The liver in Judaism

BACKGROUND

Given the title of this essay, any informed reader in the United States or the United Kingdom, or from a Jewish community in Israel or elsewhere, might be forgiven for thinking that this is a frivolous piece penned by a humorous Jewish writer, such as Mel Brooks, Woody Allen, or David Baddiel, or a witty author like Howard Jacobson, or even renowned chefs such as Israeli-born English culinary star Yotam Ottolenghi and Buenavista Miami-based Michelin-hopeful Chef Olivia Ostrow. Perhaps it came from the pen of the late Chef Rabbi, Gil Marks, who published a comprehensive “Encyclopedia of Jewish Food.”¹ (Incidentally, a Rabbi is the name given to a religious teacher and spiritual leader in Judaism.)

And why might the earlier impression of such authorship be plausible? The explanation is simple since these writers are familiar with the quintessential Ashkenazi (for definition, see later) Jewish liver paté-like side dish ”chopped liver” that is often the butt of irony and good-natured ridicule² and which, like Marmite^TM, is craved by some and reviled by others. But read on.

The author of the current essay, which is the final contribution to the current series History of Hepatology, is none other than the Series Editor himself, who brings to the writing his combined enjoyment of ethnic gustatory (over)indulgence and a penchant for all things hepatological—ie, clinical liver disease practice, basic and clinical hepatology research and, naturally, hepatology history. Whereas this essay may have some light-hearted moments, its focus is an attempt at a serious review of the subject. Incidentally, my ethnic cuisine indulgence extends to the Indian subcontinent, the Far East, the Americas, and even Europe, and so does my interest in hepatology history, which attests to the extensive spectrum of topics and the varied countries of the authors in this series.

SOME TERMINOLOGY

And this brings us to a convenient hiatus in which to explain some terminology and ancient events (with proposed and perhaps arguable approximate dates) in the next few paragraphs, with the purpose of enhancing comprehension. Adherents of the faith known as Judaism, be they fervent orthodox believers, dissenters, agnostics, or atheists, are nowadays known as “Jews,” whether they rejoice in the appellation or not. Indeed, it has been quipped that when two such co-religionists are together, there are likely to be three opinions. This accurate observation establishes the principle that argument (or let’s call it debate) is a fundamental characteristic of Judaism and by extension, of being Jewish. But, make no mistake, it should not be thought that there were no arguments in Christian or Hindu theology because obviously there were, as close inspection of the essays on these topics³,⁴ will show. As for the existence of a Jewish Nation or People, there is no generally accepted definition. Perhaps it’s akin to Supreme Court Justice Potter Stewart’s reply in 1964, when he was asked for a test of obscenity, and famously answered: “I know it when I see it.” Not that this implies any parallels—Heaven forbid.

WHERE DID JUDAISM AND JEWS COME FROM?

At any rate, Jews trace their pedigree back to the biblical Patriarch Abraham, who incidentally is also the Patriarch of Christianity and Islam. All three Abrahamic monotheistic religions are anchored in that contentious land that lies between the Mediterranean Sea to the West and the Jordan River to the East. The most recognized ancient city of the region was aptly dubbed “A Golden Basin Full of Scorpons.” The latter title was given to a recent analytical book that explores the troubled Middle East, by the British journalist and author Con Coughlin,⁵ who wrote it. The scorpion allusion was not Coughlin’s but was coined for Jerusalem by the tenth century CE Arab traveler, geographer, chronicler, and Jerusalemite, Shams al-Din Abu ‘Abd Allah Muhammad al-Muqaddasi (or al-Muqaddasi, for short), in his monumental contemporary description of all the lands of Islam, “Ahsan al-Taqasim fi Ma’rifat al-Aqalim,” which translates as “The Best Divisions for Knowledge of the Provinces.”⁶ Al-Muqaddasi’s geography included a wealth of lore about individual cities and regions, climate, products, resources, sacred sites, customs, political and religious factions, and trade routes and is considered the finest achievement in the field of medieval Islamic literature.

But I digress.

Abraham and his immediate descendants were known as Hebrews, from the Hebrew word Ivri’im עבר׳ם, which is often (mis)translated as “wanderers.” “Crossers over” would be a more accurate rendition for the foreign origin of the Israelites (as they were later identified). Abraham, after leaving his father’s home in Ur of the Chaldeans (Ur Kasdim) in ~1900 BCE was the first to cross over the River Euphrates and make his home in the Land of Canaan. It is generally agreed that Ur was the Sumerian city Ur—today, the site of Tall al-Muqayyar, some two hundred miles southeast of Baghdad. Judaism is a monotheistic religion that was developed among the ancient Hebrews and is characterized by belief in one transcendent God who revealed himself to Abraham (and later to Moses and the Hebrew prophets), and adhering to a religious life in accordance with the Jewish Scriptures and rabbinic traditions.

