If the congestion is due to cardiac disease the child is harassed with dyspncea and cough from interference with the pulmonary circulation ; his digestion is deranged, and there is often, in addition, cedema of the lower limbs, with albuminuria.
A congested liver is, as has been said, frequent in cases of ague. Often, until this condition is remedied, quinine has but little influence over the attacks. This subject is discussed elsewhere (see Ague).
Diagnosis.—A congested liver is increased in size, and pressure upon it produces some uneasiness. Mere light-coloured offensive stools are not in themselves a sign of hepatic hyperaemia. It is common for a child who is being fed upon large quantities of farinaceous food, or who, owing to a catarrhal condition of his stomach and bowels, is for the time incapable of digesting a milk diet, to evacuate more or less semi-solid pasty or putty like matter from the bowels. But the stools in such a case consist of un digested food, and are not indicative of arrested biliary secretion. If such a condition be treated, as it often is, by repeated doses of gray powder or other form of mercurial, the aperient action of the medicine produces on each occasion a dark biliary stool, but the effect of the drug having passed off, the evacuations continue to be as pasty as they were before. This con dition, as is elsewhere explained, must be treated, not by cholagogues, but by measures which rectify the gastric and intestinal derangement (see p. 640).
To justify the diagnosis of hepatic congestion we must require enlarge ment and tenderness of the liver and a sallow complexion, as well as diges tive disturbance and light-coloured stools. We must not, however, con clude too hastily that the size of the liver is abnormal. The organ is apt to vary in size in young subjects from natural causes, and in some children whose chests are exceptionally short may project for a finger's breadth or so below the ribs without being congested or otherwise diseased. Be sides, it is important not to mistake a liver merely displaced for a liver morbidly enlarged. The organ may be pushed down by fluid accumulation in the pleura, or by emphysema of the lung ; and I have known an exten sive pericardial effusion to produce the same effect. In rickety children with deeply grooved chests, the liver and spleen, although not enlarged, may be felt more distinctly than natural, being forced downwards some what from their original position. It is therefore important to ascertain
by percussion the upper limits of the liver dulness as well as the exact level of the inferior margin. Again, a liver, although enlarged, may lie completely under cover of the ribs, and its abnormal condition may thus escape notice. It may be pushed upwards by fluid accumulation and growth in the belly ; or may be placed higher than it otherWise would be through the shrinking in the chest of a collapsed or indurated lung. Therefore, in an examination of the organ, we must remember these sources of error, and ascertain all its limits before coming to a conclusion.
A good example of a congested liver is seen in the following case : A little boy, aged three years, of healthy parentage, was brought to the East London Children's Hospital with the history that for five weeks he had been noticed to be languid and chilly, with little appetite and with some swelling and tenderness of his belly. The bowels had acted two or three times a day, the motions being light-coloured, thin, and scanty. The child was restless and fretful, sleeping uneasily, and often starting and twitch ing in his sleep.
The boy was the subject of moderate rickets. His ribs were beaded, the ends of his long bones large, and his chest was flattened laterally. He had cut all his teeth and his fontanelle was closed. The skin was harsh and dry, and was tinted all over the body of an earthy yellow colour. The belly was large, and the lower edge of the liver reached to nearly the level of the umbilicus. Its substance was natural, without any increase in firmness. Its edge was not thickened. The spleen could not be felt.
The patient was treated with mercurial purges followed by salines, and an alkali with bitter infusion was given to him three times a day. In a fortnight after this treatment had been begun, the liver had become much reduced in size. Its upper border was at the fifth rib, and its lower bor der could be felt two fingers' breadths below the ribs. It was evidently pushed downwards by the rickety deformity of the chest, and was no doubt now of natural size. As the liver became smaller, the child's ap petite improved ; his skin lost its earthy yellow tint, and the colour and con sistence of the stools became natural.