404 CLINICAL APPLIED ANATOMY. 



Passive Congestion of the Liver. The liver is peculiarly 

 liable to suffer in all conditions of venous back pressure because 

 the hepatic veins are large, open into the inferior vena cava 

 quite close to the right auricle, and are quite destitute of valves. 

 Hence the passively congested, or nutmeg, liver occurs as the 

 result of valvular disease of the heart, obstruction of the pul- 

 monary circulation, adhesion of the pericardium, constriction 

 of the inferior vena cava by mediastinitis, displacements of the 

 heart which bend the inferior vena cava, or pressure on that 

 vessel by enlarged glands or aneurysm. A moderate degree of 

 passive congestion is also seen in the livers of persons who have 

 died slowly with heart failure. 



In a nutmeg liver the injected areas correspond to the intra- 

 lobular and sublobular branches of the hepatic veins, the first- 

 named branches occupying the centres of the lobules. The pale 

 areas consist of cells which have degenerated in consequence 

 of the stasis of the circulation. General pressure on the bile 

 capillaries accounts for the moderate degree of bile staining often 

 present. 



The jaundice which results from passive congestion of the liver 

 is frequently associated with dropsy of cardiac origin, which 

 indeed often precedes the jaundice. It is often noticeable that 

 the jaundice is much more intense in the upper parts of the 

 body than in the lower cedematous parts, the explanation being 

 that both the fluid in oadema and the pigment of jaundice tend 

 to accumulate in the lymphatic interspaces, and when these are 

 already occupied by stagnant dropsical fluid, it is difficult for the 

 bile pigment to exude into them. 



The venous congestion of the liver, coupled with a certain 

 amount of resistance offered by its capsule, causes the organ to 

 become tender to the touch. 



The congested liver is enlarged. This is detected by deter- 

 mining the position of the lower edge, after ascertaining that the 

 upper level of percussion dulness is not below its normal situa- 

 tion. The upper limit of dulness to light percussion corresponds 

 to the line indicating the lower limit of the lung. It is found at the 



