Cancer of the right and left colon

CANCER OF THE RIGHT AND LEFT COLON* ARTHUR BOWEN, M.D. LOS ANGELES, CALIFORNIA

A

PPROXIMATELY 8 to II per cent of a11 carcinomata are found in the intestina1 tract. OnIy about 5 per cent of intestina1 carcinoma is found in the smaI1 bowe1, whiIe 80 per cent occurs in the rectum, and 15 per cent in the Aexures, cecum, and coIon.3 Statistica reports indicate that carcinoma of the Iarge bowe1 occurs aImost as frequentIy as carcinoma of the stomach.9 PracticaIIy a11 maIignancies of the intestines are primary in origin and show a lesser tendency to metastasize than carcinoma eIsewhere. MaIignant lesions of the coIon, in most instances, are singIe-except those which arise from maIignant degeneration accompanying muItipIe poIyposis. The two mobiIe segments of the coIon, the cecum and sigmoid, are most frequentIy invoIved. Carcinoma of the coIon is jeaIousIy partia1: if it chooses the right side of the colon, it most often invoIves the junction of the cecum and hepatic Aexure. It shuns the iIeoceca1 vaIve, and hence obstruction is rare. Cancer of the coIon apparentIy predominates in males. Dixon5 finds that at the Mayo CIinic men have been affected twice as frequentIy as women. MaIignancy of the Iarge bowe1 increases in frequency as one passes from the cecum to the rectum. Cancer appears practicaIIy eight times as frequently in the sigmoid and rectum as eIsewhere in the coIon. Most of the maIignancies invoIving the coIon are primariIy adenocarcinomas. * Presented

The right haIf of the coIon differs from the Ieft in the folIowing respects; Anatomically-the bIood suppIy to the right haIf through the iIeoceca1 artery is very constant. The suppIy to the Left haIf does not have overIapping branches, and is variabIe and inconstant. The Iymphatic suppIy of the right coIon is reIativeIy scant, whiIe the Iymphatic suppIy to the Ieft is more abundant and free. Physiologically-the right haIf of the coIon is the absorbing segment, and in this is comparabIe to the smaI1 intestine with which it has a common embryoIogic origin. The function of the left haIf is that of storage and evacuation. Pathologically-the maIignancies invoIving the right side of the coIon, especiaIIy the cecum, are large, very ceIIuIar, do not encircIe the bowe1, and uIcerate earIy. Obstruction occurs reIativeIy Iate. MaIignancies invoIving the Ieft usuaIIy are smaI1, scirrhous, have a tendency to encroach upon the Iumen, producing obstruction reIativeIy earIy, but uIcerations occur Iate. Acute obstruction is infrequent in rightsided Iesions, but common in the sigmoid. Rankin’s states that aIthough about onethird of coIonic maIignancies occur in the one-haIf sigmoid flexure, approximately of the acute obstructions are found in this Iocat,ion, and in only 6.3 per cent of cases is the site of obstruction in the cecum. Lesions of the right haIf of the coIon are reIativeIy benign, and metastasize Iater than those on the Ieft. Extension to the Iiver occurs infre-

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quentIy from Iesions of the right coIon, but is found frequentIy in the Ieft-sided lesion. SYMPTOMS

The symptomatoIogy of cancer of the coIon depends upon the character and Iocation of the tumor; whether it encircIes or encroaches upon the Iumen of the intestine; whether it is uIcerative or non-uIcerative; whether it is Iocated in the proxima1 or dista1 haIf of the colon. The average duration of symptoms is shortest in cancer of the descending coIon and Iongest in cancer of the cecum. Constipation, coIic, and obstruction are predominant features of coIonic tumors in general, occurring in from 40 to 50 per cent of cases; diarrhea is noted in a substantia1 number by a11 observers. Rankin,14 on the basis of symptomatoIogy, divides cases of cancer of the right haIf of the coIon into three distinct groups: (I) the dyspeptic group, usuaIIy diagnosed as chronic appendicitis or “intestina1 indigestion”; (2) the group characterized by anemia and weakness of unexpIained origin; and (3) the group in which tumefaction is accidentaIIy discovered in the course of routine examination, without having previousIy produced symptoms. While anemia is present in a11 maIignancies of the Iarge bowel, it is most marked in those invoIving the cecum. The tendency to anemia is not 0nIy greater in cancer of the cecum, but there is a definite gradation in the anemia-producing property of cancers situated at successive points aIong the colon, growths in the proxima1 colon producing anemia and cachexia earIier than those in the dista1 coIon. The anemia is apparentIy not due to the Ioss of blood, since few of the cecal carcinomas produce macroscopic bIeeding. AIvarez’ suggests that the anemia may be due to the presence of highIy infectious and viruIent bacteria bathing the ulcerated cecum. Indeed, a marked secondary anemia may be the outstanding finding for a considerabIe time, and the existence of an unexpIained anemia should direct one’s attention to the right

