PRESIDENTIAL ADDRESS

Eponyms in Biliary Tract Surgery MacDonald Wood, MD, Phoenix,

Arizona

“Gallia est omnis divisa in partes tres.” To paraphrase Caesar, all of “gall” is divided into three parts: the liver, the biliary tract, and the pancreas. The biliary tract is one of the most frequent sites for operative intervention, with an estimated 750,000 biliary tract procedures performed yearly in the United States. Numerous eponyms are currently used in the description of biliary tract surgery. Who were these men and what were their accomplishments? Out of countless eponyms in biliary tract surgery, the selection in this report is purely eclectic. The eponyms chosen comprise two areas: gross anatomy (Glisson, Wirsung, Santorini, Winslow, Heister, and Vater) and operative anatomy (Kocher, Courvoisier;Morison, Hartmann, Calot, Roux, and Oddi). This paper presents a brief chronicle to properly place these men in the sequence of the history of biliary tract disease, provides a condensed biographical sketch of each man’s life and work, and concludes with brief comments on eponyms. History of Biliary Tract Surgery

Long before the Roman Empire, the liver and biliary tract passages were known and were thought to be divine. Early medical papyri of Egypt dating to the pyramid builders, 3,000 years B.C., indicated that surgical conditions were skillfully treated. The Edwin Smith Surgical Papyrus (circa 1700 B.C.), probably written by Imhotep about a thousand years earlier, described many surgical procedures [1,2]. In Mesopotamia 2,000 years B.C., blood, the sign of life, was thought to fill the liver, which was considered to be the seat of the soul. In addition, the livers of sacrificial animals were carefully examined in detail as omens. A key to interpretive changes in the liver and biliary tract is a model of a sheep’s liver Reprint requests should be addressed to MacDonaid Wocd, MD, 550 West Thomas Road, Phoenix, Arizona 65013. Presented at the 31st Annual Meeting of the Southwestern Surgical Congress, Las Vegas, Nevada, April 23-26. 1979.

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(in the British Museum) covered with cuneiform inscriptions describing interpretations for various abnormalities [3-51. The bronze liver of Piacenza had inscriptions indicating that the Etruscans used the liver for the purpose of divination [6]. A mummy was presented in 1909 to the Museum of Royal College of Surgeons in London. It was a mummy of Princess of Amenen of the 21st dynasty (circa 1500 B.C.) that had a preserved liver and a large gallbladder containing 30 gallstones. It was the earliest specimen of calculi surviving from antiquity. Unfortunately, it was destroyed by German bombing in World War II [5,7]. In India in 1,000 B.C., Sustrata advocated the dissection of human bodies for training surgeons [6]. Throughout antiquity, knowledge of the biliary passages in the body came from the battlefield, sacrificial offerings, or after death in mummification rituals. On the Island of Cos the great Hippocrates (460-370 B.C.), whose extensive clinical experience taught him the seriousness of biliary tract disease, recorded that “in case of jaundice, it is a bad sign when the liver becomes hard” [4]. Aristotle (384-322 B.C.) observed anatomic dissection by others, recognized jaundice as a disease of the liver, and wrote that the human liver is round like that of an ox. There is no documentation that Aristotle observed any calculi in the gallbladder [4,7]. Arthur Weigle suggested that the terminal illness of Alexander the Great (356-323 B.C.), which led to peritonitis secondary to perforation or to associated pancreatitis at an early age of 33, was compatible with acute obstructive cholecystitis [7]. The Alexandrian School, founded by pupils of Aristotle, was a background for the anatomist and surgeon Galen (129-201 A.D.). He believed that the liver was an essential organ, the center of all organs, the focus of animal heat, the origin of veins, and the former of blood. Galen also believed that the gallbladder was the formation site of one of the four humors-choler or yellow bile [5,7]. Alexander of Tralles (525-605) was a learned

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Presidential Address: Eponyms