In their early history, the Israelites were simply members of the twelve tribes of Israel, the name given by God to Abraham’s grandson Jacob (Genesis 32:28) after he prevailed in an all-night struggle with an alleged angel near the stream of Jabbok. Because of famine in Canaan in ~1600 BCE, Jacob led his family down to Egypt, where they were welcomed by the ruling Hyskos. The Israelites were said to have settled in Goshen (Genesis 45:10)—maybe the site of modern-day El Faiyum near Cairo—which gave its name to Goshen in New York state and from there to Goshen in northern Indiana. After the Hyskos were overthrown, the Israelites were enslaved (probably by Ramses II) until, after a stay of some 430 years, they were liberated (actually expelled) in the Exodus (Exodus 12:40)—a happening much challenged by modern archeologists but celebrated annually in the Spring by Jews worldwide.

After King Solomon’s kingdom was divided because his successor son Rehoboam (972–914 BCE) harshly antagonized the people in a dispute (vis: an argument) over taxes, two independent Hebrew kingdoms were established in ~930 BCE. The ten northern tribes constituted the Kingdom of Israel and continued to be known as Israelites to distinguish them from citizens of the southern Kingdom of Judah יהודה, which enclave gave rise to the name Judean, Jew or Jewish, from Yehudi יהודי (ie, of Judah), which morphed in Greek to Ioudaios Ἰουδαῖος and was Latinized to Iudeus and eventually developed into the English word Jew. The Israelites became known as Jews after their return from Babylonian exile in 538 BCE, courtesy of Cyrus the Great, the Persian conqueror of Babylonia.

ASHKENAZI, SEPHARDI, YIDDISH, AND LADINO: THE TOWER OF BABEL STILL STANDS

The adjective Ashkenazi distinguishes one of the two major ancestral groups of Jews in the Diaspora (ie, dispersion) whose ancestors, after expulsion by Rome in 70 CE, migrated and lived in France, Central, and Eastern Europe, including Germany, Poland, and Russia. The location of “Ashkenaz” quoted in the Hebrew Bible is disputed and may even relate somehow to Iran.

Most Jews in the United States and the United Kingdom are Asheknazi. Yiddish, a Judeo-German language that developed from Middle High German, with influences from Hebrew, Aramaic, and Slavic languages, was spoken widely by Ashkenazi Jews in Europe before the Holocaust and still has many ubiquitous speakers. The other ancestral group is composed of Sephardis (from the Hebrew word for Spain, Sépharad ְסָפַרד), whose ancestors also were dispersed, ie, migrated and lived in Spain and Portugal before their expulsion from Spain in 1492 — by the newly triumphant and united Catholics (The Reconquista) — and later from the entire Iberian peninsula; they also went to North Africa and the Middle East. Nowadays, ~80%–90% of world Sephardic Jews live in Israel (where they comprise 55% of the population), and the rest are in North Africa, various parts of the Mediterranean littoral and western Asia. Ladino, a very archaic form of Castilian Spanish mixed somewhat with Hebrew and many other linguistic elements, was the corresponding language for Sephardis, but it was never as popular as Yiddish and is even less so today.

One concept worth airing at this juncture concerns the ethnic and demographic implications of Judaism. In contrast to the other major religions in the world, Judaism is barely noticeable numerically, representing only 15.7 million individuals or 0.2% of the world’s population, compared to very approximately 2.24 billion Christians (31%), 1.9 billion Muslims (24.9%), 1.2 billion nonreligious souls (15.6%), 1.2 billion Hindus (15.2%), and more than 520 million Buddhists (6.6%).⁷ While there are several countries in which one religion or another predominates/dominates, a person’s religion nowadays does not usually define his/her nationality, even though some societies and some communities or populations do prefer one religion over another, which certainly has been and continues to be a cause of strife, and often, most regrettably, bloodshed and deaths. Of course, the August 1947 partition of the Indian subcontinent into India and West and East Pakistan (which later became Bangladesh), along religious lines, was tragically bloody. Yet, being a Hindu, Muslim, Christian, Buddhist, Bahai, Zoroastrian, or nonbeliever nowadays does not in itself define a person’s nationality. And yet those who are associated (self- or otherwise) in some way with Judaism are somehow (self- or otherwise) identified as members of the Jewish Nation or People, whatever that is. On the face of it, this has little to do with the liver, but actually, the liver has played a role in both the very specific religious and dietary practices of Judaism and in its history and language—in some cases to a surprising extent. It is tantalizing to reflect on how differently the liver is considered in the four religions in this small subdivision of the History of Hepatology series. Readers are encouraged to access the respective essays by Dr. Riva et al³ (Christianity) Drs. Arora and Kumar (Hinduism),⁴ and Dr. Safadi (Islam).⁸ If only there was time to explore other religions in the same way.

