Osteopathy Complete
Elmer D. Barber, D. O.
1898
DISEASES OF THE LIVER
THE LIVER
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.
EXPLANATORY
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.
ACUTE LITHEMIA,
BILIOUSNESS, OR TORPID LIVER
(Excess of uric acid or other metabolic compounds in the blood).
SYMPTOMS
Furred tongue; nausea; bitter taste; anorexia; slight
fever; constipation; headache; stupor; perspiration, alternating with flashes
of heat.
TREATMENT
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.
CHRONIC LITHEMIA
(May follow acute attacks.)
SYMPTOMS
Similar to the acute form with functional disturbance
of nearly all the organs of the body.
TREATMENT
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.
ICTERUS, OR JAUNDICE
(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.)
SYMPTOMS
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.
TREATMENT
See
Acute Lithemia, being very particular to manipulate and vibrate
the liver in an exceedingly thorough manner.
MALIGNANT JAUNDICE, OR ACUTE YELLOW ATROPHY
(Acute inflammation of the liver, with necrosis of the cells, and bile-pigment
in the urine.)
SYMPTOMS
Nausea; vomiting; headache; aversion to light; tongue
dry and coated; diminution of the area of hepatic percussion; dullness;
temperature subnormal at times.
TREATMENT
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.
HEPATIC CONGESTION
(Excess of blood in the liver, from obstructed circulation.)
SYMPTOMS
Weight, and dull pain in the right hypochondrium;
tongue coated; anorexia; headache; vertigo; digestion impaired; and there
may be pain in the right shoulder.
TREATMENT
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.
ACUTE HEPATITIS
(Inflammation of the liver.)
SYMPTOMS
Pain in the right hypochondrium: appetite impaired;
nausea; vomiting and febrile symptoms.
TREATMENT
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.
HEPATIC ABSCESS
(Abscess of the liver. May follow acute hepatitis.)
SYMPTOMS
Pain over the liver, and at the right shoulder;
may be hiccough, and dyspnea; elevation of temperature; rigors and perspiration.
TREATMENT
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.
HEPATIC CIRRHOSIS
(Inflammation, and thickening of the tissues of the liver; usually
with atrophy of the organ.)
SYMPTOMS
Impairment of nutrition; superficial veins of the
abdomen become enlarged; skin clay hue; hemorrhages of the nose and stomach.
No cure in Osteopathy.
HEPATIC FATTY INFILTRATION, OR FATTY LIVER
(Accumulation of fat in the liver.)
SYMPTOMS
Skin greasy; diarrhea; dyspnea; failure of hepatic
function. More common with drunkards.
TREATMENT
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.
HEPATIC AMYLOID DEGENERATION
(Starch-like degeneration of the liver. Generally a sequel of
syphilis.)
SYMPTOMS
Enlargement without pain; face swollen and pallid;
impaired digestion; ankles edematous.
No cure in Osteopathy.
HEPATIC CARCINOMA
(Cancer of the liver.)
SYMPTOMS
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.
HEPATIC HYDATID CYST
(Tumor of the liver occurring in people who live with dogs.)
SYMPTOMS
A local sensation of weight and dragging; no pain
but enlargement of the organ.
TREATMENT
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.
PERIHEPATITIS
(Inflammation of Glisson's capsule.)
SYMPTOMS
Pain and tenderness in the hepatic region; may be
associated with hepatic cirrhosis.
TREATMENT
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.
CHOLECYSTITIS, OR CHOLANGITIS
(Inflammation of the gall-bladder.)
SYMPTOMS
Pain in the right hypochondrium; liver enlarged;
heart action retarded; tongue coated; itching of the skin; and impaired
digestion.
TREATMENT
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.
BILIARY CALCULI, OR GALL-STONES
(Stones in the gall-bladder.)
SYMPTOMS
Excruciating colicky pains in the right hypochondrium;
nausea; shivering; vomiting; face pale; and body covered with cold perspiration.
TREATMENT
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.
CATARRHAL JAUNDICE
(Inflammation and obstruction of the gall-duct.)
SYMPTOMS
They are similar to moderate jaundice, usually following
an attack of acute gastritis. The onset is attended with chill and
fever, headache and vomiting.
TREATMENT
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.
HEPATIC COLIC
(Pain in the hepatic region, due to passage of gall-stones.)
SYMPTOMS
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.
TREATMENT
See
Acute Lithemia.
In applying this treatment particular attention
should be given to thorough manipulation and vibration of the liver
and gall-bladder.
