History of the Pancreas: Mysteries of a Hidden Organ (review)

The pancreas is probably the organ least thought about in our daily lives. We worry about having a heart attack or getting breast or prostate cancer, but who worries about the pancreas? This lack of interest is not a new phenomenon: the pancreas was missed by early anatomists because it is deeply seated and lost in the fat of the mesentery; it was not studied by early physiologists because of the difficulty in accessing the pancreatic duct; it was not operated on by surgeons because of the extremely high mortality associated with pancreatic surgery; and it was not analyzed by molecular biologists because of inadequate numbers of specimens. The last decade, however, has witnessed a revolution in our understanding of pancreatic diseases, as well as the birth of advocacy groups promoting awareness of diseases such as pancreatic cancer. It is therefore timely that John Howard and Walter Hess have written their history, telling the remarkable story of our understanding of the pancreas and its diseases.

Howard and Hess first trace the history of the healthy pancreas, from the description of the organ by the Greek anatomist and surgeon Herophilus (335-280 bc), through the discovery of the pancreatic duct system by Johann Wirsüng (1642) and Giovanni Santorini (1681-1737), to the early descriptions of pancreas histology by Moyse and Langerhans. This history is well illustrated and described in colorful detail. For example, we learn that when Wirsüng sent a letter to his old teacher Riolan suggesting that he study the pancreatic duct, Riolan replied that he could not because of a shortage of hanged criminals! Similarly, the authors describe how Claude Bernard, the father of pancreatic physiology, was almost arrested when one of the dogs he was experimenting on escaped and its angry master called the police. (Fortunately for pancreas physiologists Bernard was not arrested, and was able to retrieve his pancreatic cannula from the dog and complete his research.) The reader is then artfully taken through the wonderful discoveries that led to our modern understanding of pancreatic diseases. These sections are organized by disease type, and again are filled with historical illustrations and anecdotes that bring history to life.

The book is to be lauded for its depth and breadth. Like any work of this scope, however, it has weaknesses. First, a few topics are missed: for example, the description by Trousseau of the association of pancreatic cancer with migratory thrombophlebitis, and Trousseau's eventual self-diagnosis of pancreatic cancer after he himself developed migratory thrombophlebitis. Second, some of the figures are incorrect illustrations: for example, fig. 9.22A is said to be William S. Halsted, the first surgeon to successfully resect a periampullary neoplasm; in fact, the figure shows the internist Sir William Osler. Third, the description of the recent explosion in our knowledge of pancreatic diseases is sketchy at best: for example, the beautiful work of my friend and colleague Scott Kern at Johns Hopkins in which he discovered the pancreatic cancer gene DPC4 and helped discover the breast cancer gene (BRCA2) in a pancreatic cancer, is not mentioned. This last is a particular shame, because the opportunity to bring the reader out of the fog of the "mystery" of the pancreas and into the light of the modern molecular era of discovery is lost.

The pancreas has been long ignored because of the difficulties inherent in studying this hidden organ. Nonetheless, diseases of the pancreas—including diabetes, pancreatitis, and pancreatic cancer—cause significant human suffering and death. Howard and Hess call our attention to this important organ.