Greek physician with integrity and character who believed that dropsy arose from diseases of the liver and who described ascites, anasarca, and tympanites. He also noted calculi within the hepatic ducts of the human liver. Centuries later, Abu Bakr Muhammid Ibn Zakairya R?izi (circa 841-920), called Rhazes by Europeans, was the most original figure in Arabic medicine. A Persian who wrote prolifically in Arabic, Rhazes thought abdominal problems were due to changes in the bile and to ulcers and tumors of the intestine. He also described gallstones in an ox JS,71. Ibn Sina (980-1037), whose name was changed to Avicenna, was an eminent, physician, scientist, poet, philosopher, and statesman. He was a genius and an intellectual phenomenon who knew the Koran by heart at age 10. He wrote about surgical operations with a multitude of drawings and diagrams. He was aware that biliary fistulas occurred after drainage of an abdominal wall abscess IS]. Posthumous publication of reports of autopsies done by Ant,onio Benivieni (1440-1502) of Florence provided the first case report of gallstones in man and referred to biliary tract diseases with stones in the coat of the liver and in the tunic of the gallbladder [6’1. The renaissance in anatomy began with Leonardo da Vinci and Michelangelo. Anatomy became a true science with Andreas Vesalius of Padua (1514-1564). His epitome of seven books (Atlas Compendium) corrected Galenic errors. He described gallstones and their consequences. The internal anatomy of the liver was not carefully studied, for Vesalius thought the portal vein divided into five branches. This was not corrected for another 100 years, until Johannus Vesling of Padua correctly represented the portal vein as dividing into two main trunks [4,.5,7]. Gabriele Fallopio (1523-1562) considered himself a student of Vesalius although he never studied under him. Fallopio was an active and accurate anatomic dissector and a botanist. He described stones in the gallbladder and common duct. He is eponymously remembered by the fallopian aqueduct, the fallopian tubes, the fallopian ligament, and a polyandrous genus of plants. He also devised a primitive condom of linen that has no eponym [7,8]. At the start of the 17th century, intellectual awakening in the natural sciences was led by Descartes, Galileo, Newton, and Harvey. During the next 200 years anatomy, physiology, and pathology developed and established a firm footing. It was a period of great exploration and a multitude of eponyms evolved.

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Eponyms of Gross Anatomy (Figure 1) Glisson’s Capsule

Francis Glisson (1597-1677), t,he second of three children of William and Mary Glisson, is said to have been born in the village of Rampisham in Dorset, where he lived and was educated until he went to Cambridge in 1617. He had becoqe a Greek lecturer and was appointed Dean of Michaelmas in 1629. Medicine did not entice him until he was 30 years old. He obtained a medical degree at Cambridge in 1634. He was appointed to the regius chair of physics in 1636; he held that office until his death 31 years later, longer than any regius professor before or since id]. Glisson was closely associated with the College of Physicians. In 1666 the college was destroyed by fire and most of its property lost, including the library of William Harvey. A year later Glisson, as president of the college, aided in obtaining funds for rebuilding the institution [4]. His medical notes were written in Latin interspersed with English, in a handwriting style difficult to interpret or decipher. His greatest publication (the second) was Anatomia Hepatis in 1654 in an octave volume of 458 pages, with 45 chapters on the liver. No English translation has ever been published [4]. Glisson was the first to thoroughly describe the distribution of a common capsule investing the hepatic artery, portal vein, and the bile duct. The presence of the capsule had been noted in a letter from Johannus Walaenes to Thomas Bartholin in 1640 mentioning a common sheath to the portal vein and the bile duct [4]. Glisson was also the first to describe a sphinteric mechanism around the orifice of the common duct [9]. He deduced that the flow of blood through the portal veins traversed the capillaries into the vena cava. At that time no microscopic studies of the liver had been done [4]. His last book (the fourth) on Stomach and Intestines was published the year of his death at age 80. He died October 14,1677 and was buried at St. Bride [4]. Francis Glisson was primarily an anatomist but also made observations as a physiologist, clinical physician, orthopedic surgeon, and philosopher. He was one of the great physicians of the 17th century and a most accurate observer. A trivial anatomic structure of no practical importance carries his eponym. The Duct of Wirsung

Johann Georg Wirsung (1600-1643) was born in Ausburg, Bavaria. Knowledge of his early educational background is vague, but it is known that he studied

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medicine and became a prosector in anatomy in Padua under Professor Johann Vesling. Maurice Hoffman, a student of Wirsung who later became a professor of anatomy and botany, dissected a pancreatic duct in an Italian rooster in the autumn of 1641 and showed it to Wirsung. The following year Wirsung dissected out this pancreatic duct in a human and described it in a letter to Jean Riolan, professor of anatomy and botany at the University of Paris in 1642. Wirsung also published a copper engraving he had made of the duct. Riolan called the duct “Wirsung’s duct.” One year later, on August 22, 1643, Wirsung was murdered by a Dalmatian doctor [6,10]. Controversy and confusion surround

Wirsung’s tragic death. According to legend, private quarrels, envy, hatred, and jealousy arose among students and physicians over whether the duct should be named after Hoffman or Wirsung. A century later Morgagni accurately reviewed the records and transcribed the following: “Around midnight Wirsung had a friendly talk with some of the fellow lodgers at the door of his home, as he often did. He was then struck by a bullet from a heavy ‘sclopetum’-a carbine-which is usually called a carabinet, and dying from severe loss of blood kept repeating the words, ‘I am dying, Cambier, Cambier’ ” [10,11]. Cambier fled with a relative, Nicaise Cambier, and another student. Morgagni concluded,

Triangle of Calot Kocher’s Maneuver

[

Courvoisier’s

I

Sphincterofi 3lisson’s Capsule

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Law

\

I

Roux-en-y Figure 1. Eponyms in biliary tract surgery.

