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Congestion of the Liver

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of the liver, although a common derangement in the child, is yet often suspected when not actually present. Many symptoms attrib uted to a " torpid," " inactive," or congested liver, and treated with gray powder, are really due to a disordered state of the stomach dependent upon an improper dietary, and may be readily relieved by the exercise of a little judgment in the child's food and general management. A liver morbidly congested gives rise to a very definite group of symptoms, as will be after wards described.

Causation.—The amount of blood circulating in the liver may vary con siderably within normal limits. During digestion it is increased for the time ; and if the child be habitually overfed, or be frequently indulged with highly spiced and stimulating food, the hyperemia lasts longer and is more intense than if he eat more moderately or of a plainer diet. Want of exercise and too close confinement to the house will increase the injurious effects of this unwholesome regimen. The other principal causes of mon. bid congestion of the liver are :—Any cause which interferes with the return of blood from the liver. The commonest of these is disease of the heart interfering with the return of blood from the lungs. The pulmonary cir culation suffers primarily ; and secondarily, the impediment spreads to the versa cava and the portal vein. Congestion of the liver is also a consequence of the ague poison, for malarial fever is as common a cause of hepatic con gestion as it is of splenic enlargement, and a swollen hyperaemic liver is a familiar symptom in tropical climates. Again, chilling of the surface is one of the most frequent agents in the production of liver congestion, and en largement of tile organ from this cause is a usual accompaniment of ca tarrhal jaundice.

Morbid Anatomy. —A congested liver is enlarged in all directions, and is very thick ; its resistance is increased, and the peritoneal coat is tense and shining. When cut into, the organ 'bleeds freely, and the section shows a spotted or " nutmeg " surface from dilatation of the intra-lobular veins. Of ten, the colour of the parenchyma surrounding the central vein of the lobule is yellowish from interference with the escape of bile from the ducts ; for jaundice is not unfrequently associated with'this hepatic congestion.

If the hypermmia of the organ is a chronic condition, further changes take place after a time. The enlargement of the intra-lobular hepatic veins induces atrophy of the liver-cells in their immediate neighbourhood. Sur rounding these cells are others which are stained deeply with bile, and at the circumference of the lobule the cells are often filled with oil. The atrophied cells may completely disappear ; and eventually a new formation of fibroid tissue takes place in connection with the inter-lobular vessels. The fibroid growth shrinks, and a condition akin to cirrhosis is set up ; the organ becoming granular on the surface and the capsule thickened.

Symptoms.—If the liver be much congested, we generally find that there is some pain in the right hypochondriac region ; that it is tender when pressed ; and that coughing or a deep inspiration is distressing. The child is often unwilling to lie on either side—on the right because of the direct pressure ; on the left because of the weight of the congested organ causing an uneasy dragging sensation. On palpation of the belly, the edge of the liver is felt several fingers' breadths below the ribs, and on percussion we generally find that the upper limit of dulness, instead of beginning in the fourth interspace, begins in the third or on the third rib. Sometimes, es pecially if there is jaundice, the distended gall-bladder can be felt as a pear shaped tumour below the inferior edge of the liver.

Dyspeptic symptoms from hyperaemia of the gastric vessels generally ac company a congested liver. The tongue is furred ; there may be headache ; nausea may be complained of ; the bowels may be relaxed, and the stools light-coloured and offensive. The urine is dark, and may throw down a copious deposit of lithates. The skin is often sallow ; and if the conges tion be accompanied by duodenal catarrh, there will probably be jaundice.

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