952 MAY 2& , m)7] 3UVENILE RHEUMAT1SM.~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~I L .xneL LA The Splenic Angte.-The diagonal incision already described is very useful here, as it gives excellent exposure of the angle and allows the colon to be easily freed. It is very necessary to free the colon thoroughly to get the ends to come comfortably together. Care has to be taken in freeing the angle itself not to damage the lower part of the spleen, which is in very close contact, or the kidney and pancreas,

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... are close behindit. Soime of the best results I have seen have been in cases of resection of the splenic angle-. I removed a carcinoma of tlhe splenic angle in a-jockey eleven years' ago, and this year he won one of the classical races. The-Pelvic Colon.-This is the commonest situation, and more than half the cases of resection are included in this *area of the colon. Much depends upon the part of the pelvic colon involved. If it is in the descending colon, or upper part of the pelvic colon, the resection should not be difficult. Greater difficultv, however, occurs when the lower part of the pelvic colon is involved. In all cases the outer layer of the pelvic mesentery should be divided near its base for a considerable distance aind the bowel carefully stripped up so as to free it well from the left ijia,c fossa. There are no vessels entering the mesentery at the outer aspect, so that free stripping is quite safe, and considerable mobilization of the colon can thus be obtained. The chief difficulty arises with cases of diverticulitis, as there -are frequently dense adhesions to other structures, more particularly the bladder in males, and the uterus or left tube in females. It is very important to interfere as little as possible with adhesions in cases of diverticulitis, as serious sepsis may be lighted up. On the other hand, the condition is not malignant, and excision should be carried out when possible, eveni though parts of other organs have to be sacrificed. I have on several occasions removed the whole uterus and -left tube and resected portions of the small gut in order to remove tumours due to diverticulitis. If the bladder is extensively involved excision is, of course, out of the questioni. The Lower End of the Pelvic Colon.-For two reasons this is the most difficult situation. The first is that there is often not enough healthy bowel below the tumour to allow of a proper resection, or the bowel is so short that the resection has to take place within the abdominal cavity. The second, and more serious, difficulty is that the blood supply to the upper part of the rectum is liable to be gravely, interfered with if a portion of the pelvic colon immediately above has to be removed. The surgeon may be faced with serious difficulty in deciding what he should do. One alternative is to make a complete abdomino-perineal excision, leaving a permanent colostomy of the upper end, and this may be the only procedure possible when the growth is low down in the pelvis, but still excisable. Another alternative is the tube method, which was described by me in 1908; the principle of this is that after removing thle tumour a long rubber tube of large calibre is sewn into the upper end of the bowel, and then passed down through the rectum and out of the anus. The tube is then drawn on until the upper bowel is lightly invaginated into the upper end of the rectum and is secured there by a few stitches. This method gives very good results, but it is decidedly danigerous owing to the fact that the bl.ood supply to the rectum cannot be relied upon. If this method has to be used the surgeon must be certain that h-e is not seriously damaging the blood supply to the rectumY which will depend entirely on the two lower sigmoid arteries. In view of this doubt good drainage should be provided from behind, and a temporary caecostomy or colostomy perforined. The resuht of colectomv are good both from the point of view of immediate risk and from that of restoration of function. The mortality fronm operation is about 16 per cent., but this is counting many of the older cases and can certainly be reduced much below this figure. Tlie following table shows the mortality following colectomy (53 cases) and the conditioni for 'which the operation was performed. There must always be sme risk as the patients are-not only, old, but often' in a bad state of health -from partial obstruc.. tion and dyspepsia over long periods, which cannot be entirely compensated for by the preparatory treatment. Also colectomy carries with it a fairly high risk of post. operative infarct. The risks are not serious when we consider thegrave nature of the lesions for which the operation is done. It is now quite exceptional to have any faecal fistula after; partial colectomy. As a rule the wound heals by first intention and the patient is up in under three weeks quite healed. The restoration of function is perfect, as the loss of a few inches of colon causes no inconvenience. Wlhen performed for cancer this operation gives the best results of all cancer operations, as there is no mutilation or limitation of normal function, and the tendency to subsequent recurrence is very low. REPERENCE.