"The city of Hepar": rituals, gastronomy, and politics at the origins of the modern names for the liver

Turning points in the practice of liver surgery: A historical review

The history of liver surgery is a tale of progressive resolution of issues presenting one after another from ancient times to the present days when dealing with liver ailments. The perfect knowledge of human liver anatomy and physiology and the development of a proper liver resective surgery require time and huge efforts and, mostly, the study and research of giants of their own times, whose names are forever associated with anatomical landmarks, thorough descriptions, and surgical approaches. The control of parenchymal bleeding after trauma and during resection is the second issue that surgeons have to resolve. A good knowledge of intra and extrahepatic vascular anatomy is a necessary condition to develop techniques of vascular control, paving the way to liver transplantation. Last but not least, the issue of residual liver function after resection requires advanced techniques of volume redistribution through redirection of blood inflow. These are the same problems any young surgeon would face when approaching liver surgery for the first time. Therefore, obtaining a wide picture of historical evolution of liver surgery could be a great starting point to serve as an example and a guide.

Hepatic interoception in health and disease

The liver is a large organ with crucial functions in metabolism and immune defense, as well as blood homeostasis and detoxification, and it is clearly in bidirectional communication with the brain and rest of the body via both neural and humoral pathways. A host of neural sensory mechanisms have been proposed, but in contrast to the gut-brain axis, details for both the exact site and molecular signaling steps of their peripheral transduction mechanisms are generally lacking. Similarly, knowledge about function-specific sensory and motor components of both vagal and spinal access pathways to the hepatic parenchyma is missing. Lack of progress largely owes to controversies regarding selectivity of vagal access pathways and extent of hepatocyte innervation. In contrast, there is considerable evidence for glucose sensors in the wall of the hepatic portal vein and their importance for glucose handling by the liver and the brain and the systemic response to hypoglycemia. As liver diseases are on the rise globally, and there are intriguing associations between liver diseases and mental illnesses, it will be important to further dissect and identify both neural and humoral pathways that mediate hepatocyte-specific signals to relevant brain areas. The question of whether and how sensations from the liver contribute to interoceptive self-awareness has not yet been explored.

The prothrombotic tendency of metabolic-associated fatty liver disease

Our understanding of the function of the liver has evolved over the centuries. Early theories proposing that the liver could be used to divine the future have been superseded by our current knowledge of the importance of the liver in processes such as digestion and detoxification. Similarly, although liver disease was previously associated with only an increased risk of bleeding, there is now a substantial body of evidence demonstrating an increased thrombotic potential in patients with this disease. Metabolic-associated fatty liver disease (MAFLD) is increasing in frequency and is likely to overtake alcoholic liver disease as the primary indication for liver transplant in the future. In this review, we discuss the evidence linking liver disease, and MAFLD in particular, with arterial and venous thromboembolic disease. We review the safety and efficacy of anticoagulation in advanced liver disease and consider whether antithrombotic agents could slow or halt the progression of fibrosis in MAFLD.

Social differentiation of the perception and human tissues donation for research purposes

The willingness to donate human biological material for research purposes is shaped by socio-cultural factors; however, there is a lack of studies analysing the social perception of different human tissues, which may affect such willingness. This study aimed to distinguish different sociocultural categories of human tissues and types of potential donors based on their willingness to donate material. Quantitative research was conducted on a sample of 1,100 adult Poles representative in terms of sex, place of residence and education. According to the study, people were most willing to donate urine (73.9%), blood (69.7%), hair and tears (69.6%) and the least willing to donate post-mortem brain fragments (20%), sperm (males; 36.4%) and egg cells (females; 39.6%). A factor analysis revealed four sociocultural categories of donated tissues: irrelevant, redundant, ordinary and sensitive. Based on these sociocultural categories of tissues, four types of donors were identified: reluctant, highly cooperative, average cooperative and selectively cooperative. The willingness to donate human samples for research is shaped by the sociocultural perception of different body parts and tissues. The lower the sense of “personal relationship” with a specific type of tissue, organ or part of the body, the higher the motivation to donate such biological material for research purposes. Additionally, the willingness to donate is mostly shaped by social trust in physicians and scientists, and potential donors’ engagement in charity activities.