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Presidential Address: Eponyms

“. . . Wirsung was killed as a result of a private quarrel such as often arose between young foreigners living far from their countries” [9,11]. Wirsung was a Bavarian monk, a doctor of philosophy in medicine, and a famous scholar of anatomy. He left no treatise or book, but his immortality lives on in his eponym. The Papilla of Vater

Abraham Vater (1684-1751) was a student of Fredric Ruysch, who was a master teacher of the arts of injection. In 1720 Vater described the tubercule or diverticulum as “those double ducts (bile and pancreatic ducts) that come together in no single combination” [9]. Vater described not an ampulla but an elevation of the mucosa in the duodenum. He actually described the first case of an ampulla with two orifices. The names Paul Gottlob Berger and Abraham Vater appeared on the title page of this dissertation [12]. The Vater-Berger diverticulum was then described four times in publications, but since Haller published his Bibliotheca Anatomica (1774-1777), only Vater’s name has persisted 191. Abraham Vater, son of Christian Vater, was born on December 9,1684 in Wittenberg, where he studied and obtained a doctor’s degree in philosophy. After studying in Leipzig, he was granted a doctor’s degree in Meresbourg. He continued his scientific pursuits in Belgium, Germany, England, and Holland before returning to Wittenberg. In 1719 Vater became an assistant professor and in 1733 was named professor of anatomy and botany. With great energy he established an unusual rich and famous museum, gave anatomic demonstrations for women, and had corpses of suicides handed over for anatomic purposes. In addition to his appointment as professor of pathology in 1737, Vater also studied chemistry, applied it to medicine, and was given the chair of therapeutics in 1746. Alchemy interested him deeply, but he burned the records of his experiments. His diverse dissertations, lectures, and writings were considered unimportant by historians. He died in 1751 at age 67 after being associated with the Academy of Medicine for 43 years [13,14]. Vater was a modest man whose name persists. The Duct of Santorini

Giovanni Dominic0 Santorini (1681-1737), son of a pharmacist, was born in Venice. He excelled in his early education but had difficulty choosing a career. The Jesuits hoped he would becc?me a member of their society and a Venetian lawyer friend wanted him to be a lawyer. Santorini preferred to be a phy-

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sician; he obtained his doctor’s degree in Pisa in 1701, became professor of medicine in Venice, and in 1706 was a demonstrator of anatomy. He eventually was appointed professor of anatomy in Venice. The dead bodies of criminals were obtained for anatomic dissection from the jails by consent of the prince. Santorini arranged for the delivery of these bodies for study [13,14]. Santorini was a brilliant anatomist, one of the most exact and careful dissectors of his day, outstanding in obstetrics and art, and an acute diagnostician. His main contribution was Observationes Anatomicae in 1724. While Vater and Berger were describing the tubercule at the confluence of the pancreatic and bile ducts, Santorini was relating the first detailed observation about the orifice of the two ducts [9]. In other observations, printed posthumously in 1775 (poverty prevented their publication while he was alive), Santorini noted a second pancreatic duct of normai occurrence that had been observed previously by others. He named the upper one the superior pancreatic and the lower one the main pancreatic duct [9,14]. Unfortunately, Santorini’s observations were soon forgotten; a century would pass before Claude Bernard, in studying the physiology of the pancreas in 1856, would reaffirm the contributions of Santorini [9]. Foramen of Winslow

In Odense on the Island of Funen, Denmark, Jakob Benignus Winslow (1669-1760) was born on April 9, 1669 to a family originally from Sweden. Because his father was a Lutheran minister, Winslow was interested in religion for many years, but he desired to study medicine. He pursued premedical studies in Holland, and in Paris he was a student of Professor Duverney, an anatomist at the Jardin Royal, who encouraged Winslow because of his talent for anatomy. At age 30 Winslow repudiated the religion of his family and embraced Catholicism. His parents disowned him and withdrew financial support. He had originally obtained a fellowship to study anatomy from the King of Denmark; then for a time, financial aid was given by the bishop of Meaux. When all assistance ceased he presented himself to the faculty of University of Paris in 1702 to study medicine. The faculty supported him until he finished his degree in 1705. The Royal Academy of Science, impressed with his knowledge of anatomy, asked him to teach anatomy at the Gardens of the Kings. On the death of Hunault, Winslow became professor of anatomy, a position formerly held by his teacher, Duverney. Winslow remained the professor of anatomy for more than 40 years [8,14,15].

