The liver in Christian thought: Symbolism, morality, and spirituality

FIRE, LIFE, AND PLEASURE: HEPATOCENTRISM IN THE PAGAN CULTURE

During the Classical or Greco-Roman age, the liver was central to understanding the body. The liver was considered to be the source of blood and, consequently, the origin of life itself. This hepatocentric perspective was a product of prevailing physiological knowledge. In his work “On the Usefulness of the Parts of the Body,”¹ the renowned physician Galen of Pergamon (c. 129–216 CE) considered the warm and moist liver to be the principal instrument of sanguification (sanguifactionis officina), ie, the manufacture of blood, and the site of its enrichment in spiritus naturalis (natural spirit),¹ and the source of the veins (fons venarum) that distribute the blood manufactured by the liver around the body. The liver was at once the organ for converting the absorbed food into blood and changing the black blood into the red blood.² According to these theories, the ingested food, after being converted into chyle by the stomach and intestines, is carried and delivered to the liver by the portal vein (thus named from “porta,” the “gate”/“carrier” in Latin). In the liver, the chyle ferments, ie, there is coction (or pepsis), and divests itself of impurities, changing into the blood in the same manner as grapes must ferment in the vats, changing into wine.² The liver has access nearby to all the instruments required to complete the purification process: the gallbladder and the spleen, respectively, remove the lightest and the thickest impurities of absorbed food, while the kidneys the more aqueous parts.¹ So, all the abdominal viscera participate in hematopoiesis under the liver’s direction. The blood is then warmed in the heart, which received venous blood from the liver, enriches it in spiritus vitalis (vital spirit) and distributed it to the entire body through the arteries. As the vital spirit reaches the brain, it undergoes a transformation into spiritus animalis (animal spirit), subsequently branching out to the extremities through the nerves.¹ This intricate physiological framework assigned a dominant role to the liver in human biology, influencing the prevailing physiological beliefs from the Roman world until the Early Modern Age.²

The linguistic roots of the term “liver” further underscored its significance. The etymology of the Greek word ἧπαρ (hepar) and the Latin word iecur, revealed strong connections respectively with the Greek terms ἡδονή (hedoné), meaning “pleasure” and ignis, Latin for “fire.”³,⁴ These linguistic associations hinted at broader cultural and symbolic dimensions, linking the liver not only to physiological processes but also to concepts of fire and pleasure in the collective understanding of the era.⁴

Throughout human history, fire has consistently symbolized life, a notion vividly illustrated in the Prometheus myth written by Hesiod between the eighth and the seventh centuries BCE.⁵ In this narrative, the Titan semi-god steals fire from Zeus, the king of the gods, with the explicit purpose of bestowing upon humanity the gifts of “life, civilization, and joy.” In his wrath, Zeus punished mortals by depriving them of fire after being tricked by Prometheus into accepting the fat and bones of a sacrifice instead of the meat. The story of Prometheus’s punishment of daily piecemeal removal of his liver by an eagle while nailed to a Caucasus mountain, as depicted dramatically in the Greek tragedy “Prometheus Bound” by Aeschylus (c. 525–455 BCE),⁶ is well known in the field of hepatology. The enduring association between fire and vitality has persisted across cultures and ages.

Conversely, the connection between the liver and pleasure delves into the intricate tapestry of human psychology, encapsulating a broad spectrum of emotions. This link reflects a pervasive belief destined to resurface repeatedly in the ensuing centuries, leaving an indelible mark on western culture. The term “hedoné,” while carrying a predominantly positive connotation—particularly resonant in a society like the Greek, deeply engrossed in the appreciation and creation of beauty—also implies a negative side. The Greek philosopher Plato (c.424–347 BCE) elucidates this dichotomy in his “Phaedrus” dialog⁷ between Socrates and Phaedrus by asserting that the appetitive aspect of the tripartite soul in the liver, constituting the natural soul (and aside from the logical/reasoning part in the head and the spirited part in the chest), possesses the potential to lead the entire body astray. From both moral and health perspectives, Plato contends that neglecting supervision by the animal and vital souls results in a decline.⁴

The Greco-Roman philosophy, firmly rooted in the interdependence of body and soul, expounds the notion that virtue and health are intertwined. Plato, in the “Timaeus,” delves into the origin of dreams, positing that these ethereal visions emanate from the appetitive and lustful soul residing in the liver.⁸ This particular soul, influenced by pneuma (which strictly translates as breath but here refers to an invisible liquid or vapor held to travel throughout the body, and to be necessary for and associated with life), becomes the harbinger of dreams. Plato asserts a profound claim that liver damage can distort these nocturnal visions, leading dreams further away from truth. The philosophical underpinning is profound because it theorizes that the synergy between bodily well-being and virtuous living, an equation embraced by ancient philosophers, such as Socrates (c. 470–399 BCE) and Plato, underscores an early acknowledgment that liver impairment correlates with error and falsehood. This recognition echoes through later scholars, forming a philosophical cornerstone in the exploration of the presumed nexus between bodily functions and the quest for truth.