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colon. It is interesting to note that: (I) when these tumors are short-circuited and Ieft, the hemogIobin usuaIIy returns to normaI; (2) that the compIete remova of the right haIf of the coIon does not give rise to anemia; and (3) that tubercuIosis of the cecum with extensive destruction does not at a11 produce a comparabIe anemia. Pain in maIignancy of the coIon is a characteristic symptom, and as a ruIe is found much earIier in the course of deveIopment of cancer of the Aexures and dista1 coIon than that of the cecocoIon. LocaIized tenderness is in most cases present rather earIy in the course of maIignancy and becomes more marked when secondary infection supervenes. Tumefaction in the coIon is rareIy due to fecaIiths; occasionaIIy due to tubercuIosis and diverticuIitis; and most frequentIy to new growth. Indigestion and Ioss of weight occurs Iate in the dista1 coIonic Iesions, but is noticed earIier in the cecocoIon-probabIy due to intoxication from absorption of toxic products of the infected uIcerated Iesion and interference with the proper absorption in the cecocoIon. When the data of symptoms from the various Iocations are tabuIated, the foIIowing symptoms are highest in incidence on the right side and decrease as the rectum is approached, viz. : anemia, indigestion, Iocalized pain not reIieved by bowe1 movements, and paIpabIe tumor. The syndrome of neopIastic growths of the Ieft half of the coIon is evidenced by acute, sub-acute, or chronic obstructive symptoms. The Ieft coIon is narrower; feca1 materia1 is soIid; the Ieft-sided growths tend to encircIe and constrict the bowe1; hence obstructive symptoms predominate. The sequence of symptoms is: miId attacks of discomfort associated with gas and coIicky pains, moderate constipation, diarrhea, gradua1 obstruction, episodes of acute obstruction, and fina complete bIockage. MeIena and tenesmus occur more frequentIy in Ieft-sided growths than eIse-

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where. Rectosigmoid cancer presents an accentuation of the symptoms of the Ieft coIon, with a sharp rise in the number of patients observing bIood in the stooIs and a paradoxica1 decrease in anemia. The foIIowing features are Iowest in incidence on the right side and increase as the rectum is approached, viz.: average duration of symptoms, constipation and coIic, diarrhea, and macroscopic bIeeding. DIAGNOSIS

Next to a carefuIIy taken history and physical examination, the most important aid in the diagnosis of Iesions above the rectum is the x-ray. The symptoms to emphasize are not those which indicate that cancer is sureIy present but those which might Iead to a suspicion of cancer. There is too great a tendency to think of coIonic cancer in terms of pain, obstruction, constipation and diarrhea, but these are Iate symptoms. It must be taught and emphasized that dyspepsia, Ioss of appetite, Ioss of weight, and obscure anemia are much more common early symptoms. Any change in bowel habits, or passage of macroscopic blood is suggestive of cancer. Diagnosis of cancer of the rectum can be made in IOO per cent of eases. Eighty per cent of cancers originating even as high as the rectosigmoid junction can be feIt by digita examination; the remaining 20 per cent can be diagnosed by proctoscopic and sigmoidoscopic examination, and by barium enema. Many of these cases have been treated for colitis, amebiasis, injected for hemorrhoids, or subjected to coIonic irrigawithout digita or proctoIogic tions, examination. The negative barium enema should not be regarded as diagnostic, since a majority of the tumors of the rectum do not show a fIIIing defect. Biopsy shouId be taken to confirm the diagnosis, and to determine the grade of maIignancy. A negative report is a demand for another biopsy, especiaIIy if the growth feeIs and Iooks Iike cancer. Adenomata and poIypi, no matter how smaI1, shouId be regarded as possibIe can-

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cer, a section taken for examination, and the tumor thoroughIy cauterized. As surgery is the onIy cure-and then onIy when done earIy-the probIem of earIy diagnosis is of paramount importance in the treatment of cancer of the coIon and rectum. DIFFERENTIAL