When it comes to the current and incidentally valedictory essay of the series, it obviously all started with the Bible, the Hebrew Bible, that is, as expected. The earliest mentions of the liver in Judaism were in the second and third books of the Torah Tōrā תּוֹרָה ‎ (the five books of Moses or Pentateuch), specifically Exodus (29: 13 and 22); and Leviticus (3:4,10, and 15). According to orthodox tradition, God dictated the whole Torah to Moses during the latter’s first (40-day) sojourn on the peak of Mt. Sinai. True to form, the legendary principle of argument was active with a vengeance in the United Kingdom in the mid-1960s when an unfortunate episode, named the “Jacobs Affair,” divided the community along the lines of belief, thus far seemingly irreparably. One of the leading rabbinic theologians of the age had suggested that Moses actually wrote his Books himself of his own volution (albeit inspired by the Almighty); this opinion did not sit well with the devout traditionalists.⁹

THE LIVER AT LAST, NEARLY

The word for liver in Hebrew, Kaved כבד, is descriptively and perceptively the same as the Hebrew adjective heavy, in keeping the observation that the liver is the largest and heaviest organ in the abdomen. Kaved is from the same three-letter root (Hebrew K-B-D, ד-ב-כ, East Semitic K-B-T, Arabic: ك-ب-د) that is the source for the Hebrew words for important, honor, majesty, and glory. In most Semitic languages, the basic noun formed from the root means “liver,” “interior,” and “soul.” In Middle Eastern cultures, the liver also signifies courage, endurance, perseverance, and desire. There is a saying, “You are my liver,” which is interpreted as “You are my dearest friend or life blood.” In the ancient world, the liver was the repository of life and emotion. The prophet Mohammed used the term “Moist Liver” to refer to the Soul,¹⁰ and the book of Psalms compared death to “Laying one’s liver in the dust.”¹¹ In Guedra, the ritual betrothal dance of selected Berber nations of North Africa, the true depth of affection or emotion is expressed by saying, “You are my liver,” much as in the West one would say “You are my (sweet)heart.” Even in modern North Africa, a popular Arabic expression is Istahisht kibdati. اكتب “اصطهشت كبدات “I miss my liver,” meaning “I miss my child.” The liver was seen as the seat of life as well, evidenced in another passage in the Bible describing the metaphorical fate of one lured by a harlot, “Till an arrow struck his liver” (Proverbs 7:23). It was also the seat of all the emotions, as clearly expressed, as follows: “Mine eyes do fail with tears, my bowels are troubled, my liver is poured upon the earth, for the destruction of the daughter of my people” (Lamentations 2:11, in the Ketuvim, see below). All told it appears that the word liver is mentioned at least fourteen times in the Tanach, ie, the Old Testament. But wait for more of this biblical linguistics, etymology, and concordance later.

In Judaism. other key scriptures include (1) the writings of the Prophets Nevīʾīm נביאים, comprising the Former Prophets (Joshua, Judges, Samuel, and Kings) and the Latter Prophets (Isaiah, Jeremiah, and Ezekiel, with their twelve minor clones) and (2) eleven books of holy writings (the Ketuvim כתובים), which include the Psalms Tehillim תהילים attributed to King David. Together these three collections comprise the Tanach תָּנָ״ךְ (an acronym for Torah, Nevi’im and Ketuvim), the canonical collection of scriptures of the Hebrew Bible that Christianity calls the Old Testament (to distinguish it from the New Testament). It must be recalled, however, that the detailed laws governing all aspects of life were not included explicitly in the Torah, but were said to have been given orally by God to Moses, and in turn by Moses to his successor Joshua, and then this Oral Law was handed down by word of mouth successively through the generations eventually to be compiled and written down as the Mishnah (ie, study by repetition), in c200 CE by Judah HaNasi. The Mishnah was the foremost major work of rabbinic literature, comprising the legal statements of the rabbis and other sages whom they considered to be their forebears, from Hellenistic times to the early third century CE.