The Roman emperor Marcus Aurelius (121–180 CE) delves into the profound impact of hepatic diseases on human behavior, suggesting that an excess of bile might cloud decision-making abilities and moral judgment of a person.⁹ Indeed, Marcus Aurelius recalls: “To the jaundiced honey tastes bitter, and the victim of hydrophobia has a horror of water, and to the little children their ball is a treasure. Why then be angry? Or dost thou think that error is a less potent factor than bile in the jaundiced and virus in the victim of rabies?”.⁹ Lucius Annaeus Seneca (c. 4 BCE–65 CE), a prominent proponent of stoicism, expounds in his work “De Ira” on the connection between heightened blood mobility and passions like anger and rage, cautioning the righteous man to avoid such emotional turmoil.⁸ Seneca attributes this increased blood activity to an imbalance of “humidity” and “warmth” within the body, aligning with the prevailing physiological understanding of his era.¹⁰

In this cultural milieu, while the liver retains its symbolic status as the origin of life, a subtle shift occurs as it becomes associated with the appetitive soul. This linkage implies a connection to impaired clarity of thought and moral decision-making, gradually undermining the hegemony of hepatocentrism. Hepatic diseases begin to take on additional moral dimensions, particularly with the advent of Christianity. The conceptual shift from mere “mistake” to the weightier notion of “sin” becomes increasingly pronounced, intertwining physical health with moral conduct in the collective consciousness. This transformation contributes to a nuanced understanding of the liver’s role, marking a critical juncture between medicine and morality.

THE SINFUL LIVER: CHRISTIAN MORALITY IN THE EARLY MIDDLE AGES

In the early Middle Ages—a historical period lasting from the late fifth to the 10th century—a significant cultural shift took place. Then, waves of barbaric invasions ushered in a way of life diametrically opposed to Roman motto “in medio stat virtus” (“virtue lies in the middle”). The barbarian populations embraced a conviction diametrically opposite to the Greco-Roman moderate ideal, asserting that the strongest man is the one who is not afraid to indulge in unbridled excess, whether it be in eating, drinking, fighting, or having sexual partners. While the Roman Empire crumbled, the Christian Church underwent significant development and expansion, thanks in part to the contributions of emperors such as Constantine the Great (272–337 CE) and Theodosius I (347–395 CE). In this context, Christianity, structured within the Church and its hierarchy and solidified in its doctrines through various councils (Nicaea, 325; Constantinople, 381; Ephesus, 431; Chalcedon, 451), had to engage with the customs and traditions of barbarian populations. The Church proposed a robust alternative archetype that countered the barbaric ethos of excess and unbridled passions. The Christian model advocated for an ascetic way of life, becoming the cornerstone of monastic orders.¹¹ This deliberate cultural prototype allowed Christianity to assert itself, maintaining influence and authority amid the evolving sociopolitical landscape.

One of the Church Fathers, Jerome (c. 342–420 CE), an early priest, confessor, translator, and highly influential Christian theologian who was later canonized, is commonly credited with the quote: “The first man was cast away from paradise […] because of his submission to the belly rather than God.”¹¹ Uncontrolled indulgence in eating and drinking is perceived as a path to temptation, with gluttony and luxury emerging as 2 of the gravest sins.

The injunction against drunkenness was unequivocally articulated by Paul the Apostle (c.5–c.65 CE): “And do not get drunk with wine, for that is dissipation, but be filled with the Spirit” (Ephesians 5:18). This admonition aligns with the prevailing medical understanding of the time. Notably, Oribasius (c. 320–403 CE), a physician at the Byzantine imperial court, advocates indulgence in food and drink as a remedy for impotence, as sexuality is perceived as an expression of excess warm and humid humors.¹¹ Due to this belief, monks often preach “a carne et coitum abstinendum est,” assigning a dual meaning to the Latin word “carne”: the first literally signifying “meat,” and the second metaphorically representing the indulgence in “carnal pleasures.” In the medieval period, the virtuous Christian refrains from both consuming meat and engaging in sexual intercourse outside of marriage. The consumption of meat emerges as a contentious issue during this time. The influx of animal proteins into the western diet due to barbaric invasions brings about numerous consequences for the overall health of the population. Gout becomes a significant medical concern to the extent that, as recounted by the courtier Einhard (c.775–840 CE), complications from this disease contributed to the death of Charlemagne (747–814 CE).¹¹ The pathology arises from the liver’s incapacity to process an excessive quantity of purine integrated into the diet, leading to the accumulation of the primary catabolite, uric acid, in various parts of the body.

During medieval times, scholars acknowledged the significant role of the liver in determining a person’s health. In one of his numerous dialogs, Augustine of Hippo (354–430 CE), another Church Father, advises a friend to abstain from sweets as they could exacerbate his hepatic disease.¹² In the same conversation, Augustine later employs this concept metaphorically, likening indulgence in such pleasures to the yearning and greed demonstrated by him and his friends during the discussion. This impulsive behavior is once again juxtaposed with rationality and linked to impaired liver function. Furthermore, Augustine contends that a wise physician (prudens medicus) would prescribe some form of punishment (poenas) for those who succumb to the appetitive soul.¹² Here, the concept of hepatic disease becomes intricately intertwined with notions of sin.

