In hypertrophic cirrhosis, the liver is usually larger than in health, and may be increased to twice its natural size. It is smooth on the surface, with a normal thin edge, and on section, its substance is orange yellow or green in colour. The fibroid overgrowth in this case follows the ramifica tions of the biliary ducts. It begins round the intralobular branches of the ducts, and envelopes each lobule so as to insulate it from its neighbour. It forms a less regular meshwork than the preceding variety, and is a more diffused growth, which in some parts is thick and dense so as completely to destroy the hepatic tissue ; in others, is comparatively scanty and ill-de veloped. The affected ducts become largely dilated and their epithelium is increased. New ducts are also developed, and can be seen by the micro scope embedded in the new fibroid tissue. In this form of the disease, the obstruction is chiefly in the ducts, so that there is no necessary interference with the portal circulation.
These two forms of the disease, from their anatomical origin, have been called portal and biliary cirrhosis.
There is a third form which is very rarely met with. It has only been noticed in some cases of inherited syphilis in the infant. The disease is here primarily intralobular, and clevelopes within the lobules round the individual liver-cells. This form, as it is only discovered after the death of the child, and probably gives rise to no symptoms, need not be further re ferred to.
Symplonts.—On account of the different pathological conditions in the atrophic and hypertrophic varieties of hepatic cirrhosis, the symptoms in the two forms are not precisely similar. In both we find signs of interfer ence with general nutrition, but as the morbid change affects chiefly the por tal circulation in the one variety, and the biliary conduits in the other, the later phenomena differ greatly in the two cases, and are usually character istic.
In atrophic cirrhosis, the early symptoms are merely those of indiges tion, flatulence, and general discomfort. The child is often peevish and fret ful ; he is restless, sleeping badly at night ; and his complexion is sallow or pasty-lookina with dark discolouration of the lower eyelids. He is noticed early to be flabby, and sometimes is evidently losing flesh. His bowels are often costive. These symptoms may continue for a long time without change. The urine is apt to be thick with lithates, and may contain crys tals of uric acid, or even a deposit of uric acid sand. It is often very acid.
Sooner or later, more distinctive symptoms begin to be noticed, and in hospital patients it may be only from this point that the child's illness is dated by the parent. The occurrence of ascites, with swelling of the belly,
is usually the first symptom complained of, and there may be some wander ing pains in the side. When the child comes under observation, we usually find dilatation of the superficial abdominal veins, distinct fluctuation in the abdomen, and often a slight enlargement of the liver and spleen. There is little or no jaundice, but the skin after a time begins to have an earthy tint, and feels dry and rough to the finger. Sometimes there is a little of the feet. The ascites is found to vary greatly in amount, and the general condition of the child is subject to rapid variation. On some days he seems much better than on others, and may be then lively, playful, and although easily tired, even active if allowed to be on his feet. As the disease pro gresses, the liver shrinks and ceases to be felt, but the spleen in most cases continues to increase in size. If the ascites is great, it is often difficult to feel the spleen even when the child is laid on his right side. In such cases, it may be often readily detected by placing the patient on his hands and knees. The weight of the organ then brings it well forward within the reach of the fingers. Haemorrhages occur in the child from the gastro intestinal mucous membrane as they do in the adult ; and the motions may be dark and sooty from blood, or pure blood may be passed by stool. Vomit ing of blood is also sometimes met with. In many cases, we find a tendency to haemorrhage from other parts. The nose and gums may bleed, and ecchymotic spots may be noticed on the skin. As the symptoms increase, the digestive derangements become more and more disturbed. The child is much troubled with weight in the epigastrium, and abdominal pains. He often feels sick ; sometimes he vomits ; his tongue is furred ; he is thirsty, and his appetite is capricious or is lost. He gets thinner and thinner ; the dingy hue of his skin becomes more and more marked ; even at this early age, htemorrhoiclal swellings may be noticed, and the distention of the superficial abdominal veins is increased.
When the disease reaches this period, life is very near its close. Often there is general dropsy, but the child may sink and die without the ap pearance of any fresh symptoms ; or diarrhoea may come on and prove rapidly fatal. In other cases he dies from hemorrhage, or from an intercurrent inflammation, such as pleurisy or pneumonia. Unless a complication be present, there is never any fever. The progress of atrophic cirrhosis is slow, especially in the earlier stages. If haemorrhage occurs, it is usually a sign that the illness is approaching its termination.