When the icterus is a consequence of the condition above described, it is seldom very severe. In the mildest cases the conjunctivcc are only faintly tinted with yellow ; the appearance of the urine and the motions is normal ; and the staining of the skin is only noticed on the face, the front of the chest, and the back. The derangement is then only a passing one, and the skin resumes its natural colour in three or four days. In a higher degree, the yellowness may extend to the belly and upper arms. The con junctivm are yellow ; the urine is high-coloured, and stains the linen ; but even in this case, the stools may retain their normal tint, which at this age is naturally a golden yellow colour. In this degree, the symptoms gener ally last a week. Ea other cases, the jaundice is general, and may involve even the hands and feet. The urine is then distinctly icteric ; the con junctivm are very yellow ; the tears are tinted with bile, and the stools are clay-coloured. In some cases, Seux has noticed an ophthalmia to come on a few days after the onset of the jaundice, with a copious and deeply stained purulent secretion. As a rule, the child seems to suffer little in convenience from his derangement. He takes his food well and has no pain. Often, on palpation of the belly, the liver will be noticed to be in creased in size, and the lower border may be felt at the level of the um bilicus. It is curious that, although the urine is coloured yellow, the most careful examination of the water is unable to detect the presence of bili Parrot and A. Robin have, however, discovered in the ic teric urine yellow amorphous irregular masses, varying in size from a red blood-corpuscle to a vesical epithelium, and differing in chemical tests from the colouring matter of the bile. They have also noticed the pres ence of sediments containing uric acid, urate of soda, and oxalate of lime ; hyaline, epithelial, and fatty cylinders ; white globules, and cells from the urinary passages.
When death occurs in infants who suffer from this benign form of jaundice, the fatal termination is owing usually to other causes. There is a variety of the complaint, to which attention has been directed by Seux, where the icterus is accompanied by all the symptoms of intestinal catarrh —diarrhoea, a quick pulse, and some heat and tenderness of the belly. There is, however, rarely vomiting. In the favourable cases the diarrhma ceases before the jaundice disappears. If the looseness of the bowels per sists, it is a dangerous derangement at this early age, and the infant often dies.
Although usually a symptom of comparatively little moment, icterus neonatorum may be the indication of very serious disease. The grave form, of jaundice may be the result of three different conditions. There may be a congenital malformation of the gall-ducts ; the ducts may be compressed by syphilitic inflammation and growth (the syphilitic peripylephlebitis of Schtippel) ; or the icterus may be the consequence of umbilical phlebitis and pymmia.
Infantile jaundice from atresia of the bile-duets is fortunately not a common disease. Several varieties of malformation have been recorded : the gall-duct has been found converted into a fibrous cord ; the common duct has been known to be obliterated, or absent, or excessively narrowed ; sometimes all the ducts have been wanting ; in other cases, the gall-bladder has been rudimentary and the ducts absent. The liver itself iT normal in appearance, or greatly enlarged ; usually, it is of a deep olive or nearly black colour. It has also been noticed to be cirrhotic, and its substance has been found to be denser than natural. The microscope shows an overgrowth of the areolar tissue, chiefly in the capsule of Glisson ; and broad bands of connective tissue surround the dark green islets of liver cells. This incipient cirrhosis appears to be a constant accompaniment of obliteration of the bile-ducts, and continues to advance as long as the child survives. In animals, ligature of the ducts has been shown by Dr. Wickham Legg to lead to marked hepatic cirrhosis and consequent portal congestion.
This rare and distressing form of malformation is sometimes found to affect several children of the same parents. This tendency to appear in successive children of the same family was noticed by Cheyne in 1801, and has been commented upon by other writers. The jaundice to which retention of the secreted bile gives rise may be present at birth, but usually is not visible before a week, a fortnight, or even longer. When it first appears, the discolouration has a faint yellow tint, but the colour gets quickly darker. The conjunctivae are yellow ; the stools soon become colourless and offensive ; and the urine is high-coloured and leaves yellow or greenish brown stains on the diaper. At first, nothing abnormal is noticed about the belly ; but after a clay or two the liver begins to enlarge, and may reach a great size in a short time. The spleen may be also felt to be larger than natural. There is some swelling of the belly, and ascites may be present ; but the abdominal distention is usually due to the in crease in size of the hepatic and splenic viscera, and to flatulent accumula tion resulting from the decomposition of food. Dr. Wickham Legg men tions swelling of the limorrhoidal veins among the occasional symptoms. The child usually takes food well, but wastes quickly. The bowels are often costive. The jaundice is not constant in degree. The tint of the skin varies, and on some days the infant is much more deeply stained than on others. Before death, in some cases, the abnormal colouring almost completely disappears, as very little bile is formed, owing to the destruction of the secreting tissue of the liver. The stools do not always lose colour very rapidly ; sometimes for days, or even weeks, meconium or coloured stools may be evacuated ; but the colour is usually described as a dark green, and is due possibly to altered blood.