Social differentiation of the perception and human tissues donation for research purposes

The willingness to donate human biological material for research purposes is shaped by socio-cultural factors; however, there is a lack of studies analysing the social perception of different human tissues, which may affect such willingness. This study aimed to distinguish different sociocultural categories of human tissues and types of potential donors based on their willingness to donate material. Quantitative research was conducted on a sample of 1,100 adult Poles representative in terms of sex, place of residence and education. According to the study, people were most willing to donate urine (73.9%), blood (69.7%), hair and tears (69.6%) and the least willing to donate post-mortem brain fragments (20%), sperm (males; 36.4%) and egg cells (females; 39.6%). A factor analysis revealed four sociocultural categories of donated tissues: irrelevant, redundant, ordinary and sensitive. Based on these sociocultural categories of tissues, four types of donors were identified: reluctant, highly cooperative, average cooperative and selectively cooperative. The willingness to donate human samples for research is shaped by the sociocultural perception of different body parts and tissues. The lower the sense of “personal relationship” with a specific type of tissue, organ or part of the body, the higher the motivation to donate such biological material for research purposes. Additionally, the willingness to donate is mostly shaped by social trust in physicians and scientists, and potential donors’ engagement in charity activities.

Gaspare Aselli (1581-1625) and Lacteis Venis: Four Centuries From the Discovery of Lymphatic System

The first half of the seventeenth century may be seen as the turning point of knowledge of human anatomy and physiology, as also demonstrated by the works by William Harvey (1578-1657) on the circulation of the blood. This article aims to present biographic context of the surgeon Gaspare Aselli (1581-1625) and his rather fortuitous discovery of the lacteals in Milan in 1622, that contributed to the comprehension of the lymphatic system. The experimentation on living animals (anatomia animata, living anatomy), and particularly the vivisection used by Gaspare Aselli provided the basis for much of the subsequent investigation of the human physiology. In particular, the discovery of lymphatics challenged the basis of the Galenic doctrine, denying the liver the central role it had formerly been granted in transforming food into blood and revolutionized the ancient hepatocentrism in favor of the modern concept of cardiocentrism.

A History of the Assessment of Liver Performance

Content available: Author Interview and Audio Recording.

Giovanni Maria Lancisi (1654-1720) and the modern cardiovascular physiology

Giovanni Maria Lancisi (1654-1720) was one of the most important Italian physicians of the modern age. Orphaned of his mother, he spent his early years in the city of Orvieto; when he was 12, his father brought him back to Rome and enrolled him to study medicine at the Sapienza University in Rome. His dedication to study and work soon led him to increasingly important positions. Within a few years, the fame of Lancisi became such that he was appointed the personal physician of three popes. In De Subitaneis Mortibus (1707), he described the pathophysiology of heart diseases, identifying the cause of sudden deaths in structural anomalies of the heart, lungs, and brain. He also wrote about cerebral localizations and first discussed the physiological mechanisms of urine formation and excretion. In 1717, Lancisi described the pathogenesis of malaria and the close correlation between its onset and the swampy waters of the Tiber River, proposing the draining of marshes to eradicate malaria. In the posthumous De Motu Cordis et Aneurysmatibus (1728) he described for the first time heart dilatation and aneurysms of the great vessels, providing a fundamental contribution to the history of cardiovascular physiology. Proof of his interest in medical education is the establishment of an academy and the donation of a library to the hospital, bridging the gap between theory and practice in medical training. Over the centuries, Lancisi's memory has faded, but his work is still relevant for anyone practicing the medical profession.

