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The body has a liver

2004; Lippincott Williams & Wilkins; Volume: 39; Issue: 4 Linguagem: Inglês

10.1002/hep.20199

1527-3350

Adrian Reuben,

History of Medical Practice

Everybody has a favorite organ, but it seems that throughout the ages some organs especially have attracted the attention of philosophers and poets, sacerdotes and scientists, lay and learned writers, and physicians too. In this category is the liver, along with the heart, spleen, stomach, and intestines. Other organs have languished inconspicuously, save for the devotion of a select few. Included in this second class of less-favored organs are the lungs, kidneys, bladder, pancreas, and even the organ of Zuckerkandl, discovered by the renowned anatomist and surgeon Emil Zuckerkandl, whose wife, Bertha, was one of the more sought-after personalities of intellectual society in Vienna during the declining decades of the Austro-Hungarian Empire. The Zuckerkandl home was a rendezvous for notables of science and the arts, including Auguste Rodin, the sculptor, and composer Gustav Mahler, yet what has been referred to as Emil's "delightful little organ"1 continues to enjoy obscurity. That the liver was fascinating to early civilizations is not surprising, considering its size as the biggest solid organ in the body and given its richness in blood, which was long regarded as the "life force." In fact, very early in the cradle of civilization in Mesopotamia, and later in Egypt and further afield, the liver was deemed the "seat of life" and, truly, "the seat of the soul."2 Yet, though it was appropriate that the major vital organs were noticed and highly regarded, there was always the danger that their functions and dysfunctions could be seriously misconstrued and that organs of note would have attributes ascribed that were wholly undeserved. Such was the fate of the liver, and, to some extent, the heart and other organs too, even in the 20th century when the mysteries of physiology and pathology were already being divulged. It is not entirely clear where the brain fits in to this new classification of organs. Judging by the actions and antics of certain celebrities, politicians, monarchs, heads of state and other leaders, and some pundits, the brain is not a vital organ. On the other hand, perhaps the most exciting biological research being conducted nowdays is in the field of neuroscience, which may soon explain the language we speak, the beliefs we hold, our appreciation of the arts, and our acknowledgment of our very existence and consciousness.3-5 Modern studies of the brain should also finally negate once and for all the idea so prevalent in the 19th century that Charcot's hysteria6 (formerly called the vapors), a functional disturbance of the nervous system usually attended by emotional upset, is due to a disturbance of the uterus. Hippocrates in the 4th–5th century BCE considered that the brain elaborated phlegm—which together with blood, yellow bile, and black bile, constituted the four humors of the body—while Aristotle a few score years later had the brain merely cooling the blood that had been heated by the heart. Galen, in 2nd century CE Rome, thought that the essence of the soul, the spiritus animalis (animal spirit), which was necessary for perception and reason, came from the brain. Somewhere, perhaps between these extremes, lies the truth. While arguments raged back and forth in the centuries before and after the beginning of the Current Era over the essence of life and the proper balance of the four elements, the four qualities, and the four humors, the liver gradually lost its preeminence as the organ of soul and emotion. Even though for almost 1,500 years Galen's opinion was accepted that the liver was the source of all veins (fons venarum) and the factory that made the blood (sanguifactionis officina), eventually a cardiocentric view of life prevailed. The Aristotelian notion that the heart is the hub that the body depends on for soul, heat, and propulsive force was redeemed by William Harvey's discovery of the circulation of the blood driven by the beat of the heart.10 The heart soon became accepted as the core of love and bravery, the stomach and intestines were valued for endurance and fury, and the spleen not only provided its traditional sadness and melancholy but, paradoxically, humor and laughter too.11 Relegated from its dominant position to that of the kitchen of the body, as explained to the lay reader by Gustav Eckstein,12 the liver did not easily relinquish its influence on the body and mind. References to liver and bile were not infrequent in the plays of Shakespeare and other playwrights and authors,13 and they also appear in many languages besides English (e.g., Italian, Estonian, Japanese, and Chinese) as metaphors for bravery, anger, arrogance, and other emotions and moods.14 The concept of a sluggish or torpid liver crept into medical texts in the late 19th century,15 referring to an ill-defined functional insufficiency of the liver that was responsible for vague symptoms of ill health, including malaise, depression, flatulence, and dyspepsia. For the most part, patients with torpid liver did not have any demonstrable findings of true liver dysfunction, in a manner akin to the so-called "post-hepatitis syndrome"16 of the 1940s, which occurred in persistently symptomatic patients who had recovered from acute viral hepatitis when epidemic hepatitis was common. A more familiar term then than torpid liver was the colloquial complaint of "biliousness,"17 whereas patients in Great Britain often curiously described themselves as "feeling liverish."18, 19 In France, the same complaint gloried in the name "hepatism,"20 the more modern counterpart of which is their "crise de foie," whereas hyperhepatism afflicted the Japanese.21 The symptoms of feeling liverish have been comprehensively catalogued as nausea, vomiting, distaste for food, a furred tongue, a bitter or metallic taste, change in bowel habit, and a feeling of weight or oppression in the hypochondrium.19 Although patients with advanced liver disease do indeed have derangements in taste and smell,22 it is doubtful that alteration of chemosensory function can explain the biliousness or liverishness of the torpid liver. Sufferers also complain of giddiness, specks before the eyes, languor, moroseness, peevishness, irritability, and depression.19 Charles Murchison, in his Croonian lectures for 1874,23 erroneously blamed the syndrome of torpid liver on a functional derangement of hepatic metabolism that leads to an increase in urate production, thereby associating torpid liver with gout. Hurst surmised that the term liverish was introduced by soldiers and civilians with hepatic amebic abscess, who returned home from India to Britain to nurse their damaged livers.18 The apparent frequent occurrence of symptoms of biliousness or liverishness led sufferers on both sides of the Atlantic to seek help in medicaments that purport to increase bile flow. In the UK, Bile Beans kept one "Healthy, bright-eyed and slim" (Fig. 1). In the US, what were originally named Carter's Little Liver Pills, which initially were the only products of the Carter Medicine Company (founded 1880), were renamed many years later as Carter's Little Pills (now simply Carter's Laxative). The laxatives originally contained in Carter's Little Liver Pills — namely aloes and podophyllum in a base of liquorice and starch — actually had no effect on gallbladder contraction or bile formation,24, 25 despite the choleretic clamor of the advertisement (Fig. 1). How reminiscent of the potpourri of herbal panaceas that our modern patients consume to cleanse and revitalize their livers and souls, while they wait for real cures for hepatitis C, fatty liver disease, etc. Advertisements for nostrums, from both sides of the Atlantic, to improve the body's liver. Left: advertisement for Bile Beans seen on a wall in York, England. Right: 1939 advertisement in Life Magazine (reprinted with permission) for the once popular Carter's Little Liver Pills. Whereas these forerunners of the modern health supplement industry may have been ineffective, as is still so often the case, they emphasized for all to see that the Body does have a Liver. Though various remedies for supposed functional hepatic disorders may not have been effective, the enthusiasm with which millions of people used them and continue to do so reminds us that everyone has a favorite organ and, for most bodies, with apologies to Gustav Eckstein,12 it is clearly the liver. The author appreciates advice on all things Arabic from Dr. Amin Hila (Fellow in Gastroenterology and Hepatology at the Medical University of South Carolina), and the skill of Christine Toland (Multimedia Specialist) in the preparation of figures for this and many other "Landmarks in Hepatology." The author remembers with gratitude the receipt of the two photographs used in this month's figure, which were a gift decades ago from Dr. Caroline Riely. As usual, the author acknowledges the invaluable skill in manuscript preparation of Margie Myers.