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In Paris in 1732 Winslow published the Exposition Anatomigue de la Structure du Corps Humain, an authoritative four volume work which was the standard reference in anatomy for the following 100 years; the source of the eponym is described in Volume 2: pages 170 and 352 to 365. Winslow was a pure descriptive anatomist; order, method, clarity and precision were qualities that distinguished him [8,14,153. The foramen epiploicum was sometimes called Duverney’s foramen and even later Scarpa’s foramen. Other eponyms of Winslow’s are Winslow’s pouch (the lesser peritoneal bursa), Winslow’s stars (the choroid veins), and Winslow’s ligament. The epiploic foramen was described by Winslow with such clarity that it has been given his eponym. He died at age 91 on April 3, 1760 [8,14,15]. The Valves of Heister A thoroughly trained anatomist and surgeon, Lorenz Heister (1683-1758) was a powerful force in raising the educational standards of European surgeons. He was born in Frankfurt-am-Main. Although Heister’s father had a limited income, he felt compelled to help his talented son, and his sacrifices enabled Heister to achieve an outstanding and distinguished education at the University of Giessen and in Leyden, Holland. Heister went on to study in Amsterdam with Ruysch and Rau, ultimately achieving a doctoratc in medicine in 1708 at the IJniversity of Helmstedt in Germany. His subsequent appointment as chief surgeon in the army of the Netherlands was due to the sponsorship of his professor, Frederic Ruysch. Heister became professor of anatomy and surgery in 1719 at the University of Helmstedt; later the professorship of botany was also added to his responsibility, and he ultimately established a famous botanical garden. His 38 years at Helmstedt elevated the school of surgery to an eminence of first rank [ 1,8]. His major surgical work was the treatise of surgery Chirugia, printed in the vernacular in 1743, which summarized all previous information and had profuse illustrations of instruments and techniques. His text was the most popular surgical work of the 18th century. He also wrote a compendium of the practice of physics and treatises on ophthalmology, botany, and other subjects [11. Heister made the first postmortem dissection of appendicitis. He also introduced and described a tracheotomy procedure very similar to the procedure used today, more than 200 years later [I]. In his textbook Compendium Anatomica published in Amsterdam in 1720, the “valves” in the

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cystic duct were described and illustrated. Others at that time did not think those folds actually existed. Lichtenstein and Ivy noted that valves appear only in primates and that the valves are only folds and are an embryologic formation. They are also anatomic factors of safety preventing distention or collapse of the cystic duct when sudden changes in pressure occur in the gallbladder or common duct [ 261. The eponym “the valves of Heister” is only a minute part of Heister’s extensive contributions and teachings to advance the art of surgery. Eponyms of Operative Anatomy (Figure 1) Kocher’s Maneuver

The son of a prominent engineer and a pious mother, Theodore Kocher (1841-1915) was born in Berne, Switzerland, where he studied and spent his entire life. Assuming the chair of surgery in Berne at age 31, Kocher retained that position until his death 45 years later. Well-versed in anatomy and an ardent student of pathology, he became a meticulous and investigative surgeon, teacher, and inventor. Kocher visited and studied in the famous clinics of Langenbeck, Billroth, Virchow, and Lister, and in later life he was an intimate friend, via correspondence, of Halsted [I). A prolific writer, Kocher produced many articles, monographs, and a popular, widely translated text Operatiue Surgery [1,I 71. Goiter, endemic in Switzerland, provided the setting for some of the achievements for which Kocher was most widely known. His greatest contributions, for which he was awarded the Nobel prize in 1909, concerned the physiology and surgery of the thyroid gland. Berne became the capital of goiter therapy. Other solid contributions of Kocher were the development of aseptic technique and the management of surgical tuberculosis. He was interested in all fields of surgery. He originated a treatment for shoulder dislocation, was a pioneer in developing abdominal surgery, and advocated the use of a subcostal incision. He published a procedure for sphincteroplasty and standardized a technique in 1903 for mobilization of the duodenum [ r8]. The latter method, known as Kocher’s maneuver, was originally developed to expedite gastroduodenostomy but has since been used for biliary and pancreatic operative procedures. Kocher had artistic ability and mechanical ingenuity; many instruments devised by him are still used in operating rooms today. He was a tireless worker and meticulous in technique. Sir Berkeley Moynihan said, “Infinite accuracy, infinite care, infinite patience gave him results as near to absolute perfection as it is possible for surgery to go” [ 271.

