The carcinomatous affections of the intestine, occur in the three forms of fibrous, areolar, and medullary cancer, with and without the formation of pigment: two of these or all three, may be combined with one another, from their first origin or consecutively. The areolar form, however is, at least with us, of very rare occurrence.

The colon is almost exclusively the seat of cancerous degeneration, but there is a gradation in the proclivity of its different sections to the affection. The rectum is most frequently attacked, in second order the sigmoid flexure, and the remaining portion of the colon but rarely. The small intestine is scarcely ever the primary seat of cancer; it is almost always involved secondarily after adhesions have been effected with a cancerous portion of the colon by means of peritoneal exudation. Medullary carcinomatous cachexia, which is frequently acute and very extensive, forms an exception, inasmuch as it gives rise to a medullary, white or colored infiltration of the mucous membrane of the small intestine and its submucous cellular tissue in the patches of Peyer. If we except this case, carcinoma occurs as a primary affection of the intestine in three forms:

Firstly, In the mucous membrane, as carcinomatous infiltration of the erectile tissue, into which the former has been previously converted - fungus;

Secondly, More frequently in the submucous cellular tissue, as round nodulated accumulations;

Thirdly, Most commonly as an annular deposit of the cancerous tissue in the submucous cellular layer.

When the intestine is secondarily involved, it is attacked laterally, and the disease commonly proceeds from the lymphatic glands of the mesentery, or from those of the lumbar plexus.

A distinction of the two latter forms is of importance, in reference to the observations that we are about to make.

Here also, carcinoma presents the well-known stages of crudity and metamorphosis; and we merely direct attention to this again, because a consideration of the fact is absolutely necessary for a complete exposition of cancerous intestinal stricture, which, next to cancer itself is of extreme interest.

Cancerous stricture of the intestine1 (Enterostenosis scirrhosa, cancer-osa) is the most common variety of stricture that results from alterations in the intestinal coats, and at the same time the one that advances to the highest degree; it also offers the first elements for a rational theory of ileus.

We have already alluded to the two main forms in which cancer affects the intestine: it is either a narrow annular tumor surrounding the intestine, the primary form, which gives rise to annular stricture; or the intestine is secondarily affected by a propagation of the disease from neighboring organs; in this case one side only may be involved to a considerable extent. In the latter case, however, the cancerous degeneration may gradually extend over the entire circumference of the intestine, as in the former the original annular stricture may extend upwards or downwards over a larger portion of intestine.

The annular stricture is commonly the most important; if the morbid growth continues in the crude stage, the calibre of the intestine may be reduced to the size of the little finger, a goose's or crow's quill. The passage of the intestine is frequently much interfered with in the lateral degeneration by protrusion of the morbid growth, but there is generally a corresponding dilatation of the normal portion of the parietes, and the width of the tube is thus not unfrequently found increased, even after the morbid growth has enveloped the entire circumference of the intestine. Although the former is by far the most dangerous, and soon proves fatal by ileus, this also follows sooner or later in the second case, notwithstanding the existing dilatation.

The metamorphosis of intestinal cancer is of importance in reference to the stricture, both in its first development and in its further progress; it may render the stricture much more dangerous, or may lead to a certain improvement in the symptoms. The turgescence that takes place in the morbid growth at the commencement of the change, and the fungous excrescences that arise on the surface of the intestine during its progress, may render the stricture narrower, and even induce perfect occlusion of the intestine. On the other hand, the contraction may be relieved by sloughing of the softened morbid growth, and imminent ileus thus be postponed. The intestinal disease may, unless death ensue, as it often does from exhaustion, be subsequently ameliorated in various ways. After destruction of the morbid growth, an ichorous cavity is left, into which the descending contents of the intestine pass and stagnate; this condition is sometimes borne for a considerable period, provided there is a sufficient discharge downwards. In other cases ulcerative perforations may establish one or more communications between the portions of intestine lying above and below the stricture, or ulcerative destruction may take place in a different direction, and give rise to artificial (vicarious) anus; thus affording a hint as to the mode of cure to be adopted by the medical man.

1 Oestr. Jahrb. xviii. 1.

The degenerated and strictured portion of the intestine may remain unattached, or become fixed. The primary degeneration of the intestine, exhibited in annular stricture, is commonly unattached, and it then, in proportion as the diseased mass increases, sinks to a lower region of the abdominal cavity. This may, in the same manner as the scirrhous pylorus, when it has descended to the umbilical or hypogastric regions, give rise to an error of diagnosis. The dislocation is particularly liable to present an obstacle to the passage of the intestinal contents, if the contracted portion is bent at an acute angle, as occurs in the descent of strictured portions of the transverse colon, or of the flexures of the colon.

The diseased portion of intestine may be fixed, as is the case in the secondary lateral degeneration of the intestine from its commencement; the annular stricture may become attached in the same, or in a different manner. In the former case the intestine is either directly connected with the large lobulated morbid growths that extend to the glands of the lumbar plexus, or even to the ligamentous appendages and the periosteum of the vertebrae (Lobstein's retroperitoneal growths), or it is attached to them by the intervention of a cord or peduncle which passes through the mesentery. In consequence of the partial contraction of the tissues, and especially of the intestinal coats, and of the unequal distribution of the morbid growth, the degenerated portion of the tube is more or less inflected.