review of literature on clinical pancreatology - The Pancreapedia

PANCREATIC HISTORYEarly conceptsPancreatic anatomyThe earliest observations on the pancreas were probably made by rabbis in the BabylonianTalmud who refer to a "finger <strong>of</strong> the liver" [001]. The initial anatomical descriptions <strong>of</strong> thepancreas are generally considered to have originated from the Alexandrians Herophilus,Erasistratos, and Eudemus in the third century BC [002, 003]. Although Galen provided amodest anatomical description, neither he, Hippocrates, Erasistratus, nor Herophilus wereable to identify any relationship to disease. These ancient quasi anatomophysiologistsregarded the pancreas as unusual, given that it had no cartilage or bone. This observationled Ruphos <strong>of</strong> Ephesus (c. 100 BC) to name the organ "pancreas" (Greek pan: all, + kreas:flesh or meat) [004, 005].Andreas Vesalius (1513-1564) referred to the pancreas in the fifth book <strong>of</strong> his opus (Dehumani corporis fabrica) as a "glandulous organ or kannelly body <strong>of</strong> substance growing in theneather pannicle <strong>of</strong> the caule (omentum)" and postulated that the pancreas exerts aprotective effect on the stomach by serving as a cushion (Schutzorgan) on which it rested[006].In 1642, in an anatomical dissection <strong>of</strong> an executed criminal, Johann Wirsüng (1589-1643)described the main pancreatic duct, but neither he nor his contemporaries could decipher thefunction <strong>of</strong> the gland [007]. Giovanni Domenico Santorini (1681-1737) is credited with thediscovery <strong>of</strong> the accessory pancreatic duct, although several other contemporary anatomistsalso reported on the existence <strong>of</strong> the accessory duct [008].In 1720, Abraham Vater (1684-1751) presented his description <strong>of</strong> the duodenal ampulla[008], whereas Ruggero Oddi, as a fourth year medical student in 1887, demonstrated theexistence <strong>of</strong> the sphincter, which bears his name [009]. The dubious history <strong>of</strong> this sphincteris recapitulated in Oddi's precipitous fall from scientific grace and his ignominious demise asa member <strong>of</strong> the French Foreign legion in an unknown grave in Tunisia [010].Pancreatic physiologyDespite knowledge <strong>of</strong> the existence <strong>of</strong> the pancreas, there was little effort to investigate thephysiological role <strong>of</strong> the gland until the late 17th century when Franciscus de le Boe Sylvius(1614-1672) <strong>of</strong> Amsterdam proposed that digestion was a multistep process starting withfermentation by saliva in the mouth and the stomach, a second phase involving thepancreas, followed by the passage <strong>of</strong> chyle into lymphatics, the venous system, andeventually, the right side <strong>of</strong> the heart [011]. His pupil, Regnier de Graaf (1641-1673),ingeniously developed a method for the direct investigation <strong>of</strong> the nature <strong>of</strong> pancreatic juiceby creating canine pancreatic fistulae through which he inserted feather quills into thepancreatic ductal orifices to obtain succus pancreaticus [012]. However, his investigationsinto the nature <strong>of</strong> the succus pancreaticus resulted in his erroneous conclusion that it wasacidic in nature (he had sampled the pyloric antra <strong>of</strong> his piscine models) [010].These innovative theories on digestion were subsequently modified by John Conrad Brunner(1653-1727) whose experiments in pancreatectomized dogs led him to propose thatspecialized duodenal glands (which are named after him) were the major source <strong>of</strong> digestivejuice secretion and that the pancreas was not vital either for digestion or for life [002, 013]. In1682, Peyer described the lymphatic nodules located in the walls <strong>of</strong> the ileum and proposedthat both Brunner glands and his own "patches" were adjuncts to digestion, producing a