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The Common Vein Copyright 2008

Babylonians 3000BC – 2000BC

3000-2000 BC – Babylonians divine sheeps’ livers; the belief that the liver is the seat of the soul is probably related to the Babylonian experience during the sacsifice of the sheep and their observation of the  size, warmth, and enrichment with blood  of the liver leading them to believe it as the repository of life itself. They recognized and mentioned the gall bladder, cytic duct, and bile ducts.  They used the liver in the ancient practice of hepatoscopy which was the portrayal of the liver as a deity, and reading the liver o f the sacrificaial animal to predict the outcome of war.

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Babylonian  Culture and the Gallbladder
Sheep?s liver in clay. 14.6 cm across. Old Babylonian, circa 1900-1600 BC. Provenance: likely Sippar in modern southern Iraq. British Museum, London, Western Asia Collection # ME 92668

Reference

Hunt P, Stanford University

Chinese 2000BC

Chinese medicine  began in China over four thousand years ago.  Traditional Chinese medicine started about 2,000 years ago.  The earliest text was the “The Yellow Emperor’s Inner Classic” which was written about 2,500 years ago.  “The Herbal” was the earliest classic on herbs.

Chinese medicine is about qi, which is the is the source of life.  Qi must flow.  Movement reveals that qi exists. Warmth reveals that qi is present. It is  all the body’s energies, including electrical, chemical, magnetic, and radiant.  Natural forces such as gravity, time, inertia, friction, yin, and yang, affect us both internally and externally.

Much of the qi flows along fourteen major rivers and numerous minor rivulets. The flow in the rivers influence the fluids and energies in the body. Acupuncture points are used to regulate flow in the rivers. The most powerful points on these channels are positiones on the extremities – below the elbows and knees.  The rivers of energy are named according to the organs they subtend.

Yin and Yan are oppposite and complementary forces

 Yin Yin
Internal External
 Cold hot
Wet dry
 Empty full
Solid Organs  hollow
heart liver spleen kidneys lungs stomach, small bowel , gallbladder colon

 The gallbladder is a Yin organ

Etruscans 800 BC

The Etruscan culture starting in about 800BC coninued the practice of hepatoscopy

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Greek Culture and the Gallbladder
Etruscan Bronze Hand Mirror in Bronze  of Chalchas the Seer Reading a Liver (Vatican: Gregorian Museum, Rome, cat # 12240)  500-400BC

Reference Hunt P,

Early Greeks 

Hippocrates 460 -370 BC

Hippocrates rejected the notion that supernatural forces caused disease.  Early Greeks starting around 400BC believed in four humors in the human body: phlegm, blood, bile, and water.   Hipppocrates is credited with applying humoral theory to medicine.  When the humoral blend is perfect, man is in perfect health; when balance is upset and a certain humor is drained from the body, disease results. The concept of ?black bile? came from the Greek observations; there was an assumption that ordinary yellow bile, through corruption, could become black, and that this black bile could cause disease–notably the “black bile disease,” or “melancholy.”

Pythagorean School

The Pythagorean school was a group of philosopher-physicians.  Hippocrates was the best known of these physicians. They distinguished themselves for the following reasons.

Firstly they  worked in the temples of Asclepius, god of health, and by solemn oath to the gods they operated according to a set of defined professional standards.  The oath is today known as the Hippocratic oath.

Secondly they rejected the idea that disease was a punishment of the gods, and they attempted to define natural, rather than supernatural causes for disease.

Thirdly they viewed human life as an orderly and integrated component of nature.  Thus the 4 humors blood phlegm yellow bile and black bile were located respectively in the heart, brain, gallbladder and spleen.  Each of these reflected a human personality trait so that blood was sanguine and reflected a cheerfulness, phlegm manifest as phlegmatic and reflected sluggishness, yellow bile manifest as a choleric persona reflecting irritability, and black bile manifest as a melancholic or sad persona.  The correlative patterns in naturewere the 4 elements of of the cosmos including fire earth water and air and correlated with the seasons summer, autumn, winter, and spring.  Each of these correlated with the sensations of hot cold dry and wet and 4 geographical points east north south and west. Diseases were the result of an imbalance between man?s humors and nature?s elements. The task of medicine was to identify the imbalance and its cause and then to restore equilibrium. (http://www.mercatornet.com/articles/a_short_history_of_voluntary_death/)