Not yet satisfied and altogether not surprising (according to the argument principle described above) the rabbis debated the Mishnah, sentence by sentence, word by word, with each other—not in real time, of course—through the ether of the early centuries of the first millennium, often separated by hundreds of years and great distances. The followers and disciples of those revered sages, independently in Jerusalem (more accurately, in the Land of Israel) and Babylon, respectively, around 400 and 500 CE, collected and redacted the debates that were eventually compiled, together with the respective segments of Mishnah that they debated, as the Jerusalem (lesser) and Babylonian (greater) Talmud (literally: Study, Teaching, or Learning), respectively. From the start, the Talmud—the body of civil and ceremonial laws and legends that religiously define Judaism—was an object of political controversy within the community and much opposition and violent derision by the outside world; later, it was banned, censored, and burned for criticisms contained therein that were unpalatable to gentiles.¹²

Another composition, confusingly called the Mishnah Torah, was simply a reiteration of the laws in the Torah and their underlying philosophy, authored at the end of the 12th-century CE, by the legendary rabbi, philosopher, and physician Moshe ben Maimon (or Maimonides, in Greek), who is best known familiarly by the epithet Rambam רמב״ם,—yet another acronym, which seems to be a much-favored shorthand way of abbreviating long names. For quite a while, Maimonides was the personal physician in Cairo to Salah al-Din Yusuf ibn Ayyub, commonly known as Saladin, the Muslim Sultan of Egypt and Syria who famously defeated a massive army of Crusaders at the Battle of Hattin and captured the city of Jerusalem in 1187 CE.

The liver was mentioned in the Hebrew Bible in three contexts: (1) the laws relating to animal sacrifice that was practiced in the Temple in Jerusalem in biblical times, (2) dietary laws that emerged as the rules of Kashrut כשרות, dealing with the foods that observant Jewish people are permitted to eat, how those foods must be prepared according to Jewish law, including how animals are slaughtered for consumption, and (3) liver anatomy, in relation to sacrifice and animal consumption. Food that may be consumed is deemed Kosher כשר according to the Ashkenazi pronunciation and pronounced kashér in Sephardic or Modern Hebrew, meaning ”Fit for consumption.” Space does not permit an exposition of Kashrut כשרות, the Jewish Dietary Laws (which are easily discovered by searching the Internet), except to mention a couple of key facts germane to the current essay, namely the consumption of liver and prohibition of eating blood, or of milk products with meat, be it fowl or beast, etc. Perhaps it is a surprise that eating offal, sometimes referred to as organ meats (ie, liver, heart, lungs, tongue, brain, spleen, intestines, pancreas etc.), which for some people is awful, are permitted foods as long as they come from permitted animals and are prepared according to the rules of Kashrut. In fact, such delicacies were once among the staples of the thrifty Eastern European Jewish diet.

Human Anatomy is not discussed explicitly in the Hebrew Bible, which, nonetheless, uses many anatomical facts, metaphors, and expressions. Talmudic anatomy is richer than biblical descriptions but often plagued by fanciful distortion. Talmudic anatomical observation can be surprisingly accurate on some occasions and woefully deficient on others because the study of anatomy was not systematic but only undertaken to solve religious questions.¹³ Notwithstanding, in it one can discern the hints of future scientific methods, such as autopsy and animal dissection. Descriptions of anatomical findings were often imprecise, and graphic illustration awaited the Renaissance. Great store was invested in the appearance of internal organs since imperfections could preclude animal sacrifice and consumption for food, in much the same way that physical disfigurement disqualified a man for the priesthood.

With respect to eating the meat of sacrifices, all accessible blood was first drained completely (a harbinger of the Kashrut laws) by the priest who killed the animal. Certain parts, like the fat around the internal organs and the offal (including the liver), were burned up completely and not used as sacrificial food, and so were a few sacrifices that were mandated to be entirely consumed by the fire. Certain cuts were reserved for the Priests and Levites for their own consumption, and the rest of the meat was returned to whoever had brought the sacrifice, for their own consumption.

