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An inch was then removed from its lower end, so as to be sure that all disea-sed tissue was removed. The inner surface of the sphincter muscles, which at the first operation had been left at- tached to the skin, was then denuded and the end of the rectum implanted within the denuded surface, and the circle of the muscle completed behind by suturing its ends together. Deep sutures of silver wire approximated the posterior mar- gins of the wound, the remainder being packed with iodoform gauze. The patient suffered but little from shock after the sec- ond operation. On August 23d she left the liospital, the wound being nearly healed. On September llth the wound was com- pletely healed. The end of the rectum had united with the sphincter muscles, and while the grip of the muscle was not perfect, yet it generic diflucan fluconazole was sufficient to give the patient fair control over her bowels. On April 3, 1892, the pa'iient reported she had gained costo del diflucan thirty pounds since the operation and her general diflucan compresse costo health is excellent. She has no pain and no sign of generic diflucan no prescription local recurrence. Except when she has loose diarrhceal movements, she exercises perfect control over her bowels. She aiBrms that she is a-^ well as at any period of her life. Microscopical examination declared the tumor to be a carcinoma. Cask V. Excinon of Seven Inches of i?ecf «;//. — Female, aged sixty-three. History of constipation for several years. For the past six months rectal pain and loose blood-stained movements. On examination, beginning an inch and a half above the anus, was an irregular, hard, nodnlar mass constricting the lumen of the rectum, so that the finger could not |)a8s farther than two inches and extending upward beyond the reach of the finger into the hollow of the sacrum. Operation, August 3, 1891, in the Presbyterian Hospital. Ether. Lithotomy position. Incision began just behind the auus and ran backward as high as the middle of the pfizer diflucan costo sacrum. The sphincters were found infiltrated, and two semicircular in- cisions were made surrounding the anus and meeting on the perinwum. The incision was still further extended through the periniBum, dividing the lower inch and a half of the posterior wall of vagina. The diflucan costo lower part of the diflucan cost with insurance rectum was tied with a silk ligature. The dissection of the rectum from neighboring tissues was difficult. In front it was adherent to the vagina, part of which was removed. Behind, the mass was adherent to the anterior surface diflucan 150 costo of the sacrum as far up as the promontory. To give access to this region, the coccyx and the lower inch and a half or two inches of the sacrum were removed by cut- ting across the latter bone by bone forceps at the lower border of the third sacral foramen. The peritoneal cavity was freely opened, and, after dividing the mesorectnm, the diseased rectum, which formed a very bulky tumor, was drawn down and the gut divided an inch above the cancer at a point diflucan gel costo about seven inches above the anus. Two large indurated m.asses, consisting of enlarged glands and infiltrated fat, were afterward removed. Hardened and probably diseased tissue was felt running upward and to the right, but no attempt was made to remove it on ac- count of the condition of the patient. The cut end of the rec- tum was fastened by silk generic diflucan 150 mg sutures in the center of tlie wound. A deep .suture was inserted at the posterior part ol the wound to approximate generic diflucan online the margins. The anterior part of the wound, consisting of what remained of the vagina and perinieum, was united by suture. No vessels were ligatured, but four clamps left in position. The cavity was packed with iodoform gauze. The patient rallied well diflucan 150 mg costo from shock. The highest temperature after the operation was 101-4''. Anyust 30th. — Union by secondary intention thronghont the posterior part of wound. Union had been primary throughont its anterior portion. September l-5tli. — Wound entirely healed and [latient .able to walk. The pathologist reported that the tumor was a carcinoma. During the operation I felt that the case was not a suitable one for excision and that colotomy would have been the wiser procedure. I formed this opinion on account buy generic diflucan online of the extensive and firm adhesions of the tumor on all sides, especially at the lateral borders of the sacrum. I felt that I was working in dangerous territory and that removal of all the cancer was im- 256 McCOSH: EXCTSTON OF CANCER OF generic diflucan over counter TUE RECTUM. [S", Y. Mkh. Jock., possible. The subsequent condition of the patient has shown, however, that excision has given greater comfort than would have colotoiiiy. In February (seven months after operation) the patient was alivo and comparatively well. Her general health has improved and she suffers but little pain. She has, however, but very imperfect control over the rectum. There are a number of steps in the operation about which there is considerable difference of opinion. 1. The Incision. — Many diflFercnt nietliods of approach to the disease have been employed during the past century diflucan cost without, perhaps, much difference in the results obtained. Since, however, tlic plan of attacking the growth from be- hind rather than from below diflucan cost without insurance has been introduced, opera- tions can now be performed with comparative safety which, fifteen years ago, would have how much diflucan cost been con.sidered as unjustifia- ble. While the sacral method is appropriate in a consid- erable number of cases, yet many satisfactory operations can be done without encroaching on that bone. Of the many methods of approach, it may not be amiss to men- tion a few of them. The oldest method is that of Lisfranc. He made two semilunar incisions around the anus, and generic diflucan cost car- ried the dissection upward. Ilueter made a horseshoe-shaped incision, the bow in front of the anus and the arms running backward. Separation of the gut begins in front, and it is then divided across below the disease, and the flap con- taining the anus and sphincter muscles thrown backward, to be replaced after excision of the diseased segment. Velpeau made his incision from the tip of the coccyx downward through the posterior part of the anus, and the tumor can then be seen and handled from the interior of the gut. Kocher * makes a long posterior incision from the coccyx to the edge of the anus, and removes the coccyx if neces- sary. Dissection is carried discount diflucan down till the posterior wall of

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