This association is exemplified in the figure of Brice of Tours (370–444 CE), recognized as the patron saint for individuals afflicted by hepatic pathologies (Figure 1). Brice commenced his education under Martin of Tours (c.316–397 CE) at the monastery of Marmoutier in France, where he, despite being less adept as a scholar, faced disdain from fellow monks due to his frequent immoral behavior.¹³ Following Martin’s death, Brice succeeded him and was bestowed the pulpit of Tours, a position met with resistance from other monks who propagated malicious falsehoods against him, leading Brice to withdraw. Nevertheless, he responded to the situation with exceptional grace and dedicated the remainder of his life to redeeming his name through virtuous conduct until his death. Seven years prior to his demise, Pope Sixtus III (390–440 CE) granted Brice permission to return to Tours, where he received a warm welcome.¹³ Eventually canonized, Brice became a symbol of redemption, not only for those with hepatic diseases but also for individuals who had lost their homes and those considered societal outcasts. Regarded as an exemplar for anyone not leading a righteous life, Brice’s narrative reinforces the notion that an impaired liver is perceived as a manifestation of sin.

FIGURE 1.

Saint Brice and Saint Martin, both of Tours. Brice (270–444 CE) was a contemporary of Augustine of Hippo, when Gaul was part of the Roman Empire and Christianity was the official state religion (since the end of the fourth century) at a time when advanced Christianization was taking place. Brice had been rescued as a child by Bishop Martin. Martin raised Brice in the monastery of Moutier where he later became a monk and then Martin’s archdeacon. Ultimately, both Martin and Brice were canonized. The format of this icon accords with the Veneration in the Eastern Orthodox and Roman Catholic Churches. Source: Wikipedia.

GETTING TO THE “HEART” OF THE QUESTION: THOMAS AQUINAS’ LEGACY, PROTESTANTISM AND THE EMERGENCE OF CARDIOCENTRISM

In the Late Middle Ages, the Church deemed it crucial to distance itself from hepatocentrism, redirecting the primary role in human life from the liver to another organ — the heart. A pivotal figure in this shift was the theologian Thomas Aquinas (1225–1274), who authored a letter to a certain but otherwise little know dignitary concerning cardiac function, “De motu cordis ad magistrum Philippum de Castro Caeli” (1270–1271),¹⁴ as he sought to resolve Aristotelian philosophy with the beliefs of Catholic Christianity, in a remarkable fusion of Aristotelian rationality and Christian faith. In this letter, he underscores the heart’s supremacy by employing an argument commonly used in medieval philosophy to demonstrate the existence and omnipotence of God. With somewhat dense convoluted reasoning, Thomas asserts that the heart is not subject to the movements of the appetitive soul, as that soul governs only those movements related to increase and decrease, which are not characteristic of the heart. Simultaneously, the heart is unaffected by the sensitive or intellectual soul — while not explicitly using this terminology, it may be accepted as analogous with Plato’s vital and animal spirit, respectively. Thomas argues that both these spirits require the mediation of the appetitive soul to fulfill their functions. However, since appetite alone is insufficient to qualify the heart’s movement, all 3 spirits are excluded.¹⁴

Despite the exclusion of these 3 spirits, Thomas posits a fourth possibility to explain human physiology. He introduces the concept of an “intrinsecum principium,” signifying an intrinsic principle of the organ that enables it to express its specific function.¹⁴ In opposition to Galen’s theories, Thomas Aquinas contends that warmth, traditionally attributed to the heart in warming venous blood, is not the primary cause for initiating and sustaining human life. According to Thomas, the heart’s movement precedes the warming of the blood it contains. He asserts that the heart’s movement is the fundamental reason for any movement occurring in the body, including the activities of the liver. Thomas emphatically states that “sic igitur et cum motus omnium aliorum membrorum causentur ex motu cordis,” meaning that all movements in the body parts are determined by the movements of the heart and that the heart’s movement is entirely natural.¹⁴

Rooted in his profound understanding of Aristotle’s philosophy, Thomas defines a “natural movement” in a substance as one determined solely by the inherent shape of that substance. In the Aristotelian worldview, the shape holds primacy over the substance, as it is through acquiring a specific shape that a substrate can actualize its potential, becoming “act” (ἐντελέχεια) in every sense.¹⁴ The human body’s shape, in this context, is synonymous with its soul. Therefore, the soul possesses a natural movement that animates every human being, instilling life and prompting action. However, to initiate this movement, there must be a starting point — the heart. Thomas declares, “dico autem motum naturalem animalis eum qui est cordis”, meaning “I affirm that the natural movement of an animal is that which belongs to the heart.”¹⁴

Thomas Aquinas proposes that the heart governs all body parts to the extent that if the heart ceases to beat, life itself comes to an end (“quo cessante, perit eorum vita” or “when stopping, their life ceases”). This assertion represents a significant stride toward cardiocentrism, particularly considering that the notion of something being the “causa sui moto” (the cause of its own movement) is typically reserved to define God.¹⁴ However, within the context of this argument, Thomas aims to illustrate that the “microcosm” of humans, who within their limited nature, participates in the divine nature that God has imprinted upon the “macrocosm” of the entire universe. The human being, according to Thomas, attains the status of the perfect animal because the reason for its own movement resides within itself — in the heart — thereby mirroring the entire universe.¹⁴

Thomas supports his argument through rigorous reasoning, and this perspective can find reinforcement in certain references from the Bible, emphasizing that the soul of man resides in the heart. For instance, the book of Proverbs emphasizes: “Keep your heart with all vigilance for from it flow the springs of life” (Proverbs, 4:23).¹⁴ The reflections of Thomas Aquinas on the intrinsic movement of the heart and cardiocentrism spread in European universities, influencing not only theology scholars but also challenging Galen theories, which were more aligned with Platonic than Aristotelian thought. Thomas’s vision also influenced those attending medical faculties, contributing to the decline of hepatocentrism in favor of cardiocentrism.

