are of more varied type, coUoid, scirrhus and soft carcinomata as well as
epitheliomata of the squamous celled type commonly existing in this situation;
sarcomata are much more rare but do, at times, occiur.

Symptoms. These are by no means typical. The usual cancerous cachexia
is usually present, if not at first, in the later stages. To this may be added the
symptoms of partial obstruction such as pain, nausea, vomiting and constipa-
tion, with the presence of a tumor. This last varies in size and situation, is
usually firm in consistency, irregular of surface and generally tender. It is fre-
quently movable, but this is not always the case. It is dull on percussion and
may seem to pulsate if it is situated over the aorta. Masses of faecal matter
l)dng above it in the bowel may obscure the tumor but the administration of
irrigations or laxatives wiU remove these, after which the true character of
the lesion will become apparent.

In cancer low in the rectum digital examination or inspection by
means of the proctoscope wiU reveal the presence of a malignant obstruc-
tion.

The bowel movements are constipated in character as a rule but may be
otherwise normal in rare instances. If the neoplasm is in the rectum they are
likely to be ribbon- or pencil-shaped as a result of the stenosis. They may
contain blood and more or less foetid pus, the former both before and after
ulceration has taken place, the latter after this event only. The presence
of mucus signifies little else than that an inflammatory condition of the intes-
tinal lining is present; the occurrence, however, of sanious pus or muco-pus
is of extreme importance from a diagnostic point of view since these appear
only in intestinal cancer, in ulcerative colitis and as a result of the rupture of
an abscess into the lumen of the bowel. The large amount of the pus in the
last case and the unlikelihood of colitis being mistaken for malignant intestinal
tumor simplify the differential diagnosis of cancerous conditions. The
importance of digital rectal examination, however, in all suspicious cases
cannot be over-estimated.

The separation of duodenal cancer from pyloric carcinoma is diflacult,
the presence of jaundice, lack of early dyspeptic symptoms and normal acidity



420 DISEASES OF THE DIGESTIVE SYSTEM AND PERITONEUM.

of the gastric contents pointing to, but not rendering certain, the existence
of the former condition.

Non-malignant Tumors of the Intestine, such as polyps^ fibromata,
angiomata, etc., may exist without causing symptoms; they may, on the other
hand, produce symptoms resembHng those of mahgnant growths, such as stools
containing mucus and blood; there is no resulting cachexia and the neoplasm
may be seen or felt upon rectal examination.

The treatment of cancers of the bowel consists in removal of the growth by
surgical procedures when this is possible. The operation indicated varies
with the condition present. Resection of the bowel without the formation of an
artificial anus has prolonged life and excellent resvilts may be achieved in
favorable cases by rectal resection.

When svirgical intervention is for any reason decided against, the patient's
general condition should receive attention. His nourishment should be
maintained by the administration of easily digested foods given by the mouth
or per rectum, and stimulants should be prescribed when necessary. The
possibility of obstruction by faecal matter should be provided against by
regulation of the bowels so that a sufficient movement is obtained each day.

PROCTITIS.

Proctitis or inflammation of the mucous lining of the rectum occurs in
various types, usually as a part of co-existing colonic inflammation. For a
description of these conditions and their treatment the reader is referred to
the sections upon dysentery, entero-colitis and intestinal ulceration.

HEMORRHOIDS.

Synonym. Piles.

Definition. Haemorrhoids is the term employed to designate a varicose
condition of the veins of the lower rectum. Their most frequent situation is at
the muco-cutaneous junction at the anal orifice.

Haemorrhoids are internal or external depending upon whether they are
developed within the sphincter ani or outside this muscle.

Pathology. The haemorrhoidal tumor is composed of dilated blood-vessels,
of clots beneath the mucous membrane or of the muco-cutaneous integument
of the anal region. It is seldom single; more frequently there are two or
more. In shape they are spherical or ovoid, of the size of a small pea to that
of a good sized grape or even larger; in color they are reddish or purple, their
surface is smooth or lobulated, and in consistency they vary from soft and
fluctuating to firm and tense. On section they are found to be filled with
venous blood and if of long standing the cavity of the tumor may be intersected
with a reticular growth of connective tissue.