Greek Culture and the 

Greek Culture and the Gallbladder
27390b01 Hippocrates Gallbladder Courtesy Ashley DAvidoff MD copyright 2008

 The four humors phlegmatic, sanguine, melancholic, and choleric were respectively produced by the lung, liver, gallbladder and spleen.  These organs each produced a fluid: the lungs produced phlegm, while the liver produced blood, the gallbladder made yellow bile and the spleen was responsible for black bile.  These biological fluids each reflected an element with the lung representing water, the liver air, the gallbladder earth and the spleen fire.  Additionally each of the organs had special qualities.  The lungs were considered cold and moist, the liver hot and moist, the gallbladder cold and dry, and the spleen hot and dry.  The humors of each organ were thought to produce vapors which would ascend to the brain and would affect the person?s personality.  Thus the lungs were thought to produce a vapor that would manifest as a sluggish, dull, timid and fearful character.  The liver personality was happy, easy going, generous and optimistic. The gallbladder type was introspective, subject to gluttony, but also sentimental.  The splenic personality was ambitious, but short tempered, vengeful, and given to violence.  Thus the  lung reflecting the element water produced phlegm which in turn represented a cold and moist character that created a personality which was slow timid and dull.

 Diocles of Carystos, Greece 350 B.C.

Diocles of Carystos, Greece, writes the first book on anatomy; it describe the gallbladder as well as ascites, linking it with the liver and spleen.

Aristotle 350BC

Aristotle discussed the absence of gallbladders in certain species  in his treatise on animal anatomy in 350BC.

Galen, ca. 200 A.D.

Galen was a Roman anatomist  was a physician to the gladiators, and later to Emperor Marcus Aurelius.  Galen was influenced by Hippocrates’s idea of the Four Humours (blood, phlegm, yellow bile & black bile). He introduced the notion of using opposites to treat diseases.
He  suggested that the liver was the principal organ of the human body.  He argued that it emerged as the first organ during development of the fetus.  “The liver is the source of the veins and the principal instrument of sanguification,” (On the Usefulness of the Parts of the Body.)  For Galen the gallbladder and spleen were subordinate to the liver, but worked in concert to produce and store three of the four humors of the body:  The liver was the source of blood, the gallbladder the source of yellow bile and the spleen the source of black bile.  Both the gall bladder and spleen protected the liver from contamination.

The gall bladder and spleen also regulated the emotions.  The gallbladder was the seat of  gall.  “Its substance is slender,” wrote Berengario a surgeon from Bologna University , “because it does not digest anything and hard so that it may resist the sharpness of the gall.”  Attached to both the heart and the brain, it was a truly sensitive organ that could affect other parts of the body.

Galen’s Concept of the Organs and their Faculties
Heat plays a central role part in the theory of Galen. The three ?faculties? of the body are the nutritive, vital and logical faculties. The nutritive faculty is related to the stomach which “cooks” the food and converts it into chyle. The chyle is transported to the liver by the portal vein. In the liver further heat converts the food into blood and adds natural spirit. Some of the blood is transported via the veins to the heart where more heat is added to create vital spirit. The blood becomes thinner is distributed to the body by the arteries giving warmth and enables growth. The vital spirit is measured through the pulse. The brain adds psychic pneuma, which provides the rational and logical faculty in the form of thought will and choice. These are distributed to the body via the nerves. The logical faculty reigns supreme and is followed in orderof importance by the vital and nutrtive faculties. The transport systems of the body include the nerves which transmit the logical faculty, the arteries which transport the vital spirit, and the veins which transport the blood with nutritive faculty from the liver. Galen faculties of the body nutrition portal vein stomach liver vein heart vital faculty pneuma lungs brain logical faculty animal spirits Davidoff art Copyright 2008 13169c18b01.8s

Renaissance

Paracelsus 1493-1541

Paracelsus was a Swiss alchemist physician, who focused on astrology, chemistry  and minerals.  His ideas  supplemented the inferences of Hippocrates and Galen of disease being caused by an imbalance of the humors.   He suggested that the macrocosm of the universe was represented in the body.  Each of the known seven planets of the time, were in harmony with seven metals on the earth, each of which were in harmony with seven organs in our bodies.  Disharmony or disease was caused by imbalance of minerals and cure was instituted by replacing the correct amount of mineral.  He portrayed the gallbladder as being aligned with iron in the earth and Mars in heaven.

