Osteopathy Complete
Elmer D. Barber, D. O.

    The liver is a gland, intended for the secretion of sugar and bile, remarkable for its size, equaling that of all the other glands, and for its connection with the system of the portal vein, which ramifies in its substance.  This organ fills almost all of the right hypochondrium, a great part of the epigastrium, and advances into the left hypochondrium as far as the mammary line, in the neighborhood of the spleen.  It is situated below the diaphragm, which separates it from the lungs and heart; above the stomach, duodenum, transverse colon,  and small intestine, which forms a sort of pillow behind are the false ribs, which protect it
    Capsule. - The liver is covered by a thin, fibrous, firmly adherent capsule, which has on its free surface a layer of endothelium, derived from the peritoneum.  The capsule sends fine septa into the organ, between the lobules, but it is also continued into the interior of the transverse fissure, where it surrounds the portal vein, hepatic artery, and bile duct, and accompanies these structures as the Capsule of Glisson, or interlobular connective tissue.  The spaces in which these structures lie are known as the portal canals.
    Lobules. - The liver consists of innumerable small lobules, one to two millimeters in diameter.  These lobules are visible to the naked eye, and all have the same structure.
    Cells. - The liver or hepatic cells are irregular polygonal cells of about 1-1000 of an inch in diameter.  They form anastomosing columns, which radiate from the center to the periphery of each lobule.
    The appearance of the cells varies with the period of digestion.  During hunger, the cells are finely granular and very cloudy, and contain little glycogen, but many pigment granules, and the nucleus is more frequently absent.  During activity after a full meal the cells are larger and more distinct.
    Bile-Ducts. - The two hepatic ducts, which carry the bile out of the liver, emerge from the right and left hepatic substance, at the transverse fissure; they unite, and are joined by the cystic duct, which is a continuation of the tapering extremity of the gall-bladder.  By the union of the hepatic duct with the cystic duct, the common bile-duct is formed.  It pierces the coat of the duodenum very obliquely, and opens along with the pancreatic duct into the duodenum.
    The finest bile-capillaries, channels, or canaliculi arise at the center of the lobule, and indeed throughout the whole lobule they form a regular anastomosing network of very fine tubes or channels.  The bile-capillary network is much closer than the capillary network of the blood.  Extensive minute intercellular passages are said to pass from the bile capillaries into the interior of the liver-cells, where they communicate with small cavities, or vacuoles.  As the blood capillaries run along the edge of the liver-cells, and the bile capillaries between the opposed surfaces of adjacent cells, the two systems of canals within the lobule are kept separate.  Toward the peripheral part of the lobule the bile-capillaries are larger, while adjoining channels anastomose, and leave the lobule, where they become interlobular ducts, which join with other similar ducts to form larger bile-ducts.. These accompany the hepatic artery and portal vein, and leave the liver at the transverse fissure.
    Bile. - Although the bile is secreted continuously, and passes along the hepatic duct iii most animals, it is only poured into the intestine at certain times.  In the intervals it is carried along the cystic duct and stored up in the gallbladder.  At certain times it is poured out by the common bile-duct into the duodenum.  Bile is a yellowish-brown or dark-green transparent fluid, with a sweetish, strongly bitter taste, feeble musk-like odor, and neutral reaction.
    Gall-Bladder. - The gall-bladder is a pear-shaped sac, capable of containing 20-25 c.c. of bile.  In some animals the gall-bladder is wanting, as in the donkey, elephant, and mouse.
    Blood-Vessels. - The liver is supplied with blood by the hepatic artery and the portal vein. The hepatic artery supplies a small quantity of arterial blood to the liver.  The blood, after circulating through the liver, is returned by the hepatic veins to the inferior vena cava.
    The branches of the hepatic artery accompany the branches of the portal vein and bile-ducts in the portal canals between the lobules, and in their course give off capillaries to supply the walls of the portal veins and larger bile-ducts.  The branches of the hepatic artery anastomose frequently where they lie between the lobules.  On reaching the periphery of the lobules, a number of capillaries are given off, which penetrate the lobule, and terminate in the capillaries of the portal vein.  These capillaries, however, which supply the walls of the portal vein and large bile-ducts, terminate in veins which end in the portal vein.
