CARDIAC AND CARDIO-TUBERCULOUS CIRRHOSIS Cirrhosis from failure of the circulation and chronic congestion presents peculiar features to which the French have called our attention: Idutinel has demonstrated the especial importance of this form of cir rhosis in childhood. The cause is chronic adherent pericarditis (with more or less complete obliteration of the pericardium). of rheumatic or tuberculous origin. Such cases have been encountered often in adults and described by F. Pick as "pseudocirrhosis of the liver due to pericarditis." The liver has the typical "nutmeg appearance," with increased peri portal connective tissue formation and cellular infiltration. In the cardio-tuberculous form the liver is always enlarged and perihepatitis is present. The pericardium is much thickened, resembling in some places a fibrous sack, with extensive adhesions, the latter often extra cardiac. Pleurisy and tuberculous peritonitis as well as tuberculosis of the mediastinal lymph-nodes are reg,ularly encountered.
Aseites and enlarged spleen are associated with the large fat, smooth or slightly granular liver, and the ascites is often the principal clinical feature. Other evidences of passive congestion are absent or of subor dinate importance. The ascites is little or not at all affected by treat ment with digitalis as in atrophic cirrhosis. It is probable that a common etiological factor gives rise to the affection of the pericardium and the liver; whether the pericarditis is always primary is not certain.
Chronic pericarditis, peritonitis and also pleurisy (polyserositis) may have a common origin, and the perihepatitis may lead secondarily to cirrhosis of the liver. Of 112 cases collected by Iless, 22 were under 16 years of age, and 16 under 19 years of age.
The disease which Curschmann designated as a sugar-cake liver belongs in this category. We have to do with a peculiar form of peri hepatitis running an extremely chronic course. The peritoneal covering of the liver becomes changed in well-cleveloped cases into a pure white sugar-cake-like mass, consisting of dense hard scar-like thickenings of the peritoneum. This white mass may be found on the peritoneal covering of the spleen, the anterior abdominal wall, and, at times may extend over the whole peritoneum. In 90 per cent. of all cases a more or less extensive connective tissue thickening and obliteration of the pericardium is present, as in cardiac cirrhosis. The liver itself shows no genuine cirrhotic changes; its surface appears rough and uneven. Ascites is always present and reaccumulates after abdominal puncture. The discovery of bands of thickened peritoneum will strengthen the tliagnosis. The differential diagnosis of atrophic cirrhosis is often very difficult.
The etiology is unknown. Every age may be affected, several cases have been reported in children. The prognosis is absolutely unfavor able. The disease is progressive and terminate:3 fatally.