Ethnomedicinal Plants Traditionally Used for the Treatment of Jaundice (Icterus) in Himachal Pradesh in Western Himalaya-A Review

Ethnomedicinal plants have a significant role in the lives of people of rural and tribal areas. Thousands of medicinal plant species are used to treat various diseases, including jaundice, and are considered an important therapeutic resource to minimize these diseases. Jaundice (icterus) is a chronic disease that occurs when the amount of bilirubin in the blood increases. This review describes different ethnomedicinal plants used for curing jaundice by tribal and rural people of Himachal Pradesh. The study reveals 87 ethnomedicinal plant species belonging to 51 different families, which are used for treating jaundice in Himachal Pradesh. These plants are arranged in a systematic way, which includes a description of their common name, botanical name, along with its family, plant parts used, region, and mode of use in tabulated form. Some of the plant extracts have already been explored for their phytochemical and pharmacological significance and proved their potential in the preparation of new medicines or drugs against the treatment of jaundice. This review is an attempt to highlight the indigenous knowledge of medicinal plants, which are specifically used for the treatment of jaundice. The data mentioned in the present review is compiled from various sources like existing literature, books, Google Scholar, and Scopus publications. Among all the observed plant species, most used medicinal plants for the treatment of jaundice include Justicia adhatoda, Emblica officinalis, Ricinus communis, Saccharum officinarum, Terminalia chebula, Berberis aristata, Cuscuta reflexa, and Tinospora cordifolia. Plants that are mostly utilized for the treatment of jaundice need to be scientifically validated by pharmacological analysis and should be subsequently used for the preparation of new drugs, which may prove far more beneficial than the existing one.

Atypical immunometabolism and metabolic reprogramming in liver cancer: Deciphering the role of gut microbiome

Hepatocellular carcinoma (HCC) is the fourth leading cause of cancer-related mortality worldwide. Much recent research has delved into understanding the underlying molecular mechanisms of HCC pathogenesis, which has revealed to be heterogenous and complex. Two major hallmarks of HCC include: (i) a hijacked immunometabolism and (ii) a reprogramming in metabolic processes. We posit that the gut microbiota is a third component in an entanglement triangle contributing to HCC progression. Besides metagenomic studies highlighting the diagnostic potential in the gut microbiota profile, recent research is pinpointing the gut microbiota as an instigator, not just a mere bystander, in HCC. In this chapter, we discuss mechanistic insights on atypical immunometabolism and metabolic reprogramming in HCC, including the examination of tumor-associated macrophages and neutrophils, tumor-infiltrating lymphocytes (e.g., T-cell exhaustion, regulatory T-cells, natural killer T-cells), the Warburg effect, rewiring of the tricarboxylic acid cycle, and glutamine addiction. We further discuss the potential involvement of the gut microbiota in these characteristics of hepatocarcinogenesis. An immediate highlight is that microbiota metabolites (e.g., short chain fatty acids, secondary bile acids) can impair anti-tumor responses, which aggravates HCC. Lastly, we describe the rising 'new era' of immunotherapies (e.g., immune checkpoint inhibitors, adoptive T-cell transfer) and discuss for the potential incorporation of gut microbiota targeted therapeutics (e.g., probiotics, fecal microbiota transplantation) to alleviate HCC. Altogether, this chapter invigorates for continuous research to decipher the role of gut microbiome in HCC from its influence on immunometabolism and metabolic reprogramming.

The absence of hepatic glucose-6 phosphatase/ChREBP couple is incompatible with survival in mice

Objective

Glucose production in the blood requires the expression of glucose-6 phosphatase (G6Pase), a key enzyme that allows glucose-6 phosphate (G6P) hydrolysis into free glucose and inorganic phosphate. We previously reported that the hepatic suppression of G6Pase leads to G6P accumulation and to metabolic reprogramming in hepatocytes from liver G6Pase-deficient mice (L.G6pc^−/−). Interestingly, the activity of the transcription factor carbohydrate response element-binding protein (ChREBP), central for de novo lipid synthesis, is markedly activated in L.G6pc^−/− mice, which consequently rapidly develop NAFLD-like pathology. In the current work, we assessed whether a selective deletion of ChREBP could prevent hepatic lipid accumulation and NAFLD initiation in L.G6pc^−/− mice.