The biblical descriptions of liver structure were not made to satisfy academic anatomical curiosity but only demands of religious law and ritual, but they were nonetheless often fairly accurate. In the case of the liver, mention is made of a fatty piece that had to be burnt on the sacrificial altar (Exodus 31: 13 and 22),¹⁴ but in all likelihood, it was a part of the liver itself. The convex superior surface was thought by Maimonides to be covered by the diaphragm, while what was termed the “courtyard of the liver” has been identified as the caudate lobe. A part described as the “finger of the liver” has been postulated now to have been the pancreas — an organ that had not yet been recognized. Various parts of the spleen were described, such as the convex surface that was termed the “nipple of the spleen” and the blood vessels in the hilum. Surprisingly, even the removal of the spleen surgically was referred to in the Talmud.¹³

It should be noted that the ancient Hebrews were aware of the practice in Mesopotamia of divining the intentions of the gods to predict the future, as described explicitly by the major Latter Prophet Ezekiel (c623–c571 BCE), namely haruspicy, ie, inspection by a Haruspex (pagan priest) of the entrails of a freshly slaughtered animal (usually a sheep), more specifically named hepatomancy/hepatoscopy ie, inspecting the sheep’s liver, as has been discussed in detail in several essays in this series.¹⁵,¹⁶,¹⁷ Ezekiel says of Nebuchadnezzar, “For the King of Babylon stands at the fork in the road, at the beginning of the two roads, to perform a divination: shaking arrows, enquiring of household gods, scrutinising the liver.” (Ezekiel 21:26). In this episode, shaking arrows was a mode of divination used in Babylonia, and as mentioned by Homer was also practised among the ancient Greeks. It continued to be used among the Arabs until the time of Muhammad, who strictly forbade it in the Koran. The protocol was to shake together several arrows, each properly marked, in a quiver or other vessel, and then to draw one out. The mark on the arrow drawn was supposed to indicate the will of the gods. It was simply one form of casting lots. The Hebrew word used here for household gods is teraphim, which were the household gods or images that Rachel (Jacob’s fiancée) stole from her father Laban (Genesis 31:19), but it is not known how these were consulted. Scrutinizing the liver refers to hepatoscopy. However, what is of lasting importance is that the result of the divination was interpreted for Nebuchadnezzar to march on Jerusalem and not Rabbath (in Ammonite territory, where the modern capital city of Amman in Jordan is situated).

How different would Jewish history have been if the king of Babylon had marched on Rabbath and not Jerusalem, and how different would the Middle East look today?

In the Middle Ages, the appreciation of anatomy by Jewish physicians mirrored views that were prevalent among contemporary anatomists. It has even been recorded that Andreas Vesalius (Andries van Wesel, 1514–1584), the Flemish founder of modern anatomy, was assisted by his “Jewish friend,” the physician Lazarus de Frigeis, who allegedly is the figure wearing characteristic Jewish garb to the left of the skeleton in the frontispiece of Vesalius’s monumental De Humani Corporis Fabric.¹³,¹⁸ Lazarus furnished the Hebrew names for some of the anatomical structures in Vesalius’s epoch-making work from his Hebrew translation of Avicenna’s “The Canon of Medicine” (Al-Qanun fi-l-tibb, القانون في الطب), and in some cases directly from the Talmud. However, the convivial relationship between the Jewish physicians and their non-Jewish contemporaries did not last because of disagreements about submitting corpses for dissection.

Given the space allotted to liver anatomy in the Judaic scriptures and the great commitment of Jews to Medicine, it is disappointing to report that there seems to have been then little interest in the functions of the liver and their derangements, in other words, hepatic physiology, and pathophysiology. And yet, a quarter of Nobel laureates in Medicine or Physiology are deemed to be Jewish, although their true affiliations to Judaism are not explored. In one analysis devoted to the liver,¹⁴ the authors found that there were only two relevant sentences, one of which we have already discussed above in a different context (Lamentations 2:11), but which does not immediately appear to be physiological. The second quotation from the Talmud seems relevant “The liver causes anger: the gall throws a drop into it, and quiets it.” Even in the book by Fred Rosner,¹⁹ the legendary prolific expert in Biblical and Talmudic Medicine, the section headed “Liver” barely claims a column and a half, and the brief chapter headed “Yerakon” encompasses jaundice and likely the chlorosis of anemia too. Even Maimonides, the archetypical medieval Jewish physician, makes no claim as a hepatologist. Anyway, Maimonides is also claimed by Muslims among the physicians of the Golden Age of Islam.⁸ So was another Jew, Abū Marwān ‘Abd al-Malik ibn Zuhr (أبو مروان عبد الملك بن زهر, Latinized Avenzoar.⁸,²⁰ In fact, in Talmudic times the Jews became the greatest teachers in the Arabian medical schools situated at Basra, Baghdad and Kufa.²⁰ Avenzoar was an Andalusian physician in 12th-century Seville who described the anatomy of the liver, spleen, and abdomen, and their diseases and treatment, in Kitab Al-Taysir (Book of Simplification Concerning Therapeutics and Diet), the last book that he wrote before he died. One of the greatest physicians at that time was Izak ben Soleiman (830–940 CE), physician to the Sultan of Morocco; his works were still published in Venice in 1513, six centuries after his death.