DIAGNOSIS

Cancer of the coIon must be differentiated first, from inff ammatory Iesions, appendicitis, adnexa1 diseases, and coIitis; secondly, from tubercuIosis, syphiIis and actinomycosis; thirdly, from functiona disorders. Benign and maIignant tumors of the cecum and ascending coIon in the earIy stages frequentIy produce signs and symptoms which so cIoseIy simuIate those of appendicitis that the differentia1 diagnosis becomes most diffIcuIt. WhiIe the similarity is most commonIy encountered in inffammatory and tubercuIous Iesions, it aIso occurs in ulcerative carcinoma with secondary infection. Erdmann and Carter* reported a series of eighteen cases of tumor of the cecum, five of which had previous operations for recurring appendicitis. Rosser,16 reviewing 138 cases of right sided cancer, states that in more than two-third of the cases, the symptoms simuIated chronic appendicitis. Fifteen per cent of the PriestIy-Bargen12 group of IOO cases, and 18 per cent of BrindIey’s series of cases had been subjected to appendectomies. CASE

HISTORIES

The foIIowing brief extracts of case histories are taken from the Surgical Services of the Cedars of Lebanon HospitaI, Los AngeIes, CaIifornia. These iIIustrate the common differentia1 points. CASE I. A femaIe, aged 37, was admitted to hospita1 after a seizure of severe cramp-Eke pain the day before. Some nausea and vomiting were present, but there was no fever or chili. Neither urinary symptoms or diarrhea were reported. Pain was IocaIized in the right lower quadrant and there was marked tenderness over McBurney’s point. The Ieucocytes numbered 13,000 with 81 per cent poIys. Hysterectomy had been done ten years ago, but the

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patient did not know whether the appendix

had been removed. A diagnosis of acute appendicitis was made. Operation on the day of admission discIosed a large sausage-shaped mass involving the ascending colon and cecum. Resection and iIeocolostomy were done. The pathoIogic diagnosis was adenocarcinoma. CASE II. An ad& maIe of 49 was admitted to the hospita1 compIaining of cramp-Iike pain in the right Iower quadrant for the previous six months. He had Iost 20 pounds in the past five months, and suffered from weakness, constipation and vomiting IO to 15 minutes after meaIs. Eight months before he began to notice night sweats. The temperature was normaI. Red bIood count was 4,500,000, with hemogIobin 83 per cent. The white count was 7,300, with poIys 65 per cent. Examination reveaIed a sausage-shaped mass in the region of the cecum and a tentative diagnosis of tubercuIous cecum or carcinoma was made. Gastrointestinal x-ray reveaIed a spastic pylorus and a constriction in the iIeocecal region. A barium enema showed a narrowing at the junction of the cecum and ascending coIon. Urographic examination showed norma outIine and function of the urinary tract. X-ray of the chest showed bilateral apica tubercuIosis. The preoperative diagnosis was probable carcinoma of the cecum. The postoperative diagnosis was an appendiceal abscess which was found and drained. Three months Iater the patient was readmitted and an appendectomy was done. CASEIII. The patient was a man of 35 with a history of intermittent attacks of right Iower quadrant pain for the past six months. He reported no nausea or vomiting, and no change in bowe1 habits. He had Iost 15 pounds in weight. The temperature was normal and there was no bIood in stooIs. One month prior to admission he had two severe attacks of pain with nausea and vomiting. He was seen by one of the senior attending men privateIy and sent in to the cIinic for removal of a chronic appendix. The author saw the patient upon admission, and found tenderness on deep palpation over McBurney’s point. There was no rebound or rigidity, and no masses couId be feIt. The blood differentia1 was normal; red corpuscles were 4,72o,ooo, hemogIobin 83 per cent. Recta1 examination was negative.