In reality, the decisive contribution to the affirmation of cardiocentrism came from physiologists in the Early Modern Age (1500–1800). This period coincided with the Lutheran Reformation and the Catholic Counter-Reformation, when religious beliefs seemed to influence the hepatocentric and cardiocentric positions of individual authors, respectively Catholics and Protestants. It is perhaps not a coincidence that the main work supporting this new theory, “Exercitatio Anatomica De Motus Cordis et Sanguinis in Animalibus” was written by an Anglican, ie, Protestant physician, William Harvey (1578–1657) in 1628.¹⁵,¹⁶,¹⁷ The English physician had the opportunity to study at the University of Padua, where he learned about the new Renaissance anatomical theories despite his non-Catholic faith. During the Catholic Counter-Reformation, following the papal bull “In Sacrosancta” of 1564, a profession of the Catholic faith was required for students at Italian universities. However, due to the open-minded statutes of the University of Padua, which required no confessional declaration from graduates, many Anglicans, Lutherans, and other Protestants studied there. The Venetian Senate, on which the University of Padua depended, established the possibility of conferring degrees by “Auctoritas Veneta” (Venetian authority), without the presence of the town Bishop, making the university open to non-Catholic students.¹⁸ Harvey’s Anglicanism, his self-definition as an Aristotelian, and his rejection of bodily passions, seen as the origin of sins, may have led him to study the centrality of the heart despite the sinful liver.

Among the opponents of hepatocentrism, we can mention other Protestant physicians. Miguel Serveto (c. 1509–1553), a Spanish theologian and physician, who was the first European to correctly describe the function of pulmonary circulation, as discussed in his work “Christianismi Restitutio” (1553). He participated in the Protestant Reformation, later rejected the Catholic Trinity doctrine, and fled to Calvinist Geneva, where he was denounced by John Calvin (1509–1564) himself and was burned at the stake for heresy.¹⁸ Similarly, the Danish physician Thomas Bartholin (1616–1680), a Lutheran, also made a significant contribution to cardiocentrism, providing the definitive description of the lymphatic system. Bartholin wrote a humorous epitaph against the liver, the sense of which was that this organ, “so long famous, by means of a usurped title, is now nothing more than a poor liver only reduced to making bile.”¹⁹ As we will see subsequently, Bartholin entered into the dispute regarding the location of the wound on the side of Christ, which is crucial for understanding the influence of hepatocentrism and cardiocentrism on Christian religion.²⁰

WOUNDS OF FAITH: FROM HEPATOCENTRISM TO CARDIOCENTRISM IN CATHOLIC MYSTICISM

The Church’s explicit intention to distance itself from hepatocentrism is evident in religious tradition, especially in the narrative of the wound to the side of Christ.²¹ The Gospels recount that Jesus Christ, while on the cross, was pierced in his side with a spear by a Roman soldier: “One of the soldiers pierced his side with a spear” (John 19:34). The precise location of this puncture is not explicitly defined. Given that the soldier’s action was aimed at confirming the actual death of Jesus, contemporary biblical scholars influenced by current medical understanding tend to lean toward the belief that the spear was directed at a vital organ, likely the heart. As mentioned earlier, during the Greco-Roman era, which coincided with the life and death of Christ, the liver was considered the preeminent vital organ and the seat of the soul. This concept persisted in medical thought until the Middle Ages, in part due to the systematization of medical ideas by Galen.

Notably, the earliest medieval depictions of the crucifixion scene positioned the side wound in the right lower part of Christ’s chest, specifically in an area associated with hepatic significance (Figure 2). In this context, Louis Charbonneau-Lassay (1871–1946), the renowned symbolist and authority on emblematic Christology, emphasized the “almost total rarity of direct representations of the divine Heart […] in the numerous images that the Middle Ages dedicated to the side wound of Christ.”²² It seems that medieval artists, influenced by the prevailing medical knowledge rooted in hepatocentrism, believed that the soldier intended to strike Jesus’s liver. Only from the second half of the 16th century did clear depictions of Christ’s bleeding heart begin to emerge. These representations often featured wounds on the right side of the heart, with some also including the depiction of a spear obliquely piercing the organ.

FIGURE 2.

Crucifixion scene. Reliquary of the tooth of Saint John; back part with Crucifixion in pointillé; first half of the ninth-century BCE in the Cathedral of Monza. A Roman soldier on the right is seen pointing upward with the tip of his spear that he has seemingly already thrust into the right side of Jesus’s chest, ostensibly to test whether he has died yet or not. Blood is seen spurting from the right side of the chest. Another soldier (named Stephaton or Steven) offers Jesus a sponge soaked in vinegar wine. Museum and Treasure of Cathedral of Monza/photo by Piero Pozzi.