HAEMORRHOIDS. 421

iEtiology. Haemorrhoids are predisposed to by the erect posture of the
body and the anatomical arrangement of the structures involved; the fact that
haemorrhoidal veins drain into both the general and the portal venous circu-
lation renders the occurrence of piles common in conditions involving venous
obstruction, such as cardiac lesions, hepatic cirrhosis, etc. Haemorrhoids
are common in both men and women; the former seem to be more frequently
affected than the latter, although this may be the result of the natural disin-
clination of the female sex to consult a physician concerning such a condition.

Chronic constipation is a common predisposing cause of haemorrhoids, the
hard faecal masses pressing upon the veins of the rectum and rendering free
circulation difficult. Pelvic tumors, uterine displacements, etc., act in the
same manner and have the same resiilt; haemorrhoids are a common and
often very distressing complication of pregnancy. The tendency of the
menstrual flow to relieve congestion of the pelvic region is likely, on the other
hand, to militate against the production of piles.

Haemorrhoids are also predisposed to by the wearing of over-tight clothing
about the waist, by over-eating and drinking and by sedentary habits.

Symptoms. Piles may exist for long periods without causing symptoms.
Should an external haemorrhoid become congested for any reason the first
symptom is pain in the region of the anus, accompanied by sensations of
tingling; these increase until sitting becomes impossible and a movement
from the bowels attended with excruciating agony. Examination reveals
one or more purplish tumors at the anal margin, hard and tense and exces-
sively tender. The tumor may gradually disappear and the symptoms abate,
abscess formation may ensue and spontaneous cure result after rupture and
discharge of the pus, or the circiilation being cut off by the engorgement, the
haemorrhoid may ulcerate off. At any time inflammation may recur with its
attendant symptoms. Recurrent hemorrhage from the tumors is not infre-
quent and is not harmful provided not too much blood is lost.

Internal piles may be single or multiple. The symptoms produced by
them are a feeling of fulness or tenesmus in the rectum, with dull aching pain
and perhaps a mucous rectal discharge. Engorgement with symptoms
corresponding to those of external piles may at any time appear and haemor-
rhage is not uncommon; this latter may relieve the discomfort but at times
so much blood is lost as to jeopardize the health of the patient.

Treatment consists in attention to any causative factor in the shape of
cardiac, hepatic or pelvic disease, the securing of a normal movement of the
bowel each day (see the treatment of constipation, p. 412) and careful daily
cleansing of the parts by means of soap and warm water. Painful haemor-
rhoids when not acutely engorged may be relieved by various astringents
such as liquor ferri subsulphatis; this should be applied 2 or 3 times daily
with a brush. Ointments such as the following are often effectual: I^ unguenti



422 DISEASES OF THE DIGESTIVE SYSTEM AND PERITONEUM.

stramonii, unguenti belladonnas, aa. 5ii (8.0); unguenti gallae, 5iv (15.0); or
I^ extract! suprarenalis, 5ii (8-o); adipis lanae hydrosi, 5vi (24.0). These
ointments should be applied generously to the affected part, a wad of cotton
should be fitted over the anus and held in place with a T-bandage.

Inflamed and engorged piles may be relieved by holding a piece of ice in
contact with the tumors, by spraying them with a jet of cold water or by apply-
ing a compress of gauze impregnated with boroglyceride or by ointments
such as the following: I^ morphinae sulphatis, gr. x (0.66); unguenti bella-
donnge, unguenti stramonii, aa 5iss (6.0); ichthyolis,5v (20.0); orj^ morphinae
sulphatis, gr. iss (o.i); acidi tannici, 5ss(2.o); picis Hquidas, 5ss(2.o); cerati,
5ss (2.0); adipis benzoinati, q.s. ad §1 (30.0).

The treatment of piles which are not protruded is practically identical
with that already given. The difficulty of applying ointments to the tumors
within the sphincter may be obviated by the use of the "pile pipe," an in-
strument adapted to the injection of semi-solid materials, and the employment
of suppositories; of these the following excellent examples are worthy of
trial: I^ ichthyolis, acidi tannici, aa gr. v (0.33); extracti beUadonnae, gr. ^
(0.032); extracti hamamelidis, olei theobromatis, q.s. ad gr. xv (i.o). Fiat
suppositoria; I^ iodoformi, gr. v (0.33); olei theobromatis, gr. x (0.66). Fiat
suppositoria.