Methods

We generated liver-specific ChREBP (L.Chrebp^−/−)- and/or G6Pase (L.G6pc^−/−)-deficient mice using a Cre-lox strategy in B6.SA^CreERT2 mice. Mice were fed a standard chow diet or a high-fat diet for 10 days. Markers of hepatic metabolism and cellular stress were analysed in the liver of control, L. G6pc^−/−, L. Chrebp^−/− and double knockout (i.e., L.G6pc^−/−.Chrebp^−/−) mice.

Results

We observed that there was a dramatic decrease in lipid accumulation in the liver of L.G6pc^−/−.Chrebp^−/− mice. At the mechanistic level, elevated G6P concentrations caused by lack of G6Pase are rerouted towards glycogen synthesis. Importantly, this exacerbated glycogen accumulation, leading to hepatic water retention and aggravated hepatomegaly. This caused animal distress and hepatocyte damage, characterised by ballooning and moderate fibrosis, paralleled with acute endoplasmic reticulum stress.

Conclusions

Our study reveals the crucial role of the ChREBP-G6Pase duo in the regulation of G6P-regulated pathways in the liver.

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Hepatic deletion of both ChREBP and glucose-6 phosphatase collapses liver lipids.

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Double deletion leads to excessive glycogen storage and a liver swollen with water.

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Hepatic deletion of both ChREBP and glucose-6 phosphatase leads to death.

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Glucose-6 phosphate homeostasis in hepatocytes is a vital function.

History of Nonalcoholic Fatty Liver Disease

Based on the assumption that characterizing the history of a disease will help in improving practice while offering a clue to research, this article aims at reviewing the history of nonalcoholic fatty liver disease (NAFLD) in adults and children. To this end, we address the history of NAFLD histopathology, which begins in 1980 with Ludwig's seminal studies, although previous studies date back to the 19th century. Moreover, the principal milestones in the definition of genetic NAFLD are summarized. Next, a specific account is given of the evolution, over time, of our understanding of the association of NAFLD with metabolic syndrome, spanning from the outdated concept of "NAFLD as a manifestation of the Metabolic Syndrome", to the more appropriate consideration that NAFLD has, with metabolic syndrome, a mutual and bi-directional relationship. In addition, we also report on the evolution from first intuitions to more recent studies, supporting NAFLD as an independent risk factor for cardiovascular disease. This association probably has deep roots, going back to ancient Middle Eastern cultures, wherein the liver had a significance similar to that which the heart holds in contemporary society. Conversely, the notions that NAFLD is a forerunner of hepatocellular carcinoma and extra-hepatic cancers is definitely more modern. Interestingly, guidelines issued by hepatological societies have lagged behind the identification of NAFLD by decades. A comparative analysis of these documents defines both shared attitudes (e.g., ultrasonography and lifestyle changes as the first approaches) and diverging key points (e.g., the threshold of alcohol consumption, screening methods, optimal non-invasive assessment of liver fibrosis and drug treatment options). Finally, the principal historical steps in the general, cellular and molecular pathogenesis of NAFLD are reviewed. We conclude that an in-depth understanding of the history of the disease permits us to better comprehend the disease itself, as well as to anticipate the lines of development of future NAFLD research.

From sadness to stiffness: the spleen's progress

The spleen is a lymphoid organ that has been poorly studied compared to other solid organs, probably because it has been considered a useless and unnecessary part of the body. For many centuries it has been considered a mysterious organ with uncertain functions. The first descriptions of the spleen date back to ancient ages. The spleen has been considered as a reservoir of liquids, strictly linked to stomach digestion, and in different cultures, it has been linked to melancholy and sadness due to the accumulation of black bile (humoral doctrine). A detailed anatomic description was first made by Vesalius during the Renaissance, and further implemented with the description of its microscopic structure by Marcello Malpighi in the seventeenth century. The first case reports regarding spleen functions and pathology regarded common causes of splenomegaly, such as malaria infection, and traumatic rupture. At the beginning of the last century, the pivotal concepts of hypo- and hypersplenism were introduced, along with the cumulating evidence of the relation between spleen removal and increased susceptibility to infections and thromboembolism. The study of hyposplenic states, which occur much more commonly than originally thought in many immune-mediated disorders, has rapidly increased after the validation of a simple method for assessing spleen function, namely pitted red cell count. In recent years, spleen morphology, in particular spleen stiffness, has been proposed as a marker of portal hypertension. In this paper, we retrace the fundamental steps of the discovery of the functions of the spleen.

