The study of the liver is at least as old as written history. The Assyro-Babylonian clay model of a liver in the British Museum is approximately 4,000 years old, and its carefully inscribed segments are remarkably similar to those obtained today with modern angiographic or postmortem injection studies (6). There is good evidence that this liver, and countless others like it, was used to predict the future. The art of predicting events from examination of the liver was known as hepatoscopy or haruspicy. In ancient times, the word liver was also used to imply strength in many languages all over the world, even in the Old Testament (3,5).
The practice of haruspicy spread to the Etruscans, the ancient Hebrews, and later to the Greeks and Romans. Similar rites have been used in modern times by people living in Borneo, Burma, and Uganda.
Gradually the liver took a lesser role in both the primitive medical practices and in the mythology of the common people as the heart and the brain, at various times, assumed importance. In galenic anatomy, the heart was thought to derive its nourishment from the brain, which was regarded as the progenitor for all other organs, and the liver was both underemphasized and incorrectly described. A thousand years after Galen (129-200), Vesalius (1514-1564), Fabricius (1537-1619), and William Harvey (1578-1657), among others, made significant contributions to the study of the anatomy of the liver and, in particular, about its vital vascular connections. It was not until the 17th and 18th centuries, however, that an accurate understanding of hepatic structure was obtained.
Glisson (1597-1677) was not the first to discover the capsule of the liver, but he did come remarkably close to deciphering the complexities of hepatic vasculature, and the relationship of the vessels to the biliary tree, by producing casts of the portal and hepatic veins, and then dissecting away the parenchyma. Malpighi (1628-1694) established the firm foundation for our studies of the structure of the liver with the use of a primitive microscope. He recognized the liver lobule, although he was not able to identify individual hepatocytes. Malpighi also identified the liver as the source of bile. He suggested, after carrying out a series of injection studies, that a sinusoidal network connected portal and hepatic venous systems.
In the 19th century, many scientists contributed to our knowledge of the liver. Paul Ehrlich, in 1884, and Lucatello, in 1885, both performed “puncture” of the liver through laparoscopes for various reasons (1). Histopathology studies were still in their infancy at this time, and tissues were mostly being obtained for chemical, rather than morphologic, studies. Needle puncture of the liver was performed repeatedly during the latter part of the 19th century and the first third of the 20th century, primarily for drainage of hepatic abscesses and hydatid cysts (4).
In 1938, the Vim-Silverman needle was introduced (7). At this time, histopathology was a dominant specialty in medicine, and major advances in the study of the pathology and the pathophysiology of the liver were possible. In 1958 the technique of liver biopsy was further refined with the introduction of the Menghini needle (4), which allowed for the recovery of a core of liver tissue with relatively little artifact induced by the procedure itself. The Menghini needle helped to dramatically expand the use of biopsy, both because it was safer and easier to use than the Vim-Silverman and because it provided tissue of sufficient quality to support sophisticated light microscopic, histochemical, ultrastructural, and immunohistochemical studies. Newer core needle biopsy devices, such as the Tru-cut biopsy and biopsy guns, have refined the technique.
In the 1920s, Martin and Ellis, at Memorial Sloane-Kettering Cancer Center in New York City, developed the technique of aspiration cytology (2). Over the years, aspiration cytology was only rarely applied to the study of liver diseases because the core biopsy was the focus of most diagnostic studies. In recent years, aspiration cytology has been increasingly used for the study of mass lesions.
For most disorders of the liver, percutaneous liver biopsy can yield a satisfactory specimen. Generally, the pathologist would like to have a specimen at least 2 cm long. Laparoscopic biopsy is useful for specific lesions that cannot easily be obtained with percutaneous sampling. Recently it has become practical to obtain specimens via jugular vein entry using a venous catheter through the right atrium and inferior vena cava into the hepatic vein. Transjugular biopsy is particularly useful when the patient has a bleeding diathesis or is markedly ascitic. This wedge biopsy technique, which depends on a biopsy forceps to obtain a sample, generally yields only liver fragments rather than a core, even with an experienced operator. Refinements of this technique have been described that do obtain cores, however. In some cases, particularly when architectural rather than cytologic features are important for evaluation, the usual fragmented transjugular biopsy may not be adequate, and core biopsy is necessary.
REFERENCES
1. Chen TS, Chen PS. Understanding the Liver. Westport, CT: Greenwood Press, 1991.
2. Martin HE, Ellis EB. Biopsy by needle puncture and aspiration. Ann Surg 1930;92: 169-181.
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3. Mellinkoff SM. Some meanings of the liver. Gastroenterology 1979;76:636-638.
4. Menghini G. One-second needle biopsy of the liver. Gastroenterology 1958;35:190-199.
5. Popper H. Vienna and the liver. In: Hepatology: A Festschrift for Hans Popper. New York: Raven Press, 1985:1-14.
6. Popper H, Schaffner F. Liver: Structure and Function. New York: Blakiston, 1957:1-3.
7. Silverman I. A new biopsy needle. Am J Surg 1938;40:671-672.