liver may be of two kinds. The one consists in a mere abnormal deposition of fat-globules in the hepatic cells without any injury or degen eration of the cell-wall. This is called fatty infiltration. The other is fatty degeneration, in which the nutrition of the liver-cells is interfered with. They undergo a retrograde metamorphosis, and fat granules appear in them. Each of these varieties may be found in the child. They are most common in infancy and the earlier period of childhood.
Causation.—Fatty infiltration of the liver may arise in the child from two causes :—From overfeeding with farinaceous foods, and from various forms of exhausting disease. hi the first case, the hydrocarbon is supplied from without, and being in excess, is deposited in the liver in the form of fat. Deposition of fat under such circumstances may be looked upon rather as a physiological than a pathological process. It is often a merely tem porary phenomenon, and ceases when the diet is changed. In the case of disease, such as tubercle, scrofula, intestinal catarrh, syphilis, rickets, etc., the fat is reabsorbed from the subcutaneous and other fatty tissues. According to Oppenheimer, in infants dying during the second or third week of entero-colitis, the liver, although of normal appearance to the naked eye, is the seat of a real fatty degeneration. Fatty granules are seen in the hepatic cells along the whole course of the portal vessels, and the de generation is preceded by the formation of an abnormal plasma in the cells which completely obscures the nuclei. In other structural diseases of the liver, fatty degeneration may occur as a secondary lesion.
Morbid Anatomy.—The size of the liver is not altered unless the fatty change is carried to a high degree. In that case all its measurements are increased and its edge is blunted. The surface is lighter coloured than natural, and may have an oily, shining appearance. The hepatic substance feels soft and doughy to the touch, and the section is yellowish red or yellow. In extreme cases the blade of the knife looks greasy after the sec tion. By the microscope granules and globules of fat are seen in the he patic cells. The oily drops are larger in proportion to the stage to which the infiltration has advanced ; and if the process be carried to a high de gree, the cells may each be filled by one large drop of oil. The cells at the circumference of the lobules near to the intra-lobular veins are first and principally affected. Those towards the centre are much more healthy. Therefore, on closely inspecting a lobule, the part immediately surrounding the central vein will be found much redder in colour than the periphery. The fat consists of olefin and margarine, with traces of cholesterine.
Symptoms.—If the organ is not enlarged, and the degree of fatty infil tration is slight, symptoms may be absent altogether. Even if the liver is enlarged, there is little to draw attention to the belly. Some tenderness may be noticed in the right hypochoudrium when this is pressed, and in exceptional cases the child may complain of a feeling of heaviness on that • side. Cases where the size of the liver is notably increased from this cause
are usually those of phthisical children. There may be some digestive de rangement from interference with the portal circulation, but there is never jaundice or ascites. The fatty liver is not always easy to feel, as it yields readily under the finger, and is easily depressed from the surface. Conse quently, like the softened spleen in typhoid fever, its edge may elude the touch. It is of the utmost importance, in consideration of cases such as these, to lose no opportunity of practising the sense of touch and accustom ing the finger to appreciate slight differences in resistance.
In fatty degeneration of the liver, there is no increase in size of the or gan, and the disease, occurring as it does in the course of some exhausting illness, gives rise to no symptoms which can reveal its presence. It is there fore seldom discovered during life.
Diagnosis.—A liver enlarged from fatty infiltration differs from other forms of enlarged liver. Instead of being firm and resisting, its substance is soft and ; and the edge, instead of being sharp and thin, is rounded and blunt. Such a liver found in a case of tubercular or scrofulous phthisis, or in the course of some other exhausting disease, unaccompanied by jaun dice, ascites, or dilatation of the superficial veins of the abdomen, is in all probability fatty. Thus, in a little girl, aged three years, the subject of a chronic hydrocephalus, who died in the East London Children's Hospital from acute tuberculosis, the liver on the child's admission was found to reach as far downwards as the level of the umbilicus. Its edges were rounded and its substance seemed to be normal. There was no sign of jaundice ; the superficial veins of the belly were not visible, nor could any fluctuation be detected in the abdomen. The spleen was also enlarged. After death, the liver was found to be greatly increased in size. Its con sistence was softer than natural, its colour a fawn brown, and some yellow miliary nodules were seen on the surface. Its section had a greasy look. The spleen, which was also enlarged, was studded with tubercles.
Prognosis.—A remarkably fatty liver occurring in the course of a linger ing illness implies serious interference with nutrition ; but the prognosis depends more upon the primary disease than upon the state of the liver.
Treatment.—The indications for treatment must be derived from the primary disease in the course of which the fatty condition of the organ has arisen. If a child is known to be taking extravagant quantities of farina ceous food, measures must be taken at once to put a stop to such excess ; but many other symptoms besides fatty liver may be the consequence of such a dietary. This subject is treated of elsewhere (see Gastric Catarrh).