"I Miss My Liver." Nonmedical Sources in the History of Hepatocentrism

Hepatocentrism was a medical doctrine that considered the liver the center of the whole human being. It originated in ancient populations (Mesopotamic civilization) and persisted in Western countries until the seventeenth century. Hidden references to hepatocentrism may be found in artistic representations and literary works, from the myth of Prometheus in the Greco-Roman world to the crucifixion iconography throughout the Middle Ages. In the mid-1600s, fundamental discoveries irrefutably demonstrated the central role of the heart in human physiology, which laid the foundations for creating cardiocentrism, shifting the life's center from the liver to the heart. The advent of cardiocentrism immediately restricted the importance given to the liver, favoring the heart in the fine arts. Nevertheless, the liver maintained its importance in literature and popular belief as is evidenced by the widely acclaimed literary texts "Snow White" by the Brothers Grimm, "Moby Dick" by Herman Melville, and "Ode to the Liver" by Pablo Neruda. Our aim is to analyze the most significant artistic representations and literary works that contain references to hepatocentrism, evaluating the changing ideas and beliefs regarding the role and function of the liver throughout history. We want to underline the tight relationship between art and medicine; fine art and literature could be a valuable source for understanding the history of hepatology. (Hepatology Communications 2018; 00:000-000).

Ethnopharmacological Approaches for Therapy of Jaundice: Part I

Jaundice is a very common symptom especially in the developing countries. It is associated with several hepatic diseases which are still major causes of death. There are many different approaches to jaundice treatment and the growing number of ethnomedicinal studies shows the plant pharmacology as very promising direction. Many medicinal plants are used for the treatment of jaundice, however a comprehensive review on this subject has not been published. The use of medicinal plants in drug discovery is highly emphasized (based on their traditional and safe uses in different folk medicine systems from ancient times). Many sophisticated analytical techniques are emerging in the pharmaceutical field to validate and discover new biologically active chemical entities derived from plants. Here, we aim to classify and categorize medicinal plants relevant for the treatment of jaundice according to their origin, geographical location, and usage. Our search included various databases like Pubmed, ScienceDirect, Google Scholar. Keywords and phrases used for these searches included: "jaundice," "hyperbilirubinemia," "serum glutamate," "bilirubin," "Ayurveda." The first part of the review focuses on the variety of medicinal plant used for the treatment of jaundice (a total of 207 medicinal plants). In the second part, possible mechanisms of action of biologically active secondary metabolites of plants from five families for jaundice treatment are discussed.

Ethnopharmacological Approaches for Therapy of Jaundice: Part I

Jaundice is a very common symptom especially in the developing countries. It is associated with several hepatic diseases which are still major causes of death. There are many different approaches to jaundice treatment and the growing number of ethnomedicinal studies shows the plant pharmacology as very promising direction. Many medicinal plants are used for the treatment of jaundice, however a comprehensive review on this subject has not been published. The use of medicinal plants in drug discovery is highly emphasized (based on their traditional and safe uses in different folk medicine systems from ancient times). Many sophisticated analytical techniques are emerging in the pharmaceutical field to validate and discover new biologically active chemical entities derived from plants. Here, we aim to classify and categorize medicinal plants relevant for the treatment of jaundice according to their origin, geographical location, and usage. Our search included various databases like Pubmed, ScienceDirect, Google Scholar. Keywords and phrases used for these searches included: “jaundice,” “hyperbilirubinemia,” “serum glutamate,” “bilirubin,” “Ayurveda.” The first part of the review focuses on the variety of medicinal plant used for the treatment of jaundice (a total of 207 medicinal plants). In the second part, possible mechanisms of action of biologically active secondary metabolites of plants from five families for jaundice treatment are discussed.

