182 THE CANADIAN MEDICAL ASSOCIATION JOURNAL forced to the conclusion that he is a

malingerei. Had he contented himnself with pr.oducing niot more than a few lesions, the diagnosis,
especially in the early stage, would have been extremely difficult; but, emboldened by his success, he
veiy greatly oveidid his applications to the skin and thus rendered detection a certainty. At the time
the diagnosis was made on the above lines his previous history had not yet reached us, and one has
only to read that history to get the strongest possible confirmation. The alternative rapid
development and slow healing is utterly at variance with both syphilis and tuberculosis. The
sul2sequcnt history of the case was most inter-esting At first he r.efused absolutely to have a small
piece of tissue removed for biological examination, but on pressure being brought to bear by the
Compensation Board, he consented and one of the ulcers was removed by Dr. Bazin on August 6th
Six days later the sutures were removed and the wound was found in good condition and healing
well. For the next three days the dressings were found blood stained and the wounld at the end of
that time reopened. I then had a plaster of Paris dressing applied, and cut and hinged, so that it
could be removed when necessary, but would prevent the patient from access to the wound. We had
no further trouble with the healing, but the open wound had to granulate up and on September 6th.,
when all but the width of one quarter of an inch had healed, he was discharged. There were still one
or two of the srnall lesions that had not completely cicatrized. Report of Dr. Rhea on the tissue
riemoved: "Chronic ulcer, no evidence to support tubereulosis or lues. " In considering what agent
could have been used to produce the lesions, I was led to the suspicioIn that it might be carbolic acid
in some form because of the fact that it produces the black crusts which were so prominent a feature
in this case, and that, fr-om its local anesthetic effect, it is an application comparatively painless.
(Consequently on August 2nd. I applied, without the patient's knowledge, pure carbolic acid to a
small ar.ea corresponding in size and shape to the lesions already present. Two days later the spot
was whitish an(l somewhat translucent anld small hamorrhagic dots could be seen beneath it. Two
(lays later again the test spot became browni, and several days after that black, and could not be
distinguished from the origlinal lesions except for the markings of an indelible pencil which I had
used to define its situation. CARCINOMA OF CYECUM ALFRED J. GRANT, M.D., F.A.C.S. London,
Ontario. Patient, Male, age seventy-three. Chhief comsiplaint: A lump in right groin with peiiodic
cramp-like pains. Present illness: Patient has been having pain in right lower abdomen andl groin for
the past eighteen months. A lump has been present for six or eight nmonths. Prevlious history: Had a
fall forty-five year.s ago and injure(l right testicle which has been large ever since. Otherwise patieint
has always been healthy and never has had any serious illness. Physical examination A well-
developed inan in apparent health. Looks ten years younger than age given. Mouth and thiroat
healthy; hear.t and IlIugs negative; abdomen, somewhat distended; a hard lump is felt in right lower
quadrant extendinlg into gr.oin, slightly tender, an(l pairtly fixe(l. By inivagiinatiing scrotum with
finger can feel the imlass str.ike dowIn upoIn externIial inig when patient coughs. By rectum can feel
mass in right side by deep pressuie. X-ray exami nation -After a barium enema passed r-eadily uip
into excuinii and enabled por- FRASER: CARCINOMIA OF TRANSVERSE COLION 183 tion of caecum
and mass (apparently fixed) to be seen. Plate shows that barium enema passed through ileo-cecal
valve into small intestine. Marked deformity of cacxtm seen. Diagnosis: Carcinoma of cecum.
Treatment: Patient was advised that he was on the verge of an obstruction; that the tumour mass
could not be removed, but lateral ainastomosis might be possible to prolong life and guard against
colostomy. Operation: Right rectus incision, large mass of carcinoma was seen involving cexcum and
fixed to retroperitoneal t'ssue and psoas muscle. Last two feet of ileum dilated to twice normal size.
Lateral anastomosis between ileum and transverse colon was made grasping ileum as far as possible
from ileo-caecal valve. Note; Very smooth convalescence. Patient left hospital in eighteen days. No
pain, good appetite and normal bowel movements. CARCINOMA OF THE TRANSVERSE COLON WITH
PARTIAL DESTRUCTION OF THE BOWEL WALL AND PERFORATION OF A BRANCH OF THE MIDCOLIC
ARTERY J. 0. FRASER, M.D From the Department of Pathology, the Montreal General Hospital Male,
age forty-three years. Admitted to the Montreal General Hospital into the service of Dr. Campbell
Howard, November 8th., 1924. Complaints: Passing of blood in stool; vomiting; weakness; persistent
constipation; loss of weight; abdominal pain His family and past histories were unimportant except
for the fact that he had always suffered from constipation Present illness: In the early part of June,
1924, he began to have pains in the epigastrium, which were "cramp-like and tearing in character."
They did not tend to radiate and were temporarily relieved by carminatives. Duiing the attacks of
pain he often vomited and, once the vomitus was blood stained. Early in July he was free from pain.
The pain, however, returned, and his constipation became more marked and laxatives which he had
been accustomed to take became less and less effective. This constipation never alternated with
diarrhaea. About the middle of July he first had paiin in the "small of his back," which radiated
upwards and around to the right loin. This came on when he either sat down or lay down During
August and September he did not feel as well as usual. He occasionally vomited, but rarely had any
epigastric pain. On November 8th, while at work, he suddenly collapsed; he became very pale, his
hands andl feet became cold and a profuse perspiration appeared on his forehead. He soon
recovered consciousness and went to the toilet where he passed a large amount of fresh blood. He
was allowed to rest comfortably for two hours, when he was admitted to the Montreal General
Hospital (9.45 a.m., November 8th). At the time of admission he was in a condition of shock, and his
condition was so critical that it was not felt that a complete examination was just fied. He was put
into bed with several hot water bottles. His respirations were rapid, his pulse running, weak, and
thready. The heart sounds were distant and muffled. The abdomen was flat and somrewhat
riesistant. He was given onesixth grain of morphia with good results. By midday he had greatly
improved and his pulse rate had dropped to 112. Suddenly, at 2 p.m. he again collapsed, dyspncea
was pronounced and he became very pale. The fingers and toes became numb, and his pulse could
not be felt. There was profuse perspiration on his forehead. As soon as he had recovered somewhat
he asked for the bedpan, but there was no movement. Within one half hour after this attack he again
collapsed and died within a few minutes, five hours and forty-five minutes after admission to the
hospital. The clinical diagnosis of duodenal ulcer with hsemorrhage was made. Summary of the Main
Points of the Post Mortem "The body is emaciated. The abdomen shows asymmetrical distension,
being greatest in the right quadrant. There is no blood in the abdominal cavity and no evidence of
acute peritonitis, nor of perforation of the gastro-intestinal tract. The intestines are distended,
especially a portion of the large intestine. The great omentum is united by fibrous adhesions to the
right side of the cecum and ascending colon. There is no evidence that these adhesions have led to
obstruction. The mesenteric lymph nodes arie small and hard. When the great omentum is lifted up
there is exposed a marked area of constriction of