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Presidential Address: Eponyms

A severe attack of pneumonia at age 75 did not deter Kocher’s enthusiasm for work. He remained active until 1 year later, in July’1917, when he developed a severe headache with nausea, vomiting, and diarrhea and died 4 days later [1,17]. Courvoisier’s Gallbladder

Born in Basel, Switzerland, Ludwig G. Courvoisier (1843-1918) was a serious student and graduated in medicine at the University of Base1 in spite of a near-fatal bout with typhoid. At graduation he received a student prize for his work on “The Histology of the Sympathetic Nervous System.” After traveling to London and Venice, he served in the army hospital at Karlsruhe during the France-Prussian war. On his return to Base1 in 1883 he established a private clinic. He declined the directorship of the university clinic in 1900, believing a younger man would be better suited for that position [19]. The biliary tract was Courvoisier’s prime interest, and he wrote numerous articles on diseases and management of biliary tract disorders. He was the first to describe the removal of a stone from the common bile duct. In his monograph in 1890 [20] he discussed different types of ductal obstruction, and in a review of 187 cases he wrote, “. . . with stone obstruction of the common duct, dilatation is most common. . . consequently we have an important diagnostic point in the differential diagnosis of common duct observation.” From this article arose the eponym Courvoisier’s gallbladder or Couvoisier’s law. He died of pneumonia at age 75 on April 8,1918. Roux-en-Y

The father of Cesar Roux (1857-1934) was an inspector of schools who had 11 children and very little fortune otherwise. Cesar, the fifth son, was born in Mont-la-Ville in the canton of Vaud, Switzerland. He obtained classical studies in the village school and later at the country‘college and considered various professions, particularly veterinary medicine. However, to pursue that course he was told that as a pupil he would have to present himself to the professor at D’Alfort dressed in a complete bloomered suit with his head covered with a very high hat (much like a chimney sweep). The ridiculousness of the outfitled him to reject that profession. After Roux decided to study medicine, his brother, an engineer, assisted him financially in that pursuit. Roux studied medicine at Berne, surgery with Kocher, pathology with Langhans and finished his studies with a thesis on the anatomic structure of the anus. On Kocher’s advice he went to Vienna, Prague, and Holland for courses

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in laryngology, otology, obstetrics, and gynecology. He returned to be Kocher’s assistant for 2 years and then returned to Lausanne. Operations were performed in his office and in the country with his wife as assistant [22,22]. At the founding of the University of Lausanne in 1890, Roux was named professor of clinical surgery and gynecology; he was also named surgeon at the county hospital, a position he retained for 40 years. Credit goes to him for establishing education and surgery in Swiss medicine. Roux recommended appendectomy in 1883 for inflammation, but advocated the usefulness of placing ice over the area of the appendix before the operation. He continued to study goiter and described procedures to cure hemorrhoids, rectal prolapse, crural hernia, and pulmonary and orthopedic procedures [21,22]. His pupils regarded him as master and his peers honored him by membership in many French surgical organizations. Although he received the Commander of the Legion of Honor, the titles most dear to him were the appointments as honorary mayor of Lausanne and Mont-la-Ville [21,22]. He had great interest in gastroenteric procedures and described en-Y anastomosis in 1897 [23] for gastroenterostomy and in 1907 for bypassing esophagogastric neoplasm. Although the Roux-en-Y technique is no longer used for gastroenterostomy, it is frequently used today for various bypass procedures. Roux brought great honors to his country, where hewas eminent in the field of surgery. He was a little man, with disorderly bouffant hair, an abundant drooping moustache, and penetrating gray eyes with darts of intelligence behind the glasses. A special accent colored his speech and his repartee was full of humor and good sense. This picturesque man lived unpretentiously in a home that he had built. After the gradual failing of his health, he was buried at age 77 near the tomb of his mother and wife, having contributed to the good renown of surgery everywhere [21,22]. Morison’s Pouch

James Rutherford Morison (1853-1939), the son of John Morison, was born at Hutton’s Henry near Castle Eden, Durham in October 1853. He qualified as a doctor of medicine at Edinburgh in 1857 and was profoundly influenced by Watson, Lister, and Billroth. During 15 years of general practice in Hartlepool, he assisted in the education of several of his sisters and brothers. Under the influence of Sir David Drummond he came to Newcastle, where he was appointed assistant surgeon in 1888 at the Royal