These images probably tried to reconcile the representation made up to that time, of a wound in the lower part of the right side with what was the rising acceptance of cardiocentrism. To explain how the Roman soldier was able to strike the heart of Christ starting from the right side, several scholars of the Modern Age hypothesized that the blade of the spear had traveled a long oblique path, passing not only the liver but also the diaphragm, the pleura and the right lung.²² It is important to note that during this period, the cult of the Sacred Heart by Francis de Sales (1567–1622) and Margaret Mary Alacoque (1647–1690) began to spread in the Catholic world.²³

In the midst of this debate emerges the previously mentioned figure of the Danish physician Thomas Bartholin. In 1611, Caspar Bartholin (1585–1629), Thomas’s father, published in Wittenberg the initial version of his “Institutiones anatomicae”, an anatomy manual.²⁰ Many subsequent editions and translations of this text would ensue, establishing Bartholin’s treatise as a standard work in university education. Somewhat incidentally, Caspar Bartholin asserts in the chapter on the chest (cavitas thoracis) that within the thoracic cavity, there was evidently fluid—a mixture of blood and water.²⁴ According to Caspar Bartholin, when the soldier beneath the cross thrust the spear into the body of Christ, he must have struck this area.²⁴ This thesis faced challenges in the following years. Subsequently, in 1646, Thomas Bartholin decided to revisit and defend his father’s original arguments in a publication titled “De latere Christi aperto Dissertatio.”²⁵ Through the efforts of the Lutheran Thomas Bartholin, a conclusive medical and scientific demonstration was achieved, indicating that the wound on the side of Christ must have been inflicted at the level of the upper chest, within which a mixture of water and blood, described by Bartholin himself as “serum,” was found.²⁴ This aligns with the Gospel’s account that blood and water would flow from the wound, symbolizing the baptismal water and the wine transformed into blood in the Eucharistic ritual.

In the history of the Catholic Church, there are numerous examples of saints, who reported having received the “stigmata” on their bodies from God, ie, miraculous wounds that reproduced temporarily or permanently, completely or partially, the wounds caused on the body of Christ from the traumas suffered during his Passion.²⁶ While the sores at the level of the hands and feet are almost constant in their position in all the stigmatized saints, the same does not happen for “the plague of the rib.” In particular, Thomas of Celano (c.1190–1265) described the wounds of Francis of Assisi (1182–1226), the first stigmatized saint recognized by the Catholic Church, thus: “…his hands and feet appeared pierced in the middle by nails, whose heads were visible in the palms of the hands and on the back of the foot, while the tips protruded from the opposite side… Even the right side was pierced as if by a lance, with a large scar, and often bleeding, wetting that sacred blood with the habit and underpants.”²⁷,²⁸ The stigmata of the rib present in Francis of Assisi seems, therefore, to trace the Gospel story in a historical period, the thirteenth century, in which medieval medical doctrines were still linked to Galen’s hepatocentrism.²² Similarly, Ida of Louvain, a Cistercian nun of Roosendael Abbey in Flanders, died around 1300, was said to have a wide and oblong wound on her right side, through which air penetrated into the region of the liver.²⁶

It is curious, however, to note that the stigmatized saints belonging to the Modern Age, however, no longer seem to make any reference to the wound at the level of the right side but they mention a wound that is no longer external, but often located inside the heart. Scrolling down the list of the main stigmatized saints, Margaret Mary Alacoque, Catherine of Ricci (1522–1590), Charles of Sezze (1613–1670), Teresa of Ávila (1515–1582) and Veronica Giuliani (1660–1727), it transpires that all those who reported that they had sores in their hearts that caused them to experience acute pains in their chest. In the case of the last two saints mentioned, the tradition even demands that these lesions were also confirmed by autopsy carried out after their death.²⁶ Even more curious is the case of one of the last saints of whose stigmata the Catholic Church recognizes, namely Pio of Pietralcina (1887–1968). This Capuchin friar, who lived in Southern Italy in the last century, presented a stigmata at the level of the chest as well as the classic sores on his hands and feet. The friar’s personal physician, Giorgio Festa (1860–1940) described this wound in October 1919 as being: “in the anterior region of the left thorax, approximately two transverse fingers below the mammary papilla, presents a last and more interesting lesion, in the form of an inverted cross.” The stigma of the chest appears in the case of Pio of Pietralcina unusually on the left thorax, at the level of the heart, unlike how it was reported in the traditional medieval artistic representation.²⁶

CHRISTIAN MOVEMENTS, ALCOHOL, AND LIVER DISEASES BETWEEN INDUSTRIAL REVOLUTION AND ROMANTIC AGE

The intricate and complicated relationship between the liver and Christianity becomes even more evident when examining the stigmatization of liver diseases and hepatology between the 18th and 20th centuries. it is noteworthy that in the dictionary sense, stigmatize means “being regarded as worthy of disgrace”, an intriguing derivation from Latin and Greek terms meaning a “tattoo” or a mark made by a pointed instrument. In the 17–19th centuries, figures such as Giovanni Battista Morgagni (1682–1771), followed by Matthew Baillie (1761–1823) and René Théophile Hyacinthe Laennec (1781–1826), succeeded in revealing that numerous liver diseases find their roots in alcohol consumption²⁹,³⁰ Already in his renowned treatise “De sedibus et causis morborum per anatomen indagatis” (1761), Morgagni, the esteemed father of modern pathological anatomy, published a compelling example in the 38th letter of the third book of his masterpiece.³⁰,³¹ The case featured an alcohol-associated Venetian nobleman who succumbed to advanced decompensated chronic liver disease, later diagnosed postmortem as cirrhosis. Matthew Baillie contributed significantly to the field by publishing “The morbid anatomy of some of the most important parts of the human body” (1793). Within this work, he observed, “one of the most common diseases of the liver, and perhaps the most common […] is the formation of tubercles in its substance.”³² Baillie highlighted his observation that this disease was more prevalent in individuals of middle or advanced age, with a higher occurrence in men than women, attributing it to the more common habit of drinking in one sex.³²

