea extirpation. Freeing rectum from anterior attachments.

Colo-hysterectomy or the imagination of the colon through a slit in the anterior wall of the rectum. This operation was originated by Kelley, of Baltimore, to avoid making an artificial anus, and consists simply of the implantation of the end of the colon or sigmoid flexible into the rectum. It is the operation of choice when the growth is situated in the upper rectum or sigmoid.

Fig. 81. Completed perinea extirpation of the rectum.

The technique is as follows: The patient is placed in the Brandenburg position and an abdominal incision about four inches in length is made over the left lines-alba and the peritoneal cavity opened. The small intestine and momentum are forced inward toward the diaphragm by tracheotomy The growth should then be exposed, but cutting the mes-sigmoid about one-half inch from its attachment to the gut, down to a point where the gut appears to be healthy. A ligature should be tied above and below the growth. The tumor is then drawn out of the wound, removed and excised. The ends of the gut should be cauterized after protecting the surrounding tissue, with gauze, from being soiled. After having been cauterized, the edges of the lower segment should be paginated and closed by Alembert’s sutures. Four long traction ligatures are introduced at equal distances in the circumference of the Upper bowel segment and the entire end again cauterized with carbolic acid to guard against infection.

An incision one and one-half inches long is then made in the anterior wall of the rectum. A long forceps is introduced into the rectum and through the incision, then, the traction lug attires of the upper segment are drawn upon until the upper segment is pulled through the incision. The traction ligatures are then pulled down to the anal opening and fastened there by adhesive plaster or wrapped around the artery clamp so as to hold the paginated upper segment in its proper position after the rectal incision.A gauze drain should be introduced in the abdominal wound which should be closed, vealing room for a drain to the point of imagination The wound of the rectum heals by granulation. The patient should be kept free from vomiting if possible.

Fig. 82. Colostomy Imagination of colon through anterior wall of the rectum.

In instances where the lumen of the bowel is found to be too narrow after this operation, the principle advocated by Bacon for stricture of the rectum is a most ingenuous method of widening the bowel as illustrated in the cases reported by Cuttle Vaginal Mastectomy Extirpation of cancerous growths of the rectum through the vagina is sometimes resorted to as offering an easier method when the cancer is within three or four inches of the anal opening. The operation was first described by Mesquit, but has undergone many changes to meet circumstances and modern ideas of different surgeons.

Fig. 83. Colostomy Method of widening the lumen of gut by pressure necrosis.

Fig. 84. Vaginal extirpation of rectum. Incisions of vagina and rectum.

The technique is revised and most successfully worked out by Murphy, of Chicago, in which he goes so far as to remove the growth as high up as the sigmoid flexible The technique of the operation as worked out by him is as follows: The patient is placed with the hips slightly raised in the lithology position, the cervix is drawn down, the vagina dilated with broad detractors and the pouch of Douglas opened by a transverse incision just below the cervix, posterior The peritoneal cavity is packed with large tracheotomy sponges So as to keep the intestine pushed up out of the way. The rectum and the vaginal wall is then divided by a medium vertical incision from the transverse incision down to the margin of the anal