of CoIon WhiIe examining the Iower abdomen I noticed a puckered scar in the left inguina1 region. The patient, on questioning, recaIIed that he had had an abscess in the groin at the age of 7. Further questioning reveaIed that he had had troubIe with his spine at age of 3, when he had been hospitalized and pIaced in a cast for severa months. With a history of Pott’s disease and a Ieft psoas abscess, the possibiIity of a beginning burrowing, righGsided coId abscess was considered and operation was postponed. X-ray of the chest and spine were made. Those of the chest were negative, but those of the spine showed kyphosis of the second, third, and fourth Iumbar vertebrae without active Iesion. At operation a large mass partly fixed at the head of the cecum, with regiona gIanduIar invoIvement, was found. The history made us incIine to an operative diagnosis of tubercuIous cecum, and resection and iIeocoIostomy were done. The pathologist’s report was, however, adenocarcinoma. We are here again reminded that cases of so caIIed chronic appendicitis shouId not be operated upon unti1 gastrointestina1 and genitourinary studies have been made. CASE IV. A woman, aged 49, had had a choIecystectomy five years previous. Two weeks before admission she began to have Iower abdomina1 pain, without nausea, vomiting or fever. On examination, a moderate rectoceIe and cystocele were found, with a Iarge mass fiIIing the peIvis to the brim. This was apparentIy an ovarian cyst or peduncuIated fibroid. The patient was admitted for repair of the perineum and remova of the mass. The cystoceIe and rectoceIe were repaired; upon opening the abdomen, a carcinomatous mass about 3 inches in length and 134 inches in diameter was found surrounding the sigmoid about IO inches from the ana orifice. CASE v. The patient, a femaIe aged 53, compIained of fIeeting pains in the Ieft lower quadrant a few days before. No constipation, no diarrhea, and no blood in the stooIs were reported. The past history was irreIevant. Examination discIosed an obese woman who compIained of tenderness on deep pressure in the Ieft Iower quadrant. A movabIe mass was Iocated along the region of the descending coIon. There was a mass in the lower sigmoid and aIso a cystic Ieft ovary. X-ray examination with a barium enema showed the cecum markedIy enIarged and

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eiongated. A diverticulum was present at the junction of the descending coIon with the sigmoid. Carcinoma and diverticuhtis were considered as possibIe diagnosis. At operation a mass about 3 inches in diameter was found at the rectosigmoid junction, evidentIy at the point of rupture of the diverticuIum. The mass couId be freed by dissection. Frozen section was done, and a report of inflammatory tissue was made. Comment. An inffammatory mass produced by diverticuIitis may thus sometimes be diffIcuIt to differentiate from carcinoma cIinitally, on x-ray, and even on gross inspection within the abdomen. The inflammatory mass, which frequentIy surrounds the malignancy of the rectosigmoid as a result of seepage through the uIcerating gut waI1, may confuse the operator as to its mobiIity and remova1. It is surprising, however, after detouring the feca1 current by a preliminary coIostomy, how the mass shrinks and becomes more mobile. What appeared to be an inoperabIe fixed growth, becomes a removable one. CASE VI. A femaIe, age 62, had a history of increase in size of the abdomen; noticed in the past two weeks. She was chronicaIIy constipated and reported obstipation for the previous two days. There was no pain, no nausea, vomiting, or bIoody stooIs. Red bIood corpuscIes numbered 4,gEo,ooo; the hemoglobin was 83 per cent; white bIood ceIIs were 13,200 with poIys 64 per cent. Examination showed a moderateIy we11 nourished adult femaIe-not acuteIy iI1. The abdomen was generaIIy and reguIarIy enIarged. A mass the size of a large grapefruit couId be feIt in the right Iower quadrant, extending upward on right side. The mass was fIuctuant, sIightIy cystic and tender. The liver and spleen were not paIpabIe and no fluid wave was present. A cystic mass could be felt in the right cuI-de-sac on vagina1 examination. It extended behind the uterus but was separate from it, and was tender on deep pressure. Recta1 examination was negative except for a mass in the right cuI-de-sac. X-ray examination (a Bat pIate taken by the attending physician) showed a tumor mass lying in the peIvis, with some distention of the sigmoid and transverse colon, probabfy due to pressure. The increase in size of the abdomen in a woman of 62 with a paIpabIe cystic mass in the right lower quadrant and cuI-de-sac, confirmed

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on vagina1 examination, Ied me to make a preoperative diagnosis of right ovarian cyst. Operation discIosed a Iarge paper thin cystic mass occupying the right Iower quadrant and peIvis. In foIIowing up its origin, it was found to be a tremendously diIated cecum and ascending coIon over 6 inches in diameter. The transverse coIon was diIated and fiIIed with hard fecal matter. A search was made for the point of obstruction which must aIways be beIow the distended gut. A hard circuIar constricting growth was found in the rectosigmoid junction, but there was no surrounding extension or fixation. No gIands were paIpabIe aIong the aorta and there were no Iiver metastases. A decompression in the form of a coIostomy was done. Three weeks Iater the patient developed a biIatera1 parotitis, steadily went downhi and finaIIy expired. The autopsy, as reported by Dr. Hammack, showed a constricting adenocarcinoma of the rectosigmoid, with a Iarge, diIated, tissue-paperthin cecum and ascending coIon. Comment. This case iIIustrates: (I) the vague symptoms of rectosigmoid cancer; (2) the occurrence, as a resuIt of Ieft-sided coIonic cancer, of a tumor on the right side due to sIow, progressive constriction of the rectosigmoid Iumen, producing marked diIatation of the cecum; (3) the repeated tendency of Ieft-sided growths to produce obstructive symptoms and signs. PROGNOSIS