As lifespans expanded and the relative cost of alcohol diminished during the Industrial Revolution, the connections between alcohol consumption, jaundice, and a “scirrhous liver” became increasingly apparent. Thanks to the contributions of Laennec, who coined the term cirrhosis,³³,³⁴ the awareness that liver diseases were correlated with alcohol emerged during the same period as the rise of Christian movements condemning alcohol and advocating for abstinence. Benjamin Rush (1746–1813), a distinguished US physician, patriot and signer of the US Declaration of Independence (after whom the Rush University Medical Center in Chicago was named), was notably considered as one of the father of Christian universalism, as he played a pivotal role in this movement by vehemently condemning “ardent spirits” and championing abstinence. This marked the inception of the temperance movement, gaining traction through influential figures such as the Presbyterian minister Lyman Beecher (1775–1863), and many others. Simultaneously, religious communities grappled with the moral implications of alcohol use. The Methodists initially targeting distilled alcohol but eventually embraced total abstinence. Figures like Thomas Bramwell Welch (1825–1903), a British-American Methodist minister and dentist, catalyzed a shift away from alcohol in religious rituals, symbolizing broader societal changes. However, the impact of the temperance movement varied among Christian denominations, with Catholicism maintaining a stance of moderation while American Protestantism espoused more pronounced legislative and social effects.

The same years witnessed the emergence of moral judgments, ostracizing individuals with liver disorders as morally compromised and undeserving of compassion. This societal bias not only hindered medical understanding but also limited the progress of hepatology compared to other medical disciplines, such as the study of cardiovascular and respiratory diseases. A notable reference to this societal perspective can be found in operas of the 19th century. Romantic Italian operas express the atmosphere and popular beliefs of the 19th century. These plays can give us precious information about the medical knowledge of the period,³⁵,³⁶,³⁷ because they were not only popular shows, but the audience was composed mainly by upper class and more educated people. For this reason, these plays could be considered as a bridge between the popular and intellectual worlds. While respiratory diseases related to tuberculosis portrayed in certain characters as heroic, in operas like “La Traviata” (1853) by Giuseppe Verdi (1813–1901) and “La Bohème” (1896) by Giacomo Puccini (1858–1924),³⁷ liver diseases received little consideration. In “L’elisir d’amore” (1832), a melodramma giocoso by Gaetano Donizetti (1797–1848), Dulcamara mentions that “E fino il mal di fegato. Che in moda diventò”—meaning that “liver trouble has become trendy”—underlining the increased prevalence of liver diseases at the beginning of the 19th century, likely associated with alcohol. Nevertheless, these words remain the sole reference to these diseases in operas of the Romantic period.

INNOVATIVE FRONTIERS IN HEPATOLOGY: CHRISTIAN RESPONSES TO THE ADVANCEMENTS IN LIVER TRANSPLANT SURGERY

The 20th century was marked by significant advances in liver transplantation research. As early as the 1930s, the first experiments in renal transplantation were conducted. The inaugural human renal allograft was transplanted in 1933 by Yuriy Voronoy (1895–1961) in Ukraine. By the 1950s, kidney transplantation had become a well-established surgical procedure, sparking increased interest in transplanting other solid organs.³⁸ Thomas Starzl (1926–2017) made the pioneering attempt at the first liver transplant at the University of Colorado in 1963, although it was initially unsuccessful. The first “long-term” survival was achieved in 1967, thanks to advances in transplant immunology and the introduction of immunosuppressant agents, particularly cyclosporine, in the 1970s.³⁸

With the remarkable progress in transplant surgery, various religions found themselves compelled to take a stance.³⁹ The Christian perspective on organ donation diverges from that of Judaism, primarily due to differing views on the sanctity of the human body. While Judaism regards the human body as inherently sacred, Christianity does not hold this view.³⁹ Consequently, Christian doctrine is more amenable to endorsing organ donation for transplantation purposes.⁴⁰ In a landmark development in 1990, the Roman Catholic and Protestant churches issued a joint declaration affirming organ donation as an expression of Christian love. Notably, both major Christian denominations acknowledge brain death as the decisive criterion for determining death.

Christian theologians frequently reference 3 texts in connection with organ donation, emphasizing the compassionate and altruistic nature of this act. Pope John Paul II (1920–2005), in a special message to the Society for Organ Sharing on June 20, 1991,⁴¹ eloquently conveyed the sentiments: “With a drop of blood, you can save a life; with the donation of a kidney, you can bring hope and health back to life; donate a cornea and turn permanent darkness to light, and God will light your way; donate a heart, and your heart will continue to beat in one who still awaits death; donate a lung, and you will breathe in peace and comfort.” Interestingly, the Pope did not mention the liver in his message. Perhaps this omission reflects a persisting aspect of Catholic moralism? Additionally, Pope Benedict XVI (1927–2022) was a strong advocate for organ donation and he himself previously held an organ donor card. It was notable that after his election as Pope, he had to renounce the donation of his own organs because tradition dictated that Pope’s physical remains should be preserved intact after death.