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Victoria Infirmary and after 1897 was a full surgeon. He was associated with the infirmary for 50 years [24,25]. His good health was attributed to daily exercise. Before the great war, he walked or cycled to his consultations. Using a motorbike on one occasion cost him a broken humerus [24,25]. A man with extensive surgical expertise, Morison was a specialist in most branches, and his views were generally 20 years ahead of his time. Always a student, he was also an enthusiastic teacher without parallel. His international reputation made Newcastle famous. During his outstanding service as a surgeon to the Northumberland War Hospital, he introduced bipp as a cure for sepsis (bismuth subnitrate, iodoform, and paraffin in a paste, which is placed in a wound to be sutured primarily). Bipp was a revelation as well as a revolution and provoked considerable adverse opinion [24-261. Morison’s pouch, described in 1894 [26], was used for drainage in biliary surgery. The pouch is in the hepatorenal space, below the lower pole of the right kidney, after reflection of the hepatic flexure. Today the gallbladder area is drained by placing one end of the drain into the region of the foramen of Winslow and the other anteriorly along the course of the gallbladder fossa, which is not the area originally designated as Morison’s pouch. Morison was a practical surgeon and a beautiful but fearless operator. With his friend Sir David Drummond, he introduced omentopexy as a cure for ascites [24,25]. Although he married twice, he was a widower for many years. After a serious operation in 1923, he retired to enjoy golf, fishing, and curling. On his 80th birthday, 13 of his old house surgeons visited him and presented him with an easy chair [24,25]. Morison was a tower of strength in medical and political matters and a warm supporter of the British Medical Association. He died in Newcastle upon Tyne on January 9,1939 and was buried at St. Boswell on Tweed on the side of Eildon Hills that he loved. It is said that “he gave nothing but his best and that was good” [24,25]. Triangle of Calot

Jean-Francois Calot (1861-1944) was born in ArFens, France, and worked in Berck-sur-Mer as a surgeon in the Rothschild Hospital and the Hospital Cazin-Perrochaud. His main interest was bone tuberculosis, and he wrote extensively about the correction of deformities resulting from that disease. Forced realignment for gibbus deformity was called Calot’s operation. Calot wrote other articles on the

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correction of Pott’s disease (1897), treatment of coxalgia (1904), operative treatment of severe scoliosis (1887), and treatment of congenital luxation of the hip (1905). He also published papers on the treatment of white tumors (1906), and he wrote Indispensible Orthopedics for the Practioners (1908), Orthopedics of the War (19i6), and Orthopedics and Surgery of the War (1917) [27].

Calot is remembered by general surgeons for his doctorate thesis written in Paris in 1890, “De La Cholecystectomie,” in which he described the anatomic and technical aspects of cholecystectomy in great detail. When working around the cystic duct one is “in the more delicate part of the operation.” He described an isosoles triangle with the base the common hepatic duct, the inferior edge the cystic duct, and the superior border the cystic artery. Calot’s triangle has since been enlarged, with the edge of the liver as the superior border. This cystohepatic angle, about the size of a half dollar, is a most critical area. Within this zone one finds at some point along its course the cystic artery, the right hepatic artery, the accessory right hepatic artery, or the accessory bile ducts. Within Calot’s triangle is the ganglion (node) described by Hartmann and Broca, resting in the basin of the vesicle. This node has been called Mascagni’s node and Calot’s node. Hartmann’s Pouch

An old family from Alsace and Paris brought Henri Hartmann (1860-1952) into the world on June 16, 1860. He studied in Paris and remained there all his life. Hartmann’s character was molded in a rigorous atmosphere, where the rule of work was absolute. His mother even learned Greek so she could test him. His intelligence guided him to medicine; and he rapidly progressed through the echelons of training. He was an intern in 1881, an aid in anatomy in 1884, a prosector in 1886, an assistant professor in 1895, and a full professor in 1909. At Hotel Dieu he performed at least 1,000 operations a year for more than 20 years. He meticulously recorded over 30,000 operative procedures [28,29]. Pasteur presented the principles of surgical asepsis on April 30, 1878 to the Academy of Medicine. Hartmann’s teacher, Terreir, was admitted to the Pasteur Institute in 1882 and learned the methods of sterilization. Hartmann was impressed by the doctrine of his teacher and applied himself with dedication to asepsis. On the basis of his background in anatomy, physiology, and pathology, he established operative techniques, taught a multitude of

