INFANTILE cirrhosis of the liver.

By V. B. GREEN-ARMYTAGE, m.d., m.r.c.p. (Lond.*),

MAJOR, I.M.S.,

Second Professor of Gynecology and Obstetrics,

Calcutta Medical College and Second Surgeon to

the Eden Hospital for Women, Calcutta.

. From time to time appeals have appeared 111 the Indian Medical Gazette for information

reg"arding ,the diagnosis, treatment, and prog- n?sis of " infantile liver During the last seven years, 63 advanced

Cases of this disease, which I prefer to call

intercellular hepatic cirrhosis, have passed through my hands, and I have been able to watch the results either directly or indirectly. Of these 63 cases, 27 have been European or Anglo-Indian children, 30 have been Hindus, and 6 have been Mohainedans. In all these cases the children have ranged in age between 5 months and 3^ years; 17 children were on the breast, and in 12 out of these 17 cases the mother was a multipara. In all the

remainder, the children, though temporarily on the breast, were suffering from obvious dietetic errors; for instance, 33 children were

being fed on patent foods supplemented with sweets, jellabis, rosagallas, or any other fanciful food-stuff which a distracted mother may give to a peevish child in order to keep it temporarily quiet.

It is not therefore to be wondered at that

the digestive system of the child mutinies, and additional work is thereby thrown upon the excretory functions of the liver, which at

first enlarges due to swelling and congestion of the cells (the result of toxins), and in the

final stages contracts in consequence of the

reactive intercellular fibrosis.

My own views as regards the aetiology of

this disease are as follows:?

(1) If a mother feeds incorrectly before the birth of her child she ma}' predispose her infant to develop this disease, for, if it be

accepted as a fact " that the vitamines are

to the endocrines what the endocrines are to the economy," it will readily be understood

that if the mother's diet is deficient in

vitamines, she will not only influence and

diminish the quality of her breast secretion, but will also influence the endocrine system of the foetus in ntero, which as has now been

proved, commences to function between the

8th and 20th week of foetal life.

(2). A nursing mother frequently suffers

from pyorrhoea, anaemia, or constipation resulting in, or the result of, auto-intoxication. The consequence of this is that the baby obtains a supply of milk from its mother

lacking in stimulatory hormones, calcium, iron, phosphorus, iodine, etc.?such defects

culminating in intestinal and hepatic derange- ment in the infant.

(3) An infant reared on patent foods, or

given indiscriminate articles of diet by its parents, is the one most frequently seen, and I think the explanation is obvious, for many of these children are overfed and the liver, pancreas, and intestinal glands are taxed to

such a degree that the inevitable toxaemia or cirrhotic liver occurs. For instance, it is no

uncommon thing to hear that a child has

gone off its food and is being given cod-liver oil, olive oil, cream, ghee, lumps of sweet or chocolate, etc., in order to encourage or

442 THE INDIAN MEDICAL GAZETTE. [Sept., 1926.

persuade it to eat, although its tongue is dirty and its stools indicate that there is an upset of the metabolism and more particularly of the glycogenic function of the liver. As a

result of this hepatic toxic irritation there is hepatic inflammation with consequent en-

largement, and if the condition is neglected the child goes from had to worse.

(4) Another feature in the aetiology must not be forgotten, and that is that during many months of the year in India cows

particularly, and less often goats, are fed on

dry fodder and are unable to graze properly because the grass has dried up. The conse-

quence of this is that the cow's or goat's milk fails to contain those adequate and normal quantities of salts and endocrines which are necessary to the infant, if it is fed on boiled cow's milk.

Symptoms.?The first thing that I should

like to lay stress on is the fact that this disease is one of insidious onset, and that in minor degree it occurs more frequently than is generally supposed. Fortunately, however, mothers and doctors are gradually beginning to realise that when a child goes off its food and becomes flabby and peevish it is Nature's own effort to cure the child by rest and starvation.