Christianity draws from biblical passages, such as Matthew 10:8, emphasizing the principles of healing the sick, cleansing the lepers, raising the dead, and casting out devils as acts of freely giving and receiving. Another pivotal biblical reference is John 15:13, highlighting the profound sacrifice of laying down one’s life for friends.⁴² The Russian Orthodox Church adopts a favorable stance toward postmortem organ donation, emphasizing the faith in the bodily resurrection of the dead based on Divine Revelation. While the church expresses reverence for the body in Christian burial, it acknowledges that posthumous organ and tissue donation can manifest love beyond death. Importantly, such donation is not considered a duty, and the voluntary consent of the donor during their lifetime is deemed ethically acceptable. In cases where the potential donor’s wishes are unknown, efforts should be made to ascertain it from relatives.⁴² The Greek Orthodox religion underscores the importance of treating the human body with respect based on 3 fundamental doctrines: the belief that Man was created by God, faith in the resurrection of Jesus, and the expectation that, in the end of days, the dead will be raised to life. Both the Greek Catholic and Protestant churches assert that individuals cannot be compelled to decide to donate an organ. Furthermore, they emphasize the separation of religion and medicine, precluding the church from expressing an official position on the issue of organ donation.⁴⁰

An exception to these positions is that of the Jehovah’s Witnesses. The Jehovah’s Witness religion, a Christian movement founded in the United States in the 1870s, boasts 6 million members worldwide. Members of this faith hold strong beliefs based on passages from the Bible interpreted as prohibiting the “consumption” of blood. These beliefs prevent them from accepting transfusion of whole blood or its primary components, considering removed blood as “unclean” and advocating for its disposal. Procedures involving the removal and storage of their own blood are often unacceptable, even blood retrieved during the transplant operation itself. Given the considerable risk of life-threatening perioperative bleeding in liver transplant procedures and the refusal of blood transfusion on religious grounds by Jehovah’s Witnesses, this scenario presents a significant clinical challenge, accompanied by ethical and legal concerns when this procedure is indicated.⁴³ Nonetheless, there is a growing literature of successful transplantation in Jehovah’s Witnesses from centers dedicated to this formidable undertaking.⁴³,⁴⁴

CONCLUSIONS

The exploration of the relationship between Christian culture and hepatic physiology reveals a complex interplay of cultural beliefs, moral values, and scientific advances throughout history. The journey presented here progresses from classical antiquity, when the liver was deemed the center of life and emotions, to the medieval transition where the church shifted focus from the liver to the heart, and into modern times where medicine and theology grapple in the realm of liver transplantation. The liver, symbolizing life, sin, and even sacrifice, has traversed centuries of cultural and scientific evolution. While our understanding of hepatic physiology and pathophysiology has exponentially grown, the symbolism associated with the liver continues to resonate across epochs, providing a unique perspective on the intersection of body, spirit, and society. This nexus of science and spirituality poses stimulating questions about the nature of human existence and how culture and religion shape our perception of vital organs and life itself.

The classical era, rooted in the philosophical teachings of Galen, witnessed the liver’s ascent to prominence as the origin of blood and consequently of life itself. Galen theory, with its separation of the heart and liver, drew analogies between the vital and natural spirits, reflecting prevailing beliefs on the interconnectedness of physiology and psychology. The Greek etymology of the word “liver,” linked to “ignis” (fire) and “hedoné” (pleasure), underscored its dual association with life and the vast spectrum of human emotions. This belief persisted through Greco-Roman philosophy, where the pursuit of virtue and health became intertwined, as exemplified by the Roman poet Juvenal’s famous first-century CE sentence: “Orandum est ut sit mens sana in corpore sano,” which means “You should pray for a healthy, mind in a healthy body.” He was, of course, preempted half a millennium earlier by Plato’s correlation between a healthy body and a virtuous soul. However, with the advent of Christianity, a cultural shift occurred in the perception of hepatic centrality. The Church, grappling with the influx of barbaric influences, promoted asceticism, based on associating excessive eating and drinking with sin. The liver’s role transitioned from being the seat of life to a potential source of moral transgressions. Figures like Marcus Aurelius and Seneca highlighted the impact of hepatic diseases on human behavior, aligning excesses of bile with impaired decision-making. The patron saint Brice of Tours became a symbol of redemption for those suffering from hepatic diseases, reinforcing the notion of an impaired liver as a manifestation of sin.

The Middle Ages further solidified the connection between the liver and morality. Monastic orders advocated abstinence from meat and sexual indulgence, attributing gout and other ailments to excessive consumption of animal proteins. Augustine of Hippo’s dialogs emphasized the liver’s role in assessing health, with impulsive behaviors linked to sin. Theological considerations prompted a symbolic shift in the church’s narrative, with the heart supplanting the liver as the central organ of human life. Theologian Thomas Aquinas argued for cardiocentrism, asserting the heart’s intrinsic role in initiating life’s movements.