    The portal vein is formed by the confluence of the gastric, splenic, inferior and superior mesenteric veins, whereby the short, wide, vena portae is formed.  It enters the liver at the transverse fissure, accompanied by the bile-duct and hepatic artery, and is distributed between the lobules.  The portal vein returns the blood from the stomach, pancreas, intestines, and spleen; hence it carries some of the products of digestion directly to the liver, where some of them are materially changed by the hepatic cells, as they pass slowly through the hepatic blood-vessels.
    The portal vein, after its entrance into the liver, at the portal fissure, gives off numerous branches, lying between the lobules, and ultimately forming small trunks which each the periphery of the lobules, where they form a rich plexus.  The branches of the portal vein, lying between the lobules, are called the interlobular veins, which are always provided with thick muscular walls.  From these veins numerous capillaries are given off to the entire periphery of the lobule.  The capillaries converge towards the center of the lobule.  As they proceed inward they form elongated meshes, and between the capillaries lie rows or columns of liver-cells.  The capillaries are relatively wide, and are so arranged as to lie between the edges of the columns of cells, and never between the surfaces of two adjacent cells.  The capillaries converge toward the center of each lobule, where they join to form one large vein, the hepatic, intralobular, or central vein, which traverses each lobule, reaches its surface at one point, passes out and joins similar veins from other lobules to form the sublobular veins.  Branches of the hepatic veins have very thin walls.
    Nerves. - The nerves consist partly of medullated, but chiefly of non-medullated fibers.  From branches of the sympathetic, the terminal branches of the right vagus, and some branches of the left vagus, to the hepatic plexus, the hepatic plexus being that portion of the solar plexus which embraces the portal vein, bile-duct, and hepatic artery, as they pass into the liver at the portal fissure.
    Functions. - To understand the functions of the liver we must remember its unique relation to the vascular and digestive systems, whereby many of the products of gastric and intestinal digestion have to traverse it before they reach the blood, and some of them as they traverse the liver are altered.  The liver has several distinct functions, some obvious, others not.  The liver secretes bile, which is formed by the hepatic cells, and leaves by the bile-ducts, to pass into the duodenum.  Glycogen is also formed in the liver, and does not pass into the duct, but, in some altered form, passes into the blood-stream, and leaves the liver by the hepatic vein.  One of its functions, also, is to destroy the hemoglobin of the blood; hence the study of the liver materially influences our conception of a secreting organ.  In this instance we have the products of its secretary activity leaving it by two different channels, the ducts and the blood-stream.  The liver , therefore, is a great storehouse of carbohydrates, serving them out to the economy as they are required, preventing the blood from being overcharged with sugar, and, on the other hand, it prevents a deficiency of this important body in the blood.  All this points to the liver as being an organ intimately related to the general metabolism of the body.  In a certain period of development it is concerned in the formation of blood-corpuscles.  It has some relation to the breaking up of blood-corpuscles and the formation of urea and other metabolic products.  Some importance is attributed to the liver in connection with the arrest of certain substances absorbed from the alimentary canal, whereby they are either destroyed, stored up in the liver, or prevented from entering the general circulation in too large an amount It converts the poisonous, odorous products of putrefaction, derived from proteids in the intestine, into harmless compounds, by conjugation with sulphates.
    We have entered rather minutely into the anatomy and physiology of the liver, desiring to call the attention of the reader more particularly to its immense double blood-supply (which equals, after meals, one-fourth of all the blood in the body), and to the fact that it is a great chemical laboratory, placed on the highway by which the great majority of material absorbed from the intestines reaches the blood.  It is, therefore, obviously in a position to act as the guardian of the blood's purity, and health; and the necessity of a free and unobstructed circulation. to, through, and from this organ cannot be overestimated.