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pupils and physicians, and stimulated his students to investigative works. He dedicated himself to medicine and surgery. He was a sedentary person who was exacting of his pupils. He wrote about tumors of the breast, the urinary tract, and gynecology, and he also wrote extensively about the diseases of abdominal viscera [28,29]. His operation for cancer of the rectosigmoid is still called Hartmann’s procedure. In 1891 Hartmann described the ampulla of the gallbladder as a vesicle or pouch [30]. Named “the pouch of the vesicle” by Paul Broca, it has since been called Hartmann’s pouch. This pouch of the gallbladder is a main structure in liver transplantation today; the gallbladder provides a conduit for bile from the donor liver to the recipient patient. “HH,” as he was called, was one of the great French surgeons of his day and justified the phrase of Mikulicz, “I recognize a good surgeon not for the way he cuts but for the way he sews.” He died in his 91st year on January 1,1952, and was buried in the cemetery Pere-Lachaise [28,29]. Sphincter of Oddi

Ruggero Oddi (1864-1913) was born in Perugia, Italy on January 20, 1864. He made important discoveries in his fourth year of study at the University of Perugia. The next year in Bologna he rediscovered Glisson’s sphincter and did studies in dogs noting the holding quality of the sphincter of the outlet of the choledochus [9]. His thesis was on the workings of the sphincter; he received his MD degree in 1889 in Florence [31]. Oddi was the first to measure the resistance of the sphincter and to demonstrate that removal of the gallbladder causes dilation of the bile ducts, which has now been shown to be a nonphysiologic response. He became director of the Physiology Institute in Genoa at age 29. He carried out numerous physiologic studies on the nervous system, the brain, and the spinal cord as well as studies on metabolism and respiratory exchange [32]. Oddi became associated with an aristocrat Capranica who, though not a doctor of medicine, established a biochemistry laboratory in his family’s palace. Capranica used x-rays and studied their biologic effects, and he offered the lab to the Medical School of Genoa. On the death of his mistress, Capranica converted to fanatical spiritualism, became addicted to morphine, and died in 1899. Because of litigation and confiscation of the laboratory, Oddi resigned from the University of Genoa. He went as a doctor to the Congo for 3 years. Because of ill health he returned to Belgium and became converted to a pan-

Volume 139, December 1979

acea called Vitalina, to which he attributed his survival in the Congo [32]. He was brought to trial in Italy on numerous occasions for “abusive commerce of medicinal products.” Oddi became a broken man: spiritually because of losing his scientific position and physically because of an appendectomy and operations to relieve intestinal obstruction. He left scientific materialism, embraced a new philosophic religion, and repeated the fate of his lost friend Capranica [32]. Historians prefer to remember Oddi in his younger days, when he devoted himself to research that became a model to others. Comments

In many books on the study of language toponyms, patronyms, and eponyms are discussed. Medical dictionaries attach eponyms to diseases, tests, instruments, syndromes, anatomic names, signs, operations, maneuvers, and on and on. Many worthy names, unfortunately, are not honored by eponyms. Purists desire absolute accuracy in anatomic terminology and the elimination of eponyms. Organ and Sojka [33], in their editorial “The Eponym Problem,” listed many disadvantages of using eponyms for anatomic designation: “multiple eponyms to the same structures . . . no descriptive value . . . a source of error. . . the same surname to designate entities . . . historical inaccuracies . . . eponyms compounded on each other. . . pathologic entities confused with anatomic data. . . redundant.” Anatomists are correct that basic terminology should be accurate; nevertheless, all eponyms need not be abolished because of their inconsistency. We stand on the shoulders of the great pioneers of the past, and to honor them is due and fitting. An eponym is a small expression of mankind’s recognition of worthiness and a badge of individuality. Perhaps, as MacDermott [34] suggests, “we should like to see. . . a dictionary devoted to eponyms with full and accurate details.” In an etymology of words that were once names by Will&d R. Espy [35], hundreds of eponymous words are described in a humorous and entertaining manner. Espy notes that the supply of eponyms is endless and that each of us has the makings of an eponym. In “Incubations of Immortality” Espy concludes, as I will, with a poem [36]: So mind your Q’s and mind your P’s; Say “Thank you, sir,” and “If you please.” Then some day, in the future dim, You too may be an eponym.

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Summary A selected group of men whose eponyms are currently used in biliary tract surgery are described. The eponyms chosen comprise two areas: gross anatomy (Glisson, Wirsung, Santorini, Winslow, Heister, and Vater) and operative anatomy (Kocher, Courvoisier, Morison, Hartmann, Calot, Roux, and Oddi). A brief review of biliary tract disease from antiquity until the 17th century places these men in proper historical sequence. A condensed biographical sketch of each man’s life and work is provided and a few closing comments are made about eponyms. Aeknowledgmerzt: The author expresses appreciation to Clare Still and Margo Nitschke for persistent research and to Lydia Haberman, Eleanor Herring, Peter Hernreid, MD, and Jean Angelchik, MD, for valuable translations.