It may come as some relief to learn that one of the most famous (and truth be told, unfairly regarded as notorious) 19th-century physiologists, Moritz Schiff (1823–1896), was Jewish, and he made fundamental discoveries in hepatobiliary function²¹,²² that set the stage for other significant developments in hepatology.²³,²⁴,²⁵

JAUNDICE AND PIGEONS

It seems possible that several of the complications of advanced liver disease were actually noted In the Hebrew Bible, and later in the Talmud and were derived from Hippocrates and Galen.²⁶ A fanciful etymological interpretation by the renowned French Biblical commentor Rashi (1040–1105) — whose familiar name is actually an acronym too, רשי, of Rabbi SHIomo Yitzchaki, רבי שלומה יצחק׳ - claimed that the Hebrew word for disease, machalah מחלה, is synonymous with the Hebrew word for bile or bitterness, marah מרה.

Swelling of the abdomen with fluid in the “Ordeal of the Bitter Waters,” was thought to be a curse that proved a woman’s adultery (Numbers 5:12–28), but it is not altogether clear that this was bone fide ascites.

However, Jaundice (the term derived from Old French) or alternatively and interchangeably Icterus (derived from Greek)²⁷ was noticed by physicians as a sign of liver disease as far back as Hippocrates and even earlier in the clay tablets of Mesopotamia, in ancient Chinese literature ~200 CE, and repeatedly in the Hebrew Bible²⁶ as Yerakon. But herein lies a trap.

Yerakon and segulah

The term Yerakon is found six times in the Hebrew Bible²⁸: Deuteronomy 28:22; Kings I 8:37; Jeremiah 30: 6; Amos 4: 9; Haggai 2:17; 8:37; and Chronicles III 6:28.

Rashi and others considered Yerakon ירקון to refer to a disease that afflicted grain, giving it a pale and yellowish-green surface. Other commentators interpreted Yerakon as jaundice or chlorosis, the latter being a yellowish-greenish hue seen in young effete Victorian women with severe anemia. That the Biblical Yerakon refers to some type of epidemic, is clear from the discussions in the Talmud. Unfortunately, no symptoms of the disease are described anywhere in the Bible or Talmud, so we can only interpret the word Yerakon from its derivation, namely from yarok ירוק meaning green or maybe yellow, but always referring to a green herb or grass. A bluish tinge to the green is implied in the case of a suspected adulterer whose “face turns green, whose eyes protrude, and veins stand out.” The human malady of jaundice is said by the sages of the Talmud to result from “Divine punishment for causeless hatred and to be produced by the withholding of urination.” In the final analysis, since the cause is hatred and anger that were thought to be related to yellow bile or gall, it would seem logical to conclude that Yerakon is in fact, jaundice.

And if all of these far-fetched interpretations were not enough, what could be more colorful than to use therapeutically a pigeon or an Eurasian Golden Oreole (Oriolus oriolus — the name derived phonetically from the Latin aureolus for gold), a small bird with golden yellow plumage, In ancient Greece and elsewhere to be cured of jaundice/icterus, it was only necessary for the patient to catch sight of the Oreole and the disease would to be transferred to the doomed bird.²⁴ On the other hand, for segulah — meaning remedy or protection — pigeon therapy (although doves and turtledoves allegedly work as well), the hapless creature must be placed on the naval of the patient in order to receive jaundice and save the life of the patient, at the bird’s expense.²⁹ Sometimes, apparently, more than one pigeon was required.

VIRAL HEPATITIS

In the case of jaundice and other liver derangements, hepatitis viral infections were undoubtedly the cause of many cases over the millennia, but the etiological factors were 20^th-century discoveries. Transmission was especially likely in crowded conditions, including those typified by unsanitary military and other communal settings,³⁰,³¹ and where Public Health is poor in deprived communities that encourage epidemic transmission by feco-oral spread.³² Circumstances in which parenteral transmission is assured by high risk social behavior³⁰,³¹,³²,³³,³⁴,³⁵,³⁶ or by the use of infected therapeutic reagents (like blood, plasma, serum, coagulation preparations, etc.) for transfusion or inoculation, respectively,³³ are modern-day plagues. In the cases of the discoveries of hepatitis viruses B³⁰,³⁴ and C,³³ Two of the several investigators who shared the plaudits were American Nobel Laureates who just happened to have Judaic affiliations. I found it personally pleasing that the junior co-author of the first publication that recognized HBV or, more precisely, the so-called Australia antigen HB_sAg³⁶ that started the trail that led to Blumberg Nobel prize, eventually was awarded a Nobel in his own right.³³

For HAV,³¹ sterling work (or should that be shekel שקל work?) was done by a world-class hepatologist from Israel²⁷ in the field of vaccination that brought about the near complete prevention of HAV infection.