Five year survivals foIIowing successful extirpation of colonic growths are higher than in other types of gastrointkstinal malignancies. The average case of coIonic maIignancy has a better chance of cure than other maIignancies with the exception of those of the skin. Adequate preoperative preparation and management pIay a prominent rGIe in reducing the mortality of coIonic surgery. Rankin,16 reviewing 753 cases of maIignancy of the Iarge bowe1 operated upon at the Mayo Clinic, reported five year cures in 57 per cent of a11tumors invoIving the right c&n; 47 per cent in those invoIving the Ieft colon; and 35 per cent of a11 Iesions invoIving the rectum. Cancer of tbe large bowel when seen early is curable in a large percentage of cases. The

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tragedy of the fina resuIt Iies in the fact cent. He states that graded operative that not many over 50 per cent are operabIe procedures, both in the right and Ieft when first seen by the surgeon. Lahey haIves of the coIon, may be undertaken noted that cases coming to his cIinic with a hospita1 mortaIity rate ranging from averaged nine months since the onset of 5 to IO per cent without sacrificing the symptoms, whiIe Rankin reports an averoperabiIity ratio. age of ten and one-haIf months deIay from The outIook for surgica1 treatment of onset of symptoms to surgica1 consuItation. carcinoma of the coIon and rectum is thereOn the other hand, Dixon and 0Isor-P report fore far from hopeIess in the cases amenabIe tweIve patients who Iived for more than to surgery. twenty years after radica1 operation for OPERATIVE PROCEDURE carcinoma of the Iarge intestine. The size of the growth has IittIe, if anyThe surgica1 management of coIonic thing, to do with the prognosis. The diamIesions consists of: (I) decompression; (2) rehabiIitation; and (3) resection. MedicaI eters of the growths removed by Rankin15 decompression is done in the subacute and in cases of five year cures averaged the coIons by means of same as in those where death occurred as a chronicaIIy obstructed miId purgations and irrigations for a period resuIt of recurrence. ActuaIIy cancers of the of three to six days preoperativeIy. SurgicaI cecum and ascending coIon are the Iargest of a11 growths found in the coIon-yet it is decompression is used in acuteIy obstructed cases, in the form of cecostomy or colosstatisticaIIy demonstrable that Ieft coIonic tomy. RehabiIitation measures fortify the Iesions are of poorer prognosis than tumors resistance of the patient, and consist of of the right haIf. The occurrence of highIy maIignant high caIoric, Iow residue diets, adequate lesions in young individuaIs warrants a ffuid intake and bIood transfusions. FunctionaIIy and anatomicaIIy, the segguarded prognosis. EnIarged Iymph nodes, more frequentIy ments of the coIon differ, and therefore the than not, are benign and inflammatory, type of operation is adapted to the Iocation secondary to the uIceration which is of the tumor. The cecum and ascending aIways present in maIignancy. Fixation, coIon are more easiIy mobiIized than the which sometimes makes one fee1 that the descending coIon. The Iymphatic suppIy of growth is inoperabIe, is aIso more often the the ascending coIon is not nearIy so free as resuIt of inffammatory change than of that of the descending coIon, whiIe the maIignant extension. bIood suppIy is so constant that the Rankin15 beIieves that the scientific ascending coIon offers, from the standpoint criteria of microscopic grading Iaid down of infection and recurrences, the most hopeby Browders estimates more accurateIy fu1 outIook. In maIignancies of this segthe prognosis of cancer than any rother ment, the iIeocoIostomy with immediate or yardstick. FortunateIy, the majority of subsequent resection gives the most satiscoIonic growths faI1 into the moderate factory resuIts. grades of maIignancy (I and 2). Because the transverse coIon is freeIy The operative mortaIity is higher in movabIe except at the extreme ends, it is cancer of the Ieft haIf of the coIon than in technicaIIy the Ieast diff%uIt to resect, but that of the right haIf. Rankin,16 between the chances for infection and compIications 1930 and 1933, did sixty iIeocoIostomies for are probably greater than in any other part Iesions of the right coIon with four deaths, of the Iarge gut. The bIood suppIy is a mortaIity of 6.6 per cent. In 1935, he never constant and the Iymphatic drainage reported16 eighty-nine radica1 perineo-abis free. In malignancies of this part of the domina1 resections for Ieft-sided Iesions, bowe1 a two-stage operation is practicaIIy with eight deaths, a mortahty of 8.8 per aIways advisabIe.