The Renaissance and subsequent periods witnessed an evolution in societal perspectives towards liver diseases. The burgeoning temperance movement in the 18th and 19th centuries, led by figures like Benjamin Rush, stigmatized individuals with liver disorders as morally compromised. Operas of the Romantic period reflected contemporary beliefs, portraying respiratory diseases heroically while neglecting liver ailments. Meanwhile, medical pioneers like Morgagni and Laennec laid the foundation for understanding liver diseases’ connection to alcohol consumption.

The 20th century marked unprecedented advances in liver transplant surgery. Theologians and religious leaders grappled with the ethical implications of organ donation, culminating in a joint declaration by the Roman Catholic and Protestant churches affirming its compatibility with Christian love. The Russian Orthodox Church embraced postmortem organ donation, viewing it as an expression of love beyond death. The Greek Orthodox religion emphasized the importance of treating the human body with respect, acknowledging the separation of religion and medicine. However, the Jehovah’s Witnesses presented a unique challenge in liver transplant procedures due to their prohibition of blood transfusion.

In essence, the journey through the cultural and scientific evolution of the liver in Christian thought unveils a rich tapestry of symbolism, morality, and medical progress. The liver, once revered as the source of life, became entangled with notions of sin and morality, only to witness a transformative shift in the modern era with advances in transplantation.

SERIES EDITOR’S POSTSCRIPT

I have long respected, enjoyed and been illuminated by the numerous writings of Professor Michele Riva and his colleagues from Milan and collaborators elsewhere, on the history, linguistics, and sociology of medicine and anatomy in Antiquity and the Middle Ages, and in particular about the liver and its diseases. It was this experience that prompted me to invite him to write this essay on The Liver in Christianity. And how fortunate we are that he responded to my entreaty and took time from his busy activities to furnish the essay, which we have just read, so ably assisted by his co-authors, esteemed Professor Pietro Invernizzi—Director of the Division of Gastroenterology and Center for Autoimmune Liver Diseases and European Reference Network on Hepatological Diseases (ERN RARE-LIVER) of Fondazione IRCCS San Gerardo dei Tintori, and Dean of the Medical School of the University of Milano-Bicocca—and by Chiara Valnegri, who graduated with a Bachelor degree in Philosophy in Milan and is now a medical student at the same medical school in Milan. It must be obvious from the quality, style, and breadth of the current contribution and his other publications that Professor Riva’s background is impeccably suited for this task. I should add that the quality of the prose was equally impeccable and gave the Series Editor no need for adjustments.

Professor Riva, a Milanese, is an associate professor of History of Medicine at his university and also director of the Division of Occupational Health of Fondazione IRCCS San Gerardo dei Tintori in Monza. In addition to specialization in Occupational Medicine, he completed a PhD in Medical Humanities at the University of Insubria (Varese). Where he conducted research in the fields of history of epidemiology, history of neuropsychiatry and paleodemography and paleoepidemiology. During 2009–2015, he was Chair of the International Commission on Occupational Health (ICOH) Scientific Committee on History of Prevention of Occupational and Environmental Diseases. Currently, the is the Italian National ICOH Secretary. Space does not permit description of projects, for which he is the leader, his other awards and activities concerning health and safety at work, medical history, and editorial board membership of international journals.

The current essay clearly demonstrates the degree to which medicine, anatomy, and the role of the liver in human life and theology were topics for animated debate in Christianity throughout the ages. While there was also debate on similar topics in Hinduism, Judaism (both topics for future essays in this series), and Islam, as reported in his essay in this series,⁴⁵ by Professor Safadi (Director of The Liver Institute. Hadassah Hebrew University Medical Center, Jerusalem, Israel), it does not appear as if the intensity shown by Christian theologians was attained elsewhere. Conceivably, that difference in controversy may relate to the concept of deity in the different religions. When it comes to modern medicine and particularly hepatology, in which transplantation poses special ethical and religious challenges, it seems that the churches have come together better than most, in not only approving liver transplantation but advocating it. Of course, liver transplantation is practiced by adherents of other religions, but the question has been very effectively addressed in the church and in Hinduism, perhaps more so than elsewhere.

By and large, it appears that the Hindu attitude towards organ donation and transplantation is a very positive one, there seemingly being no religious law that prohibits it. In fact, in Hinduism, organ donation is considered to be selfless giving or doan, which is a virtuous act. This view of organ donation as a means of helping others, coupled with the belief in karma — the performance of an individual’s duty or dharma — suggests that acts of kindness and charity can contribute positively to one’s karmic balance, which influences one’s fate in future lives or in the afterlife. Thus, many Hindus see organ donation as an opportunity to perform a life-saving act that has spiritual merit. The situation in Islam is more complicated, as carefully reasoned in Professor Safadi’s essay entitled “The liver in Greco-Arabic and Islamic medicine,” in the current Clinical Liver Disease series. In Judaism, the question concerning organ removal after death is fraught with ethical and orthodox religious sensitivities. But one of the highest ethical obligations in Judaism, known as pikuach nefesh פיקןח נפש the saving of a life, takes precedent. And thus, organ transplant programs are established in Israel, in Muslim countries, and among various orthodox Muslim and Jewish communities, elsewhere.