Scores of times I have seen, in consultation, European children with such symptoms for whom1 nothing more was necessary than strict limitation in diet and semi-starvation for a

week or ten days with gentle saline laxative treatment. On such lines the slightly tender enlarged liver has retrogressed and Nature's own method of cure been aided. The old maxim " You have to get worse to get better

"

is a useful line of argument in such cases, for no child or animal is the worse for a week's semi-starvation.

The early symptoms are low fever almost continuously, accompanied by constipation with earthy or putty-coloured offensive stools. The child has no appetite and peevishly refuses all food. It sleeps restlessly and often lies

upon its stomach. The urine is scanty and high coloured, and contains indican and acetone. The mother will tell you that the infant is losing weight, that its muscles are

flabby, and its face sallow and anaemic.

Signs.?The liver will be obviously large to

start with, perhaps 3 or more inches below the costal margin, and the child will cry when you palpate it. The spleen, in the early stages, is not enlarged, but later becomes easily palpable. The conjunctivae look muddy coloured, and in the late stages of the disease there may be actual jaundice. The skin is dry and inelastic, and frequently there is oedema of the feet. In the last and hopeless stages the liver seems to recede, and there may be marked ascites,

A typical blood count taken from one of these cases, aged 7 months, is as follows:?

Red blood cells . .

White blood cells

Haemoglobin Polymorphonuclears Lymphocytes Large mononuclears Eosinophils

70 27 65 7 1

4,000,000 8,000

per cent.

No parasites found. Stool examination in all cases has been

negative, except that bile salts and pigment and excess of fat have been present with undigested debris. No ova or abnormal cocci or bacilli have been found on plating. The diagnosis is as a rule perfectly easy,

and in no case of mine has the possibility of kala-azar, syphilitic liver, or malarial cirrhosis been neglected in the examination. Indeed most of the cases that T have seen in con-

sultation have already been treated with

quinine or its derivatives, or with a prolonged course of grey powder,?that poor panacea for all evils, beloved of mothers and doctors!

In my opinion there is only one condition which might give rise to error, and that is infection with one of the typhoid group of

organisms, but with this you would have high fever with more or less an acute illness, whereas infantile intercellular cirrhosis is a

disease of gradual onset and progressive debility over many months. One final word of caution is necessary

however in making the diagnosis and that is.

do not stamp the disease as rickets, for.

although from the aetiology, this disease, like rickets, is a metabolic deficiency one, if you hint to the parent that the condition is due to rickets it is a thousand to one that nurses,

friends, or an outside doctor will tell the

parent to put the child on to cod-liver oil, Ostelin, Virol, or other vitamine A product before the baby is able to digest it and while its tongue is still dirty, with the result that

Pelion is piled upon Ossa and fatal vomiting and coma may occur within a few weeks or

even days. Treatment.?If the serological factors are

understood the treatment of these cases,

provided that they are seen early enough and before ascites or anaemic oedema occur, is suc-

cessful in 70 per cent, of cases.

(1) Prevention. A mother, during the

ante-natal period, must be fed properly, and the following diet for all pregnant mothers is recommended, with the addition if need be

of cod-liver oil, and Parrish's Food f?r

anaemia or diminished calcium content.

Cereals.?Oatmeal porridge or any of the breakfast foods, with milk. Brown or wholemeal bread, toast,

rusks, cream cracker biscuits. Vegetables.?Any vegetable in any form except fried.

Fruits.?Any fruit either fresh or stewed-

Sept., 1926.] INFANTILE CIRRHOSIS OF THE LIVER: GREEN-ARMYTAGK. 443

Meat.?Beef, lamb, mutton, veal, not at all or only very occasionally. Pork never. Curry never.

Chicken (avoid duck, goose, game). Croquettes or rissoles if not fried in deep fat. Eggs.

Fish.?Any fish except salmon, mackerel, hilsa. Soups.?Any soup, thick or clear, but free from fat.

Sweets.?Any jam or jelly, marmalade or honey, but pure honey is best of all.

Milk puddings. Boiled puddings occasionally. No pastry, no cakes.

Salads.?Any salad, but sparingly of salad dressing. Fluids.?Water, aerated water, home-made lemonade,

orangeade, weak tea, coffee, milk if desired.