Haemorrhage from protruded piles may be controlled by the application of
a wad of cotton thoroughly impregnated with iodoform, powdered supra-renal
extract, powdered calomel, bismuth subgallate or aristol, or a compress saturated
with a 10 percent, solution of calcium chloride; bleeding from the non-protru-
ded variety may be stopped by the injection of 5 drachms (20.0) of 10 percent,
calcium chloride solution or the introduction of suppositories such as the
following: I^ extracti supra-renalis, gr. v(o.33); olei theobromatis, gr. x (0.66)

For a description of the treatment of haemorrhoids by injection and radical
surgical measures, which are indicated when medicinal treatment fails, the
reader is referred to works upon rectal diseases or upon surgery.



DISEASES OF THE LIVER.

ABNORMALITIES IN SHAPE AND POSITION OF THE LIVER.

The most common and important abnormality in the shape of the liver
is the result of the constriction of tight waist bands or corsets, the so-called
"corset" or "lacing liver." The deformity consists of a division of the right
lobe into two parts by a transverse groove of varying depth. At times the
furrow is so deep that the right lobe is divided into two more or less equal por-
tions by a tendinous band. The symptoms which ensue are usually unimpor-



DISEASES OF THE LIVER. 423

tant the chief interest of the condition lying in the fact that the lower division
of the lobe, which often reaches to the umbilicus and may extend as low as
the iliac crest, is likely to be mistaken for an abdominal tumor or a mis-
placed kidney; its margin, however, in most instances, is continuous with that
of the left lobe of the liver and the displaced organ descends with inspiration.
If the intestine lies in the groove and is tympanitic upon percussion there is
an added difficulty in the differentiation of the condition. The symptoms,
if any, are those incident to the dragging down of the tumor, and nervous
manifestations such as those caused by a movable kidney may be present.

At times the corset liver lies almost entirely above the costal margin, it is
narrower above than below and the transverse furrow is just superior to the
lower margin of the organ.

These deformities of the liver are said to offer an obstruction to the normal
flow of the bile and consequently to predispose to the formation of hepatic
calculi.

Abnormalities of Position. The liver may be upon the left side of the
abdomen in instances of visceral transposition. Not uncommonly is the organ
tilted forward so that, although there is no increase in size, the lower border
may be palpable bfelow the costal margin. This tilting may be so extreme
that the vertical diameter of the organ may become horizontal. The liver
may also be displaced upward by the pressure of abdominal growths or by
peritonaeal effusions and downward by fluid in the right pleural cavity or by
the expanded lung of emphysema.

The movable liver is a rather rare condition, which may be caused by tight
lacing and also may occur as a part of a general visceroptosis. The displace-
ment of the organ may be slight only or so considerable that the entire liver
may fall below the edge of the ribs in which case the coronary and suspensory
ligaments are so elongated as to form a mesohepar.

Physical examination in instances of marked hepatoptosis reveals an absence
of the normal liver dulness and the existence of a tumor having the size and
shape of the liver in the abdominal cavity below the normal position of the
organ. The tumor is usually freely movable and may be replaced if the
patient assumes the recumbent position.

The symptoms usually observed are analogous to those of movable kidney,
namely a dragging sensation in the abdomen together with the nervous mani-
festations which so often are associated with nephroptosis. In a considerable
proportion of instances jaundice with pains resembling those of hepatic colic
occurs.

Treatment consists of the application of a properly fitting belt or bandage
calculated to hold the organ in place. When the hepatoptosis is a part of a
general ptosis of the abdominal viscera the treatment is that of the viscer-
optosis (see p. 367).



424 DISEASES OF THE DIGESTIVE SYSTEM AND PERITONEUM.

PERIHEPATITIS.

Synonym. Capsular Cirrhosis.

Definition. A localized peritonitis involving that portion of the membrane
which surrounds the liver.

Etiology. Perihepatitis is observed as a result of extension of some hepatic
inflammation such as abscess; in association with a general peritonitis; as an
extension of a pleuritic inflammation through the diaphragm; as a result of
trajimatism; as a result of perforation of the stomach, intestine or gall-blad-
der or as a part of a general inflammation (panserositis) of the serous mem-
branes including the pleura, pericardium and peritonaeum. It has also been
considered as due to an arterial nephritis.

Pathology. Fibrinous perihepatitis is characterized by the exudation of
fibrin upon and the formation of adhesions of the peritonaeal covering of the
liver. These adhesions may, in the purulent type of the inflammation,
encapsulate collections of pus between the liver and the diaphragm (sub-
diaphragmatic abscesses) which may ultimately perforate upward into the
pleural cavity.