Many of the respective senior hepatitis authors whose publications are cited above²⁷,³²,³³,³⁴,³⁵ have been essayists in this series.

THE LIVER AS A JEWISH COMESTIBLE

And now it seems appropriate to return briefly to the opening theme of this essay, in other words, the liver as food and its humorous perspective. The notion of chopped liver as a delicacy, admittedly an acquired taste for many, originated in the poverty of a bygone Eastern Europe, where it has been speculated that, for thrift, every part of the chicken was consumed. A mixture of sautéed liver that had been flame-koshered, boiled eggs, and lightly fried onions were all chopped, combined and well mixed with either rendered chicken fat (schmaltz in Yiddish) or olive oil (for the health conscious), to provide cheap nourishing fare. That chopped liver was once a side dish thought to be unimportant and often overlooked, occasioned the self-deprecating Woody Allen-style New York Jewish lament “And what am I, chopped liver?” as if the supplicant had been side-lined and ignored.

More recently, chopped liver has moved center-stage at some family life cycle celebratory banquets, often crassly fashioned into sculptures or served in the shape of a heart²; chopped liver has made the transition from the food of peasants to high-brow kitsch. A good thesaurus offers us some choice alternative derisions for the word “crass,” like oafish, boorish, asinine, and in poor taste—the latter double entendre is no accident. More recently, surprisingly good ersatz vegetarian chopped liver has appeared using sautéed plant substitutes, like eggplant (aubergines, my favorite — recipe available on application), string beans, walnuts, and mushrooms.

The history of foie gras has an unexpected Jewish component, according to American-Israeli foie gras passionate devotee, chef, food historian, and goose farmer, the late Michael Ginor.³⁷ The story of the creation of foie gras is worth retelling for its culinary serendipity. Geese and ducks were a mainstay of the diet of the ancient Egyptians, and hunting them in the Nile marshes was a favorite pastime sport of their aristocrats. The center of the goose trading in Egypt was Chenoboscium (chenos χηνα, [Greek for goose] as in chenodeoxycholic acid), a town at the edge of the Upper Nile, marshes, whose name is believed to mean “Place, where geese are fattened.”

The goose was highly regarded in ancient Egypt and figured prominently in Egyptian myths. Geb, the Egyptian Earth God, was often portrayed with a goose on his head or as a goose-like being. As this latter avatar, he gave birth to a cosmic egg out of which was hatched the Sun, filling the world with light. It was anathematic to Herodotus (fifth-century Greek historian and geographer) that their holy men should eat the birds that they revered as sacred.

When the ancient Egyptians slaughtered wild geese for the table, they noticed that the livers were grossly enlarged, cream-colored, extremely steatotic, and delectable in those birds who had gorged on corn to store energy at the beginning of the scorched Egyptian summer in preparation for their return northern flights from their winter Mediterranean feeding areas to cooler summer nesting grounds in Europe. Hence, the practice of force-feeding geese (Figure 1A) and ducks by gavage with corn (as recorded in bas-reliefs on Egyptian tombs) to produce a specific type of fatty liver, foie gras in French, for which a useful acronym perhaps might be GIST (for Gluten-induced SteaTosis). In the following centuries, this practice spread throughout the eastern Mediterranean, including Greece), as recorded by Homer (Figure. 1B). It was not until the Roman period that foie gras was mentioned as iecur ficatum, meaning “fig-stuffed liver,” as the Romans included figs from the sacred Ficus Ruminalis tree, in the feed. Ficatum became the root for liver in the Romance languages: French foie, Spanish higato, Italian fegato, and Romanian ficut. After the demise of the Roman Empire, interest and knowledge about foie gras faded, along with other accoutrements of fine living. Foie gras did not experience a reawakening or revival until beyond the Renaissance. It has been hypothesized that the Romans brought the knowledge of foie gras production to France, where it was imparted to the peasantry until it was rediscovered in the 17th century by chefs associated with the French courts, and hence its fame in French cuisine despite the fact that goose played only a marginal role in the contemporary French diet. According to Michael Ginor, who may not be an impartial witness, the Ashkenazi Jews of western and central Europe were the more likely guardians of the foie gras secret, which they witnessed in Roman Palestine and carried with them during their continual wonderings in Europe (their Diaspora). Food is a preoccupation of Jews, in one sense or another, and this was possibly influenced by Roman aristocratic mores. It appears that Rashi of Troyes, whom we met earlier, and who was a vintner by trade, was a gourmet with an appreciation of fine cooking but, not altogether paradoxically, he expressed his opposition to the cruelty of force-feeding geese to fatten them, and their livers. Ginor elaborates exhaustively on the history of cuisine in Europe in the Middle Ages and beyond. Buried in these pages are two gems pertinent to this dissertation on the importance of the liver in Judaism. One, and notwithstanding Rashi’s objections, the foie gras made by the Jews was second to none, for the Gentiles among whom they lived were keen to purchase their paté de foie. Two, the very fatty paté proved to be excellent for frying, roasting, etc., within the dietary laws’ restrictions, where lard and other forbidden fats would not be used.