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The descending coIon has almost no mesentery except at the sigmoid Aexure. The bIood vesseIs do not overIap whiIe the lymphatic drainage is very free. Obstruction occurs earIy. Graded procedures are most appIicabIe in this segment-a primary coIostomy foIIowed by resection from above or beIow or a combined approach. SUMMARY

A brief comparison of the right- and Ieft-sided coIonic cancers has been made, with reference to pathology, prognosis, symptoms, diagnosis and treatment, and with brief extracts of cases iIIustrating differentia1 Iesions. CONCLUSIONS I. EarIier diagnosis of cancer of the Iarge intestine wilI be made when any changes in the bowe1 habits wiII be regarded with suspicion, and when digita and proctoscopic examinations wiII be made part of every compIete physica examination. 2. Five year survivaIs foIIowing extirpation of coIonic growths are higher than in other types of gastrointestina1 maIignanties. Fifty per cent of patients who present themseIves earIy can be cured. 3. The two haIves of the coIon are anatomicalIy, pathoIogicaIIy, and cIinicaIIy different. 4. The most common erroneous diagnosis in the presence of cancer of the right coIon is unexpIained secondary anemia, choIecystic disease, peptic tubercuIosis, uIcer, or appendicea1 abscess. If the growth is in the Ieft side the erroneous diagnosis is more IikeIy to be coIitis, diverticulitis, spastic coIon, or adnexaI disease. CoIitis and hemorrhoids are the most erroneous

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diagnoses where there is growth in the rectum. 5. On the whoIe, graded operative procedures for coIonic cancer seem the safest, and these can be undertaken with a hospitaI mortaIity ranging from 5 to I0 per cent. REFERENCES 1. ALVAREZ, W. C., JUDD, E. S., and others. Varying degrees of anemia produced by carcinoma. Arch. Surg., 15: 402 (Sept.) 1927. and diagnosis 2. BRINDLEY, G. V. SymptomatoIogy of cancer of the large bowe1. Texa.s State J. Med., 23: 325 (Sept.) 1927. 3. BROWN, T. R., and GANTHER, E. H. Tice Practice of Medicine, 7: 761. Hagerstown, Md. Prior. 4. DIXON, C. F. Carcinoma of the rectum: what are the chances for cure? J. A. M. A., 103: 1605

(Nov. 24) ‘934. 5. DIXON, C. F., and STEVENS, G. A. Genera1 aspects of surgery of the large intestine. Southwest. Med., rg: 378 (Nov.) 1935. 6. DIXON, C. F., and OLSON, P. F. Twenty year cures of carcinoma of the colon. Surg., Gynec., @ Obst., 62: 874 (May) 1936. 7. DIXON. C. F. MaIicnant lesions of the coIon-a review of the Iiteriture from July, 1935 to JuIy, 1936. Internal. Obst. of Surg., 63: 505 (Dec.) 1936. 8. ERDMANN, J. F., and CARTER, R. F. Malignancies of coIon. New York State J. Med., I I 5: 649 (June 7) x922. 9. JONES, T. E. SurgicaI Iesions of the Iarge bowe1. Radiol. Rev., 58: 169 (Sept.) 1936. 10. JORDAN, S. M. Diagnosis of earIy malignancy of the colon. Surg. Clin. Nortb America, 8: 61 (Feb.)

1928.

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MASON, J. T., DWYER, M. F., and PALMER, L. J. Carcinoma of the colon. Sure. Clin. Nortb America, 7: 1367 (Dct.) 1927. 12. PRIESTLEY, J. T., and BARGEN, J. A. Diagnosis of carcinoma of the large intestine. Am. J. Surg., 22: 515 (Dec.) 1933. 13. RANKIN, F. W. SurgicaI Iesions of right haIf of coIon. J. Oklaboma M. A., 23: 24 (Jan.) 1930. 14. RANKIN, F. W. The surgica1 treatment of carcinoma of the coIon. Surg., Gynec. @ Obst., 53: 229 (Aug.)

II.

1931. 15. RANKIN, F. W. The curability of cancer of the colon, rectum, and rectosigmoid. J. A. M. A., IOI : 491 (Aug.) 1933. 16. ROSSER, C. Diagnostic criteria of coionic cancer. J. A. M. A., 106: Iog (Jan. II) 1936.