664 DISEASES OF THE LIVER 



higher than it was some weeks or months previously. Not unfre 

 quently, while the anasarca is moderate, the ascites increases, so thai 

 we are compelled to tap the patient. In the cases that I have ob- 

 served, where in heart and lung diseases I have been able to diagnose 

 atrophic nutmeg-liver from the disproportion between the ascites and 

 anasarca and from the perceptible diminution in size of the enlarged liver, 

 I have not found the spleen enlarged. If we rightly understand 

 atrophic nutmeg-liver, the explanation of the above symptoms is not 

 difficult. The contraction of the connective tissue of the liver com- 

 presses the vessels, hence the flow of blood from the veins of the peri- 

 tonaeum is opposed in two ways : first, by the heart or lung affection ; 

 secondly, by the compression of the hepatic vessels. The absence of 

 enlargement of the spleen is the only thing that could appear remark- 

 able ; as, by compression of the vessels of the liver, the flow of blood 

 from the spleen is also obstructed, and since in cirrhosis of the liver 

 (see Chapter in.), where the same circumstances prevail, we almost 

 always find enlargement of the spleen, and usually ascribe this en- 

 largement to obstruction of the blood in the splenic vein. I propose, 

 when speaking of cirrhosis of the liver and hyperaemia of the spleen, 

 to discuss this apparent contradiction more fully. 



TREATMENT. The causal indications require the removal of the 

 circumstances inducing the fluxion to or the congestion of the liver. 

 In the fluxions caused by excess in eating and drinking, the diet is to 

 be regulated ; in those cases resulting from misuse of spirituous liquors, 

 alcohol should be forbidden. In the same way it may be necessary 

 to advise a change of residence when persons in the tropics, or from 

 the influence of malaria, suffer repeatedly from hyperaemia of the liver. 

 Finally, if severe fluxions to the liver occur just before the menses or 

 during then- absence at the time they are expected, the causal indica- 

 tions require the application of leeches to the os uteri or of cups to the 

 inner surface of the thighs. In congestion of the liver we are either 

 unable to fulfil the indicatio causalis or, where we can do so, it is al- 

 most always some other trouble than the hyperaemia of the liver, which 

 decides us to interfere. For instance, when we bleed in pneumonia, and 

 thus moderate a congestion of the liver, the venesection has not been 

 induced by the latter, but by the congestion in the brain, or some 

 other cause. 



For the fulfilment of the indications from the disease, the abstrac 

 tion of blood from the region of the liver, which is so frequently recom- 

 mended, is just as irrational as it is inefficacious, and Henoch is right 

 in saying that the leeches would do just as much good if applied to 

 the wrist or ankle-joints as when applied to the right hypochondrium. 

 On the contrary, leeches about the anus are strongly to be recom 