13. 14. 15. 16. 17. 18. 19. 20.

21. 22. 23.

References 24. 1. Zimmerman LM, Veith L: Great Ideas in the History of Surgery. Baltimore, Williams & Wilkins, 1961. 2. Berry FB: Evolving institutes (principles) in surgery. Med Times 94: 315, 1966. 3. Dowdy GS Jr: The Biliary Tract, chap 1. Philadelphia, Lea & Febiger, 1969. 4. Walker RM: Francis Glisson and his capsule. Ann R Co// Surg Eng/ 38: 71, 1966. 5. Glenn, F: Biliary tract disease since antiquity. Bull NY Acad Med 47: 329, 1971. 6. Major RH: History of Medicine, Vol 1. Springfieid, IL, Charles C Thomas, 1954. 7. Glenn F, Grafe WR Jr: Historical events in biliary tract surgery. Arch Surg 93: 848, 1966. a. Mettler CC: History of Medicine. Philadelphia, Blakiston, 1947. 9. Boyden EA: The pars intestinalis of the common bile duct, as viewed by the older anatomists (Vesalius, Glisson, Bianchi, Vater, Hailer, Santorini, etc.). Anaf Ret 66: 217, 1936. 10. Morgenstern L: The murder of Johann Georg Wirsung. Surgery 57: 906, 1965. 11. Debrou: Letter sur la mort de Wirsung et la decouverte du canal pancreatique. Gaz Med Paris 49: 869, 1850. 12. Vater A: Dissertatio anatomica qua novum bilis diverticulum circa orificium ductus cholidochi respondente Paulo

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25. 26.

27. 28. 29. 30.

31. 32. 33. 34. 35. 36.

Gottlob Berger, Witterbergae, 1720. In A. Hailer’s Disputationum anatom. Selectarum 3: 259-273, 1748. Titius SC: De Meritus Vaterovum. Vol 2. Wittenbergae, 1795. Jourdan ADL: Biographie Medicale, Vol 3, p 508. Paris, Panckouche CLF. 1820. Welton TS: “Foramen of Winslow.” Am J Surg 11: 133, 1931. Lichtenstein ME, Ivy AC: The function of the “valves” of Heister. Surgery 1: 38, 1937. Klebs AB: Theodore Kocher, 1841-1917. USNavMedBu(/ 12: 59, 1918. Kocher T: Mobilisierung des duodenum und gastroduodenostomie. Zentralbl Chir 30: 33, 1903. Morgenstern L: Ludwig G. Courvoisier and Courvoisier’s Law. Surg Gynecol Obstet 110: 383, 1960. Courvoisier LG: CasuistischStatistische Eieitrage zur Pathologie und Chirurgie der Gallenwege, pp 57-58. Leipzig, FCW Vogel, 1890. Clement G: Le Professeur Cesar Roux (1857-1934). RevMed Suisse Rom 55: 257, 1935. Marion M: Cesar Roux (1857-1934). Bull Acad Med Paris 113:123, 1935. Roux C: De La Gastro-Enterostomie. Rev Gynecol Chir Abdominale Paris 1: 67, 1897. Willan RJ: Rutherford Morison, Obituary. Br Med J 1: 139, 1939. Obituary, James Rutherford Morison. Lancet 1: 178, 1939. Morison R: The anatomy of the right hypochondrum relating especially to operations for gallstones. Br Med J 2: 966, 1894. Biographischas Lexikon 1880-1920. Berlin, Urban and Schwartzenberg, 1962, pp 212-213. Moulonquet P: Obituary: Henri Hartmann. J Chir 68: 169, 1952. Monod R: Obituary: Henri Hartmann. Bull Acad Naf Med Paris 136: 201, 1952. Hartmann H: Quelques points de I’anatomie et de la chirurgie des voies biliares. “Hartmann’s pouch,” a dilatation of the neck of the gallbladder. Bull Sot Anat Paris 5: 480. 1891. Oddi R: Dune disposition a sphincter speciale de I’ouverture du canal choledoque. Arch ltalBiol8: 317, 1887. Belloni L: Sulla vita e sull’opera di Ruggero Oddi (1864-1913). Riv Stor Med 9: 19, 1965. Organ CH, Sojka LA: The eponym problem. Am J Surg 102: 1, 1961. MacDermott HE: The problem of the eponym. Can MedAssoc J. 53: 74, 1945. Espy WR: 0 thou improper, thou uncommon noun. New York, Clarkson N. Potter, 1978. Espy WR: Incubations of immortality. Chest 2: 109, 1978.

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