In the chronic form the inflammation consists of a marked thickening of
the entire capsifle of the liver with consequent contraction and diminution
in the size of the organ which, however, is itself seldom the seat of a cirrhosis.
The thickening is often extreme at the hilum of the liver and there may be
stenosis of the blood-vessels and bile ducts at this point; adhesions to sur-
rounding structures are very common.

Symptoms. These are often not in the least characteristic and frequently
the condition is unsuspected during life; pain over the hepatic region may
be present. In some instances the symptoms are those of atrophic cirrhosis
with recurrent ascites but no jaundice. Physical examination may reveal
the presence of a friction sound over the liver or over the epigastric region
when there is marked general capsular thickening. When there is a purulent
exudate between the diaphragm and the liver there is also a septic tempera-
ture with chills and sweating; the lower ribs of the right side may be forced
outward and the physical signs of pleuritic effusion may be present with flat-
ness and absence of voice, breathing and vocal fremitus even as high as the
angle of the scapula. Rupture of the pus cavities may take place upward
into the pleura, into the abdominal viscera or outward through the
skin.

The diagnosis between suppurative perihepatitis and pleuritic effusion is
sometimes difficult but the early symptoms of the former are abdominal
rather than thoracic. The liver is displaced further downward in the former
condition. Aspiration may be of assistance in differentiation and it has
been stated that the pressure of the out -flowing fluid is increased during the



ABSCESS OF THE LIVER, 425

descent of the diaphragm with inspiration in subphrenic abscess while in
effusion into the pleura the opposite is the case.

The non-purulent perihepatitis with localized thickening is seldom recog-
nized during life.

The prognosis in the suppiurative type is unfavorable; the localized thick-
enings of the hepatic peritonaeum are not prejudicial to life but the generalized
perihepatitis with associated thickening of the other serous membranes is a
serious and ultimately fatal condition.

Treatment. In the more acute instances of perihepatitis before pus-
formation the patient should be kept in bed on a light diet. The pain may
be relieved by counterirritation in the form of hot compresses, mild mustard
poultices, cupping or leeching. The application of straps of adhesive
plaster will lessen the movement and prevent stretching of the adhesions
but has the disadvantage that the interference with motion tends to per-
manency of the adhesions.

When pus is present surgical measures should be immediately undertaken
with its evacuation in view.

In the general thickening of panserositis with ascites the treatment is
identical with that of hepatic cirrhosis with peritonaeal exudate (see p. 432).
The intake of fluids should be limited, depletion by purgatives and diuresis
may be given a trial. Inunctions of 10 percent, iodine in vasogen may be
prescribed in the hope of causing absorption of the peritonaeal proliferations.
Large accumulations of ascitic fluid necessitate paracentesis. Repeated
tappings are sometimes indicated. The treatment of ascites by means of
operation will be discussed in the section upon the treatment of hepatic
cirrhosis.

ABSCESS OF THE LIVER.

Synonym. Suppurative Hepatitis.

^Etiology. Hepatic abscess is in all probability, in every instance, the
result of microbic infection. The possibility of chemical insult to the organ,
however, may be considered.

Infection of the liver tissue and subsequent abscess formation may result
from a number of causes; of these the most frequent are:

1. Infection with the amoeba coli. In most instances of this form of the
affection there is a preceding tropical amoebic dysentery but amoebic abscess
of the liver has been observed in the absence of symptoms referable to the
intestine. Amoebic abscesses are usually single, of considerable size and
as is natural, most common in tropical countries.

2. Pyaemic abscesses occur as a result of the lodgment in the blood-vessels
of the liver of septic emboli. These are often multiple and usually of small



426 DISEASES OF THE DIGESTIVE SYSTEM AND PERITONEUM.

extent. They occur in pyaemia, osteomyelitis, malignant endocarditis, ulcer-
ative inflammations of the intestines, pelvic suppuration, peritonaeal inflam-
mations, etc. ; when the primary suppurative process is in the area of the sys-
temic circulation the infection is brought to the liver by the arterial system
as a rifle; more rarely it may be transmitted by means of the inferior cava
and the hepatic vein.

3. Foreign bodies, such as hepatic calcifli or parasites may set up an
infective cholangitis which may proceed to abscess formation.

