In the hypertrophic variety of cirrhosis, the initial symptoms of gastro intestinal derangement, pallor, and wasting, are the same as in the other form ; but the after-course of the disease varies from the previous type. While in atrophic cirrhosis the more characteristic phenomena are de pendent upon the obstruction to the portal circulation, in the hypertropliic variety the symptoms are due to interference with the biliary system of ducts. Jaundice, rare and faint if it occur at all in the previous form, is here an early and characteristic symptom. The skin, conjunctivae, and urine soon become deeply tinged with orange yellow, and the motions are light-coloured or chalky. The liver is generally enlarged, and the spleen in most cases can be felt of unusual size ; but there is little dilatation of the superficial veins of the abdomen. Pain may be complained of over the liver. The bowels are relaxed or inclined to be costive. There is no as cites.
As the disease progresses, the jaundice increases in intensity, and, the symptoms generally undergo temporary exacerbation. At these times, rapid enlargement of the liver is noticed ; there is slight fever ; the child is peevish and fretful, crying with pain in his side, and his condition appears to be changing quickly for the worse.
The illness often closes with all the signs of malignant jaundice, due, probably, to acute degeneration of the hepatic cells. The pulse undergoes curious alterations in frequency, sometimes beating rapidly, at others slackening to GO or 70. The tongue gets dry and brown, and sorties appear on the teeth. The child refuses food, and seems to care only to be left alone. He sleeps much, and is drowsy and stupid when awake. Petechioe are often seen on the skin ; the gums may bleed, and blood may be vomited from the stomach. The drowsiness soon deepens into stupor ; and the child lies with his eyes closed, insensible to all that passes, often grinding his teeth continuously. There is no pyrexia. The wasting is now rapid, and the patient sinks and dies without recovering conscious ness. Sometimes death is preceded by convulsions.
Although these two types of the disease differ in the distribution of the fibroid overgrowth in the liver, they may be both present together. In such cases the liver is enlarged, and we find jaundice combined with ascites and swelling of the abdominal veins. The hepatic disease may be the only lesion of the kind present, or may be accompanied by similar changes in the lungs, the kidneys, or the spleen.
Diagnosis.—So many cases are now on record of hepatic cirrhosis oc curring in children that the diagnosis should be no more difficult iu them than it is in the adult. It is probable that many cases of ascites, the origin
of which is obscure, may be attributed correctly to this condition of the liver. If in such a case fibroid disease of the lungs can be detected, it ren ders a similar condition of the liver highly probable. A swollen fluc tuating abdomen, an enlarged spleen, dilatation of the superficial veins of the belly, piles, a dry, faded, earthy skin—these symptoms occurring in a child who is not feverish, but who has a history of previous failure of health and of wasting, should make us strongly suspect the existence of the atrophic form of cirrhosis. The absence of fever is an important ele ment in this group of symptoms. If haemorrhages occur from the stomach and bowels, or elsewhere, the temperature still remaining normal, the symptom is strongly confirmatory of our opinion. The chief difficulty in these cases arises from the occurrence of a febrile complication ; but this is a source of perplexity common to most forms of chronic disease in the child. If there be fever when the child first comes under observation, it is advisable to withhold a positive opinion until time has been allowed for the pyrexia to subside.
In the case of hypertrophic cirrhosis, the occurrence of gradually in creasing jaundice, with an enlarged liver and pains in the side, but without ascites, piles, or dilated parietal veins of the belly, the child being the subject of chronic digestive derangement and wasting, is a characteristic grouping of symptoms. If the illness end with convulsions, coma, a ty phoid condition, and the symptoms of malignant jaundice, the case may be mistaken for one of acute yellow atrophy, especially if, as may happen, the liver is not notably enlarged. The latter is, however, an acute disease, and comes on very abruptly, with few or no premonitory symptoms ; while hypertrophic cirrhosis is essentially a chronic illness, with a long history of failing health. Moreover, acute yellow atrophy is so rare in the child that it may be practically excluded from consideration.
Prognosis.—When the disease reaches the stage at which signs of serious impairment of nutrition are noticed, evidenced principally by a dry, earthy-looking skin, the prognosis is very unfavourable ; and if haemorrhages occur, the end may be judged to be near. At an earlier period, when the spirits are fairly good, even although there be consider able ascites, we may take a less gloomy view of the case. The more se rious symptoms are sometimes found to clear away completely—for a time, at any rate, even if they subsequently retiirn.