No alcohol of any kind. Butter may be taken if desired, but not in large

amounts. Cream, fat meats, and any fish fried in deep fat should be avoided. Fruits and vegetables must be taken at least twice a day, and meat, if at all. not more than once everv other day. Mild cheese, such as

St. Ivel's, is permissible.

(2) During- lactation, the mother's diet should he on the same lines, the idea being to increase the calcium, iron, potassium, phos- phorus, iodine, salts, etc., and also the hormone content of her secretion. If the mother is anaemic or a multipara, encourage her to take cod-liver oil or Ostelin, together with Parrish's Food. A healthy wet-nurse

may mean salvation in infants under 1 year. (3) When weaning occurs, see that the

food supply of the cow or goat is, or has been correct, that is that green fodder is and has been provided. It is for this reason that in India I so particularly urge that goats should be kept, for they can be supervised, led properly, and milked easily and cleanly.

(4) Avoid giving patent foods, sweets,

chocolates, jellabis, rosagallas, ghee, or other rich articles from the table. Remember that

monosaccharids such as honey and ripe sugar-cane are digestible, but all disaccharids, such as sweets, etc., are indigestible and there- fore are not permissible.

(5) No child should have less than 2 to

3 ounces of fresh fruit juice per day, oranges, pineapples, tomatoes, mangoes, grapes, and

pomegranates are easily obtainable all over India.

(6) All children, European or Indian, should allowed out in the sun from 6 to 9 a.m. and

3 to 6 p.m.?that is when the ultra-violet rays ?f the sun are at their maximum. If possible

course of 10 to 20 exposures to ultra-violet

r<iys from a mercury vapour quartz lamp is most

beneficial.

(7) Remember that chicken broth is no food

hut merely a purin stimulant. Vegetable soup on the other hand, made as in France of fresh green vegetables boiled for no more than 15 minutes, contains vitamine C and phosphorus, sodium,

Potassium, iron, calcium, magnesium, and iodine, hut in Bengal and India generally owing to the

poverty of the soil, vegetables contain smallei

quantities of these salts, especially iodine, than 'n Europe. It is, therefore, best to follow the

example of those who live in the valley of the

Mississippi and add iodised salt to all food. An easy method of doing this is to purchase " Iodosol " which is a ready prepared iodised salt sold by all leading chemists.

Actual Treatment.?Keep the child in bed and unclothed in the sun, or, if well enough, let him run about in the sun semi-naked at the hours stated above; and bear in mind that the absolute essential of the following treatment depends upon a fat-free diet which relieves the overworked and

congested liver. I.s7 Day.?Give only barley-water, or rice-

water, sweetened if need be with \ grain of sac- charine to the pint. 2nd Day.?Begin the skimmed milk treatment,

?that is fat-free milk. The easiest way of making skimmed milk is

to take a small enamel douche can, insert a cork in the tube outlet, and simmer therein fresh milk for half an hour; then remove and place on ice or in a cool place for 2 to 3 hours. The fat of the milk will by then all have risen to the top, and the lower two-thirds in the vessel can now be obtained by removing the cork from the outlet and letting the milk run into a clean jug. This

(lower two-thirds) milk is to all intents fat-free and should be given diluted 1 in 3 to start with, gradually increasing its strength. As regards the quantities to be given, remember

the law that an infant requires not more than lj ounces of milk per pound weight per diem in order to maintain life. For instance, a child

aged 9 months was brought to me with typical signs and symptoms of infantile hepatic cirrhosis. Its weight was 12 lbs., that is, it must have 18 ounces of milk per day, and the following directions were given:?Skimmed milk 2 ozs., water 6 ozs. Feed three-hourly.

3rd Day.?Skimmed milk 2% ozs., water 5|- ozs. 4th Day.?Skimmed milk 3 ozs., water 5 ozs. 5th Day.?Skimmed milk 3^ ozs., water 4j ozs. 6th Day.?Skimmed milk 4 ozs., water 4 ozs. 7th Day.?Skimmed milk 4j- ozs., water 3|- ozs.