 Planet  Metal  Organ
 Sun  Gold  Heart
 moon  Silver  Brain
 Jupiter  Tin  Liver
 Venus  Copper  Kidneys
 Saturn  Lead  Spleen
 Mars  Iron  Gallbladder
 Mercury  Quicksilver  Lungs

Paracelsus’s 7 planets aligned with 7 minerals of the earth aligned with 7 minerals in the body

Modified from Wikipedia http://en.wikipedia.org/wiki/Paracelsus

 

Vesalius 1514-1564

Andreas Vesalius writes a series of texts published as seven books under the title “Fabrica”; Book Five is on the abdominal viscera, and it discusses the vermiform appendix cecum. The gallbladder is extensively discussed, but there is little mention of the stomach, liver, or spleen.

 

Vesalius
13237 abdomen small bowel liver gallbladder anatomy Vesalius historical drawing DB

Da Vinci 1452-1519

Artist scientist, architect, botanist, musician and writer from Vinci in the region of Florence, is considered one of the most talented people to have lived .  Among many of his interests observation and drawing of the human body is relevant to this module where his drawing of the gracile, tubular gallbladder with its blood supply and ductal drainage are shown.

Da Vinci and the Gallbladder
11518.8 gallbladder stomach gastric esophagus normal anatomy da Vinci leonardo daVinci art

Harvey 1578-1657

William Harvey an English physician is best known for his work in the cardiovascular system, described the gall bladder as  “a very long pear compressed from base into neck”

Heister 1683-1758

Lorenz Heister was a German anatomist who in 1732 reported his observation of spiraling folds in the lumen of the duct and described them as valves.

Courvoisier 1843-1918

 Ludwig Courvoisier was a Swiss surgeon who described Courvoisiers sign that suggests that painless jaundice in the presence of a palpable gallbladder is a sign of pancreatic cancer.

 

Ludwig Courvoisier
This image of Ludwig Courvoisier (1843-1918), who was a surgeon who described ‘Courvoisier’s law’ – ‘if in the presence of jaundice the gallbladder is palpable, then the jaundice is unlikely to be due to a stone.’ This was first published in his book ‘The pathology and surgery of the gallbladder’ in Leipzig in 1890. 54478

Origin of this photo from surgical tutor.org a free on line resource and may be subject to copyright http://www.surgical-tutor.org.uk/default-home.htm?surgeons/courvoisier.htm~right code gallbladder historical pancreas carcinoma clinical portrait

 

Surgical Therapy

1733 Louis Petit suggested that removal of stones from the gallbladder as  a therapy gallbladder disease.

1867 John S Bobbs a sugeon from Indianopolis did a cholecystotomy in a patient whom he thought had an abdominal tumor, in a room above a chemists shopin the presence of seven other doctors and a medical student.

1878 Dr Marion Sims and American coined the phrase cholecystotomy and performed an unsuccessful procedure in Paris unsuccessful

1882 Johann August Langenbuch first attempt at cholecystectomy – was unsuccessful

1886 Doctor Justus Ohage, performs first successful gall bladder surgery in the U.S.

1989 Dr Eddie Joe Reddick developed and popularized laparoscopic cholecystectomy.

Famous People with Gallbladder Disease

James K. Polk (President) At age 16, Polk developed severe gallstones  which were removed without the benefit of modern technology, sterilization, or anesthesia. Remarkably, he survived the procedure, performed by celebrated Kentucky surgeon Dr. Ephraim McDowell. He lived to the age of 54.

Lyndon B. Johnson (LBJ) had his gallbladder out in 1965

Jack Lemmon died of of gallbladder cancer

Caroll O’connor died in 2001 at the age of 76. Had his GB removed in 1994

John Ashcroft

Larry Hagman had Gallstones too.

Andy Warhol was recovering from routine gallbladder surgery on the 22nd of February 1987, and died in his sleep presumably after suffering a myocardial infarction.

 

 References

Kuntz, Erwin,  Dieter Kunt. Hans –  Hepatology, Principles and Practice Published by Birkhäuser, 2006

Subhuti Dharmananda, Ph.D Chinese Culture