This incision should be made boldly with one stroke through the skin, muscles and ligaments into the cellular tissue posterior to the rectum; the rectum is then rapidly separated by the fingers from the sacrum, and the space thus formed and the wound should be firmly packed with sterile gauze. A transverse incision down to the bone is then made at a level of the 4th sacral foramen, the bone is rapidly chiseled off in this line, and the triangular flap is pulled down to the left side and held by retractor. At this point it is usually necessary to catch and tie the right lateral and middle sacral arteries. Frequently these are the only vessels that need to be tied during the entire operation, although if one cuts too far away from the sacrum, the right sciatic may be severed. The first step in the actual extirpation of the rectum consists in isolating the organ below the level of the resected sacrum, so that a ligature can be thrown around it, or a long clamp applied to control any bleeding from its walls. If the neoplasm extends above this level and it is necessary to open the peritoneal cavity to extirpate it, one should do this at once, as it will be found much easier to dissect the rectum out by following the course of the peritoneal folds. By opening the peritoneum and incising its lateral folds close to the rectum, the danger of wounding the ureters is greatly decreased and the gut is much more easily dragged down. When the posterior peritoneal folds or meso-rectum is reached, the incision should be carried as far away from the rectum, or, rather, as close to the sacrum, as possible in order to avoid wounding the superior hemorrhoids artery, and to remove all the sacral glands. The gut should be loosened and dragged down until its healthy portion easily reaches the anus or healthy segment below the growth. A strong clamp should then be placed upon the intestine about one inch above the neoplasm, but should never be placed in the area involved by it; for in so doing the friable walls may rupture and the contents of the intestine be poured out into the wound. As soon as the gut has been sufficiently liberated and dragged down, the peritoneal cavity should be cleansed by wiping with dry sterilized gauze and closed by sutures which attach the membrane to the gut. By this procedure the entire intraperitoneal part of the operation is completed and this cavity closed before the intestine is incised. After this is done the gut should be cut across between two clamps or ligatures above the tumor, the ends being cauterized with carbolic acid and covered with rubber protective tissue. The lower segment containing the neoplasm may then be dissected from above downward in an almost bloodless manner until the lowest portion is reached. It is much more easily removed in this direction than from below upward, and there is less danger of wounding the other pelvic organs. If the neoplasm extends within one inch of the anus, it will be