34 hourly. 8th Day.?Skimmed milk 5 ozs., water 3 ozs.

3j hourly. 9th Day.?Skimmed milk ozs., water 2j- ozs.

3-2- hourly. 10th Day.?Skimmed milk 6 ozs., water 2 ozs.

4 hourly. 11th Day.?Skimmed milk ozs., water lj- ozs.

4 hourly. 12//? Day.?Skimmed milk 7 ozs., water 1 oz.

4 hourly. 13th Day.?Skimmed milk 7\ ozs., water oz,

4 hourly. 14^/i Day.?Pure milk. 4\ to 5 hourly. Rules up to the 14th day. (1) 2 to 4 ounces

of fresh fruit juice to be given between meals. (2) Keep the teeth and mouth clean. (3) Allow as much water in between meals as desired, but no aerated waters or sugared waters. (4) On

444 THE INDIAN MEDICAL GAZETTE. [Sept., 1926.

the 4th day add a teaspoonful of Mellin's

(Dextrimaltose) to each feed. On the 7th day H teaspoonful of Mellin's (Dextrimaltose). On the 10th day 2 teaspoonful of Mellin's (Dextri- maltose) per feed. On the 14th day 2-^ teaspoon- ful of Mellin's (Dextrimaltose) per feed.

(5) The bowels must be opened daily, and if

possible twice daily, by giving milk of magnesia and paraffin, of each one teaspoonful. (6) If

you desire to give a cholagogue, 3 grains each of atophan, German Carlsbad powder, sod. salicylate, with or without gr. of hydrarg. cum creta, will be found efficient at bedtime or twice a day.

I have found benefit also from rectal douches of potassium permanganate 1 grain (B. W. tab- loids) dissolved in a pint of water, given slowly, b.d. with funnel and catheter. From the 14th to the 21st day the child is kept

on pure skimmed milk with Mellin's (3 tea-

spoonfuls), and following the above rules it may also have Mellin's or Allenbury's rusks.

On the 21st day give skimmed milk 7 ozs. Ordinary milk 1 oz., 41-5 hourly.

22nd

23rd

24th

25th

26th

27th

28th

29th

30th

31st

32nd

33rd

34th

35th pure milk.

64

6

54

5

44

4

34

3

24

2

14

1

a

2

2i

3

3i

4

4i

5

5i

6

61

7

74

The rules after the 14th day are the same as before, except that one should substitute one or two feeds with fresh vegetable or fish soup. The amount of fruit juice should be increased if

possible; and I am in the habit, after the 14th day, of giving fractional doses of extract thy- roidse sicc., e.g., 1|8 gr. b.d. as it seems to fan

up the dormant metabolism, and is, as McCarri- son states,

" as the draught is to the fire."

By this time the stools and general condition of the child, including its liver, will have much

improved, and as progress continues the diet can gradually be increased, with due regard to any set-back which may occur and have its origin in some particular food substance. When the tongue is clean and eyes clear, begin

giving a quarter of the yolk of an egg per day in one of the bottles, gradually increasing to one whole yolk. Cod-liver oil may now be given either in 5 drop doses increasing to 15 drops t,d.s., or Ostelin 1 drop b.d. in honey or milk

for the first week; 2 drops b.d. for the second week; 3 drops b.d. for the third week.

Rice, butter or ghee, should be given sparingly for many months. European children should not be given meat or highly seasoned food substances. Fish roe and boiled fish or minced chicken or

liver may be given gradually with advantage. Prognosis.?Cases seen early, and the parents

of whom are sensible and obedient to the written details of treatment which I have given, get well in the majority of cases in 6 to 10 weeks; but

any lapse on the part of the parents or servants, catering to a peevish child's inordinate appetite or desire for some article of food not allowed, will tend to cause relapse.

Bronchitis, broncho-pneumonia, and skin dis-

eases,?such as boils and intertrigo?are fre-

quently serious complications. L,ate cases,

jaundiced or with ascites, I have never known to recover.