4? Tuberculous hepatitis may be characterized by the development of
multiple abscesses.

5. The passage of foreign bodies from the oesophagus, stomach or duod-
enum into the liver itself, where an abscess may result, or into one of the portal
vessels, where an infective pylephlebitis followed by an abscess may take place,.
is a rare cause of hepatic suppuration. Hydatid cysts of the liver are subject
to infection and subsequent abscess formation.

6. Traumatism over the liver is a recognized cause of hepatic abscess and
head injuries may be foUowed by the occurrence of this lesion.

Pathology. Abscess of the liver may be single or multiple. Large abscesses
are most frequently situated in the thickest part of the right lobe, the cavity
being sometimes so large as to involve the whole of this structure. The liver
may be enlarged and, if the abscess is near the surface, a fluctuating sweUing
may be noted. The lining of the larger abscess cavities is usually ragged
and their contents may be thin and foetid or thick and viscid; it is often bile-
stained. It often contains cholesterin and bilirubin cr}^stals. The pus of
the amoebic abscesses usually contains the amoeba coli. The pus of echi-
nococcus abscesses contains the characteristic booklets.

Pyaemic abscesses are usually small and mifltiple but they do not often
communicate. They begin as a phlebitis which spreads to the adjacent tis-
sues. The liver is enlarged but its external appearance may be unchanged; if
the abscesses are near the surface there may be capstflar inflammation and
adhesions to neighboring structures. Superficial abscesses may be evidenced
by the occurrence of yellovnsh spots upon the surface of the organ. In marked
instances of suppurative pylephlebitis the liver on section exhibits a number
of small yellowish areas, rounded or branching, from which pus exudes on
pressure. Careful examination wiU reveal the fact that these small abscesses
communicate with the portal vein and are really branches of this vessel in a
state of suppuration. Involvement of the entire portal system may be observed
and the infective process may extend into the mesenteric or gastric veins.

In the multiple abscesses of cholangitis the appearance of the Hver is similar
to that just described but the pus is in the bile ducts instead of in the branches
of the portal vein. Gall-stones and suppurative cholecystitis are often present.

Perforation of large abscesses into the pleura, lung or any of the adjacent



ABSCESS OF THE LIVER. 427

viscera, into the peritonseal cavity or through the skin externally may take
place.

S)auptoms. These may be very indefinite; in rare instances death from
rupture and general peritonitis may occur before there is suspicion of the true
natiire of the affection.

Elevation of temperature is quite constant, the curve being of the pygemic
t}-pe and reaching as high, in some instances, as 105° F. (40.5° C). The fever
is accompanied by irregular chiUs and sweating, the latter often being marked
during sleep. Fever may be sHght or absent in chronic instances of the
affection. Jaundice in varying degrees may be present but is a rather incon-
stant symptom. There is pain in the region of the liver or it may be referred
to the shoulder or back. The patient is often more comfortable when lying
on the right side. There is tenderness upon pressure over the liver especially
at the margin of the ribs anteriorly. There may be a co-existent diarrhoea,
especially in amoebic abscess and the presence of the amoebae in the faeces
is a great aid in diagnosticating the condition;

Perforation into any of the sttrrounding structures or through the skin
may take place. Rupture into the lung is characterized by con\ailsive cough
with the expectoration of sputum of reddish brown tint resembling anchovy
sauce, and the signs of consolidation at the base of the right lung. The spu-
tum may contain the amoeba coli.

Physical examination reveals an increase in the size of the liver, usually
of the right lobe, which is enlarged upward rather than downward. This
enlargement is evidenced by an extension of the normal liver dulness upward;
this is especially marked in the mammiUary and mid-axillary lines. Large
superficial abscesses may cause a bulging of the overlying surface and it may
even be possible to detect fluctuation. • Adhesions to the abdominal wall
may take place and as a result of these fremitus may be elicited. The com-
pressed lung moves less upon respiration than normally. In some instances
of extreme hepatic enlargement the margin of the organ may be palpable
below the costal margin; its surface is smooth and tenderness is often
present.

The symptoms of the multiple pyaemic or pylephlebitic abscesses occur
as part of those of a general pus infection. The pyaemic temperature, with
its accompanying sweats and chills, is present and the skin may be jaundiced.
There is pain in the hepatic region with tenderness on pressiire and the liver
is the seat of a uniform increase in size.