(Excess of uric acid or other metabolic compounds in the blood).

    Furred tongue; nausea; bitter taste; anorexia; slight fever; constipation; headache; stupor; perspiration, alternating with flashes of heat.

    1.  Place the patient on the side; beginning at the upper cervicals, move the muscles upward and outward, gently but deeply, the entire length of the spinal column, being very particular and thorough in all regions which are in the least sensitive to the touch; endeavoring in these regions to discover muscles in a contracted, cord-like condition, which are obstructing the circulation, and thereby affecting nerve-centers which control the alimentary canal.  Such muscles must be kneaded and manipulated very thoroughly.  Treat opposite side in a similar manner.
    2.  Place the patient upon the back; the operator grasping the shoulders, an assistant now grasps the patient's ankles, and a very thorough extension of the spine is given; pull gently at first, gradually stronger, the patient relaxing all muscles, for two minutes (cut 23).  Care must be exercised, in giving this extension, to make it no stronger, but just as strong as the patient can conveniently stand.  This thorough extension of the spine relieves the pressure upon the intervertebral fibro-cartilage, thereby relieving, in a measure, any undue pressure upon the spinal nerves, and also freeing the circulation to the cerebro-spinal cord, any obstruction to which means disease in some of its varied forms.
    3.  Place one hand under the chin, the other under the occipital bone (cut 8), and give careful extension of the neck, pulling gently until the body moves.
    4. Place one hand under the chin and draw the head backward, rotating it from side to side with the disengaged hand manipulate the muscles immediately over the pneumogastric nerve.  It is also well to manipulate all the muscles of the sides and front of the neck in a very thorough and careful manner, as this treatment not only frees and stimulates the pneumogastric, but also frees the blood-supply to the head.
    5. In all cases where constipation is present, beginning at the cecum, manipulate very deeply and gently, following the colon its entire length, endeavoring to move any hardened lump of feces toward the rectum.  Manipulate the small intestine carefully and thoroughly (cut 17).
    It is also well, in constipation, to knead, as much as possible, the gall-bladder, endeavoring to empty its contents into the duodenum.
    6. Flex the limb against the abdomen strongly; while in this position, move the knee three or four times from side to side, giving quite strong abduction; extend the leg with a light jerk.  This treatment stretches the adductor muscles of the thigh, thereby freeing the circulation to the leg, and assisting to equalize the same.  Treat the opposite limb in a similar manner.
    7. Place the hand upon the ribs over the liver; press gently at first, gradually increasing the strength, until the ribs are pressed strongly downward upon the liver; relax the pressure gradually.      This operation should be repeated two or three times each treatment, as it assists very materially in stimulating the liver to correctly perform its allotted task.
    8. Place the fingers of the right hand under the ribs, immediately over the liver (cut 25); with the left hand grasp patient's right wrist and draw the arm strongly above the head; at the same instant, with the right hand, raise the ribs as much as possible, off of the liver.
    9. Place the hand lightly over the liver; vibrate gently two or three minutes.
    10.  Place the patient upon a stool; with the thumbs close to the spine, at about the second dorsal, have an assistant raise the arms high above the head, as the patient inhales, filling the lungs to their utmost capacity; press hard with the thumbs, as the arms are lowered with a backward motion, patient permitting the elbows to bend (cut 24).  Repeat this operation, moving the thumbs downward each time to the next lower vertebra, until the eighth dorsal vertebra is reached.
    This treatment will occupy about twenty minutes, and should be given each day.  Immediate results can be expected, and a speedy cure will be effected, if this treatment is given in a correct and careful manner.

(May follow acute attacks.)

    Similar to the acute form with functional disturbance of nearly all the organs of the body.

    See Acute Lithemia.  Treatment to be given every other day.  A change for the better will be noticed in one or two weeks, if the treatments are correctly given, and a cure may be looked for in from two to three months.

(May be hematogenous, (1) when the function of the liver cells have been suppressed, and (2) when the destruction of hemoglobin is in excess of the capacity of the liver to remove the product of destruction; hepatogenous, when there is obstruction of the ducts.)

    Skin and mucous membranes become yellow; irritation of the skin; discoloration of the secretions; bile absent in the feces; slow pulse; irritability and depression of spirits, drowsiness and stupidity of mind, advancing with the disease.

    See Acute Lithemia, being very particular to manipulate and vibrate the liver in an exceedingly thorough manner.

(Acute inflammation of the liver, with necrosis of the cells, and bile-pigment in the urine.)

    Nausea; vomiting; headache; aversion to light; tongue dry and coated; diminution of the area of hepatic percussion; dullness; temperature subnormal at times.

    See Acute Lithemia.  The entire treatment should be given in a very thorough, careful manner, every other day, being particularly thorough in vibration of the liver.

(Excess of blood in the liver, from obstructed circulation.)

    Weight, and dull pain in the right hypochondrium; tongue coated; anorexia; headache; vertigo; digestion impaired; and there may be pain in the right shoulder.

    1. See Acute Lithemia.
    2. Place the hands on the sides of the neck, the fingers almost meeting over the spinous processes of the upper cervicals; tip the head slightly backward, pressing gently with the fingers three or four minutes upon the vaso-motor.

(Inflammation of the liver.)

    Pain in the right hypochondrium: appetite impaired; nausea; vomiting and febrile symptoms.

    1. Place the patient on the side; make a careful examination of the spine.  A very sensitive spot will usually be discovered over the origin of the splanchnic nerves in the dorsal region, which should be treated in a very thorough and careful manner, moving the muscles upward and outward.  It is always well in this disease to treat the entire length of the dorsal region, on both sides of the spinous processes, after which, placing the finger-tips directly over the origin of the splanchnics in the spine, give gentle vibration two or three-minutes.
    2. With the patient lying on the back, place the hand lightly over the liver; vibrate gently five     minutes.
    3. Place the hands on each side of the neck, fingers almost meeting over the spinous processes of the upper cervicals; press gently with the fingers three or four minutes upon the vaso-motor (cut 13).
    Treatment should be given each day, and occupy about fifteen minutes.