FIGURE 1.

(A) Ancient Egyptian farm laborers force-feed geese and other birds to fatten them up. (B) From Homer’s time onward, fatted geese were a Greek delicacy. Source: General Research Division, the New York Public Library, Astor, Lenox, and Tilden Foundations.

THE LIVER IN JUDAISM

As we have seen here, the Judaic linguistic, literary, and culinary aspects of the liver are indisputable, but what is the status of the liver in the hierarchy of the organs in Judaism? Where does it stand in the confrontation between hepatocentrism versus cardiocentrism and perhaps cerebrocentrism?³⁸ In most cultures, the liver was regarded in times past as one of the ruling parts of the human body, the other two being the brain and the heart, but it was never seen as Alpha organ in Judaism. Strange to relate, that top role was assigned to the kidneys³⁹ — always in the plural. Kidneys are mentioned eleven times in the Pentateuch and more than thirty times in the Old Testament as a whole, mostly in Jeremiah and Psalms, where they are cited figuratively as the location of temperament, emotions, prudence, vigor, and wisdom. They are proposed to be the organs examined by God to judge the individual (Jeremiah 11:20), and as sites for divine punishment. But nowadays, the kidneys have slipped from prominence and so the kidneys are no longer the ruling organs in Judaism.

Finally, in the Zoha ְהר (splendor or radiance) ie, the foundational work in Kabbalah (something received) קבלה, — the Jewish mystical interpretation of the Bible — there is a discussion about the acronym MELECH מלח, for מוח לב כבד ie, brain, heart, and liver. The interpretation is that when one (ie., one’s brain) is in control of one’s heart, then together they regulate the liver — which is the materialistic part of one’s soul, and not vice versa. MELECH spelled another way מלך means King or Ruler, implying that a human being should have command over his/her materialistic soul.

CONCLUSIONS

The place of the liver in Judaism is indisputable, in which it has had a vital role since biblical times, spiritually, theologically, historically, and culinarily.

SENIOR EDITOR’S POSTSCRIPT

It would be invidious of me to write a postscript about my own essay, which would be somewhat akin academically to writing a case report manuscript about one’s own illness, as a handful of physicians have done, including one eminent hepatologist who amusingly but seriously did so and then submitted a follow-up note to the editor.⁴⁰

I had previously invited other individuals to author this essay, but they defaulted at the eleventh hour. So, it only remained for me to do it myself and feel the responsibility that all the other authors have had in this series. This gives me the opportunity to thank all of the contributors with my deepest gratitude, not only for their efforts in writing in a genre to which they are not accustomed — outside of their comfort zones, so to speak—but also to thank them for putting up with my embellishing such worthy manuscripts composed by world experts in their fields. I also have the duty to thank Nancy Reau, the immediately previous editor of Clinical Liver Disease, for trusting me in the first place with this formidable and fearsome responsibility. I also cannot thank enough both of the Senior Publication Managers at AASLD, earlier Kareytis Martinez and currently Emili Malatesta, whose skill and experience escorted me through some very difficult times, not to forget the critical work of getting the essays to publication. I also want to acknowledge the current editor of Clinical Liver Disease, Joseph Lim, who has taken over the command of this ship seamlessly.

Finally, although the editing has been a vast labor these past few years, it has been a labor of love and learning, and here I also express my gratitude to my wife, Tricia — an editorial widow — for all those times that I have been glued to my computer and chained to my desk. Fortunately, no eagle visited me to peck out my liver.