Occupational health in fairy tales

Myths and folklore, as expressions of popular beliefs, provide valuable information on medical knowledge in earlier times. Fairy tales have often recounted occupational maladies throughout the ages and also provide some insight into the toxic effects of certain metals, such as mercury. Much historical information can be gleaned from unexpected sources, and as such, fairy tales should be more carefully scrutinized by contemporary researchers with an interest in the historical origins of workplace injury and disease.

The Neurologist in Dante's Inferno

The year 2015 marks the 750th birth anniversary of the Italian poet Dante Alighieri (1265-1321). It is less known that Dante had a sound level of medical knowledge, probably derived by his academic studies. In his works, medieval notions of neuroanatomy and neurophysiology (e.g. the connection between brain and spinal cord, function of optic nerve and peripheral nerves, knowledge of vegetative nervous system) and descriptions of neurological disorders (e.g. epileptic seizures, effects on nervous system by metal intoxication, and narcolepsy) may be found, specially in the Inferno, the first part of his masterpiece, the Divine Comedy. These accurate descriptions have led some authors to believe that the poet himself may have suffered from a neurological disease (epilepsy or hypersomnia). Damned souls of the Inferno seem to be also afflicted by psychiatric disorders, such as melancholia and depression. The analysis of Dante's works confirms that poetry - as well as literature in general - may be an important source of information for historians of neurology.

Nonalcoholic fatty liver disease: a precursor of the metabolic syndrome

The conventional paradigm of nonalcoholic fatty liver disease representing the "hepatic manifestation of the metabolic syndrome" is outdated. We identified and summarized longitudinal studies that, supporting the association of nonalcoholic fatty liver disease with either type 2 diabetes mellitus or metabolic syndrome, suggest that nonalcoholic fatty liver disease precedes the development of both conditions. Online Medical databases were searched, relevant articles were identified, their references were further assessed and tabulated data were checked. Although several cross-sectional studies linked nonalcoholic fatty liver disease to either diabetes and other components of the metabolic syndrome, we focused on 28 longitudinal studies which provided evidence for nonalcoholic fatty liver disease as a risk factor for the future development of diabetes. Moreover, additional 19 longitudinal reported that nonalcoholic fatty liver disease precedes and is a risk factor for the future development of the metabolic syndrome. Finally, molecular and genetic studies are discussed supporting the view that aetiology of steatosis and lipid intra-hepatocytic compartmentation are a major determinant of whether fatty liver is/is not associated with insulin resistance and metabolic syndrome. Data support the novel paradigm of nonalcoholic fatty liver disease as a strong determinant for the development of the metabolic syndrome, which has potentially relevant clinical implications for diagnosing, preventing and treating metabolic syndrome.

Dante and cardiology: Physiopathology and clinical features of cardiovascular diseases in the Middle Ages

Ancient non-medical texts can unexpectedly provide useful information on the development of knowledge about the heart and its diseases throughout history. The 750th anniversary of the birth of the Italian poet Dante Alighieri (1265-1321) provides a timely opportunity to analyze medical references in his works, in particular, focusing on literary descriptions that may be attributed to cardiovascular disorders. Dante's high level of medical knowledge, probably derived from his academic studies, is testified by his affiliation to the Florentine Guild of physicians and pharmacists. In all his works, the poet shows a deep interest for the heart. However, his anatomical and physiological knowledge of the circulatory system appears to be poor, probably due to it being based on theories and concepts brought forth by Aristotle and Galen, which were taught in medieval universities. Despite this, accurate descriptions of some symptoms (emotional syncope, orthopnea, dyspnea on exertion) and signs (ascites, paleness), which may be attributed to cardiovascular disorders, can be easily found in Dante's works, particularly in his masterpiece, the Divine Comedy. The literary and historical analysis of cardiovascular signs and symptoms allows us to assume that clinical features due to alterations of heart function were probably known by medieval physicians, but their etiology and pathophysiological mechanisms were not completely understood in that period. Historians of cardiology and clinicians should consider analysis of non-medical texts (including poetry) as an opportunity to better investigate the evolution of their discipline throughout the ages.