A CARCINOMA of the colon may reach a considerable size before any bowel symptoms are noticed by the patient. Commonly a carcinoma of the colon causes an acute abdominal emergency before any bowel symptoms have been experienced and a carcinoma of the colon may cause only vague dyspepsia or anaemia. Laberge (1960), in a clinico-pathological study of 116 patients with carcinoma of the splenic flexure of the colon, treated at the Mayo Clinic during 1935-50, gives the following statistical analysis of symptoms and signs: pain 90 per cent; constipation 50 per cent; diarrhoea 30 per cent; melaena 35 per cent; bowel obstruction 26 per cent; extracolonic fixation 75 per cent, including fixation to the abdominal wall, either lateral, anterior, or posterior in 7 per cent. Such figures indicate the variability of presentation.Two patients are recorded in whom the presenting feature of the carcinoma was a subcutaneous abscess, an abscess over the left costal margin from a carcinoma of the splenic flexure, and an abscess between the level of the left 12th rib and the iliac crest from a carcinoma of the descending colon. No record of this mode of presentation has been found in the literature. CASE REPORTSCase I.-A man aged 56 years, previously well, developed an abscess over the tip of the left 10th rib after a week's influenza-like illness. Pneumococci and coliform organisms were cultured from the abscess. Biopsy of the sinus which persisted after opening of the abscess revealed adenocarcinoma of the type found in growths of the large intestine (Dr. J. A. Dossett).Laparotomy was carried out and a carcinoma of the splenic flexure, densely adherent to the parietes, was resected and end-to-end anastomosis of the colon was carried out. In the second postoperative week the patient developed acute obstruction of the small intestine caused by a band which was divided and his subsequent convalescence was uneventful.The patient remained well until four years later when he developed haematuria which was caused by a fibroma of the right renal pelvis. Case 2.-A woman aged 54 years felt pain above the left iliac crest and after 3 days developed a subcutaneous abscess midway between the level of the left 12th rib and the iliac crest. The contents of the abscess had a FIG. 543.-Care P. Barium injection of operation specimen demonstrating fistula.faeca1,odour and culture gave a pure growth of coliform organisms. Radiological examination of the urinary tract was normal, a sinogram failed to show any connexion with the colon, but the barium enema (Dr. J. Wall) showed an area of stenosis at about the level of the sinus.Laparotomy revealed a bulky lesion in the lower part of the descending colon, fixed to the posterior abdominal

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is now made to some of the investigations on this patient.Blood.-18 Aug., 1965. Blood-urea, 20 mg. per IOO ml. 24 Aug., 1965. Serum alkaline phosphatase, 7.5 units per 100 ml.; Serum calcium, 9.4 mg. per IOO ml.; Inorganic phosphate, 2.8 mg. per 100 ml. Repeated serum calcium, 9.6 mg. per IOO ml.; Inorganic phosphate, 3.6 mg. per IOO ml. X I Nov., 1965. Serum alkaline phosphatase, 5.6 units per IOO ml.; Blood-urea, 26 mg. per 100 ml. Urine.-17 Nov., 1965. 24-hour urine volume, 1800 c.c.; Sulkowitz test-no abnormality of urine calcium content. 18 Nov., 1965. Serum alkaline phosphatase, 7.1 units per xooml. 24 Nov., 1965. Hb, 81 per cent; Prothrombin activity, IOO per cent; Serum alkaline phosphatase, 6.8 units per IOO ml.; Calcium, 9.8 mg. per IOO ml.; Inorganic phosphate, 3.4 mg. per 100 ml. Blood.-I Dec. and 2 Dec., 1965. 24-hour urine volume, 2250 ml.; 24-hour urine calcium output, 135 mg.; Inorganic phosphate output, 333 mg. 2 Dec., 1965. Serum alkaline phosphatase, 7.3 units per