(Abscess of the liver.  May follow acute hepatitis.)

    Pain over the liver, and at the right shoulder; may be hiccough, and dyspnea; elevation of temperature; rigors and perspiration.

    1.  See Acute Hepatitis.
    2.  In case of difficult breathing, pressing upon the angle of the second rib, upon the right side, with the left hand draw the right arm with the right hand with some strength slowly and strongly above the head as the patient inhales; lower the arm with a backward motion, pressing hard at the same instant upon the angles of the second rib; place the fingers upon the third rib; raise the arm as before; and repeat until the fifth rib is reached.  Treat the opposite side in a similar manner.
    In the treatment of this disease, a great deal will depend upon the good judgment of the operator, who should not only apply the above treatments, but should apply such parts of the treatment for Acute Lithemia as the conditions necessitate.

(Inflammation, and thickening of the tissues of the liver; usually with atrophy of the organ.)

    Impairment of nutrition; superficial veins of the abdomen become enlarged; skin clay hue; hemorrhages of the nose and stomach.
    No cure in Osteopathy.

(Accumulation of fat in the liver.)

    Skin greasy; diarrhea; dyspnea; failure of hepatic function.  More common with drunkards.

    1. See Acute Lithemia, omitting No. 5.
    2. Place the patient upon a stool; with the knee against the back, just below the last dorsal, bend the patient backward quite strongly; hold in this position a moment; and repeat (see cut 20).
    3. Place the knee between the scapulae, at about the third dorsal; draw the arms slowly but strongly above the head as the patient inhales, filling the lungs to their utmost capacity (cut 5); press hard with the knee as the arms are lowered with a backward motion.
    While we cannot hope to effect a cure in this disease, the patient often derives much benefit from the above treatment, carefully given every other day.

(Starch-like degeneration of the liver.  Generally a sequel of syphilis.)

    Enlargement without pain; face swollen and pallid; impaired digestion; ankles edematous.
    No cure in Osteopathy.

(Cancer of the liver.)

    Loss of flesh; cachexia (malnutrition and general bad health, characterized by a waxy or sallow complexion); enlargement of the liver; fluids in the peritoneal cavity; deranged digestion; lancinating pains.
    No cure in Osteopathy.

(Tumor of the liver occurring in people who live with dogs.)

    A local sensation of weight and dragging; no pain but enlargement of the organ.

    1.  Place the hand lightly over the tumor; vibrate for five minutes very gently.
    2.  Press the ribs slowly but strongly down upon the liver; slowly relax and repeat the pressure; thus manipulate the liver for two or three minutes.
    This treatment frees the circulation and often gives relief.

(Inflammation of Glisson's capsule.)

    Pain and tenderness in the hepatic region; may be associated with hepatic cirrhosis.

    1.  Place the patient on the side; move the muscles upward and outward, gently but deep, the entire length of the dorsal region.  Treat the opposite side in a similar manner.
    2.  Place the patient on the back; the hand resting lightly over the liver, vibrate gently for five minutes, thus starting the circulation, and thereby reducing the inflammation.

(Inflammation of the gall-bladder.)
    Pain in the right hypochondrium; liver enlarged; heart action retarded; tongue coated; itching of the skin; and impaired digestion.

    See Acute Lithemia.
    Treatment should be given in a very thorough, careful manner, particular attention being given the gall-bladder, which should be manipulated, and vibrated very carefully.

(Stones in the gall-bladder.)

    Excruciating colicky pains in the right hypochondrium; nausea; shivering; vomiting; face pale; and body covered with cold perspiration.

    Very thorough and careful manipulation of the gallbladder will, if persisted in, cause the stones to move forward into the duodenum.  The treatment should be continued at short intervals, until the desired results are obtained.
    Operator must exercise great caution in not continuing any one treatment a sufficient length of time to unduly exhaust or fatigue the patient, in case the stones do not readily more forward.

(Inflammation and obstruction of the gall-duct.)

    They are similar to moderate jaundice, usually following an attack of acute gastritis.  The onset is attended with chill and fever, headache and vomiting.

    See treatment for Acute Lithemia, which should be given in a very careful manner, particular attention being given to manipulating the liver and gall-bladder.

(Pain in the hepatic region, due to passage of gall-stones.)

    Attack may be sudden, with pains along the margin of the ribs on the right side and right shoulder; patient becomes doubled up in agony; pulse rapid; retching and vomiting; profuse perspiration after paroxysms.

    See Acute Lithemia.
    In applying this treatment particular attention should be given to thorough manipulation and vibration of the liver and gall-bladder.