Ep 184 The Gallbladder: Humor us

For most of us, there probably hasn’t been a good reason for you to think about your gallbladder. Ever. Much of the time, it sits there, silently storing, concentrating, and, when needed, churning out bile every day. But occasionally, this unassuming organ will announce itself through waves of unceasing, excruciating pain brought on by a blockage of some sort. Why it does this to us, what we do about it, and how we can live a gallbladder-free life are just some of the things we cover in this episode. We’re also taking this opportunity to deep dive into the substance most closely associated with the gallbladder: bile. Bile plays an outsized role in the history of medicine, mostly through its role as one of the four humors in the humoral theory of disease. Are you of a choleric temperament or is your vibe more sanguine? Maybe melancholic or phlegmatic suits you better. Don’t know what the heck we’re talking about? Tune in to find out.

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Episode Transcript

Speaker 1 (00:00):
It started on a Sunday afternoon. I was sitting on
the couch working on my laptop when I suddenly got
an upset stomach. I hid cramps the nausea, but it
quickly escalated. But in a few minutes, I was crouched
in my bathroom floor with a sharp pain just below
my rib cage. It felt like I was being repeatedly
stabbed on my right side. The pain was so intense
that my diaphragm wasn't contracting. It felt like it was

(00:22):
stuck in place. I crawled into the next room, where
my husband was napping, and I tried to gently call
to him so as not to alarm him, but I
was having trouble breathing, so I just managed to stammer,
I don't feel well. He startled awake and was instantly worried.
He said my lips were white. He was calling nine
one one no, I croaked, I just need water, Bring
me a glass of water. He hesitated, but acquiesced and

(00:45):
went to the kitchen while I lay on the floor
trying to reason through what was happening. My symptoms didn't
match appendicitis or a heart attack, and since I was
out of ideas, I figured it must not be anything serious.
Silence from the kitchen.

Speaker 2 (00:57):
Now.

Speaker 1 (00:57):
My husband is not a whimp, but he has been
to faint while having his blood drawn, and once when
an acquaintance went into diabetic shock, he stepped outside to
call nine one one, and then promptly passed out on
the phone with a dispatcher, such that when the EMTs
arrived they attended to my husband crumpled on the sidewalk,
and not the man inside having a seizure. So the
silence worried me. I called to him, Yes, he said, quietly.

(01:21):
Are you passing out right now? I asked, trying not to,
he said meekly. I made a mental note not to
allow him in the delivery room if I ever went
into labor, and tried to remind him of the task
at hand. I could really use that water. I heard
the faucet turn on, and then a few moments later
he shuffled over and set a glass down next to me,
then plopped down on the floor with his head in

(01:43):
his hands to fight the light headlessness. I was flattered
on my back. I can't drink this, I told him,
I need a straw. He looked at me as if
I'd asked him to climb everest, but he stood up
and shuffled back into the kitchen. It was at this
point that I realized I need to snap out of it,
because I would need my wits about me when he
inevitably fainted and hit his head on the countertop and
I had to call nine on one for him. I

(02:04):
brought myself up to sitting against the wall, and he
shuffled back with a travel mug of water. I took
a sip, and in a few minutes I started to
feel better. I returned my place on the couch. That
was weird, I said. Now, let it be known that
my husband wanted me to go to the hospital anyway,
but I told him I didn't have time to sit
in the r all night. And sure, that was pretty strange,

(02:25):
but I felt fine now. My husband flew the South
Dakota the next day and the rest of the week
when as usual until Saturday afternoon, when I took her
dog for a walk. I made it one block to
her forest trailhead and the stabbing pain returned. I couldn't
stay upright. I had to lay down on the forest floor.
It was tick season and I live in a place
with a very high incidence of lime disease, so this
didn't seem prudent. You're gonna feel like an idiot if

(02:47):
you get lime disease because of a stomach ache, I thought,
and forced myself up. The walk was excruciating, but I
managed to stumble home without vomiting in my neighbor's yards.
When I got in my door, I laid down on
the entryway bench. There I ride and literally moaned in
agony for over an hour until I eventually made it
to the couch, where I continued to writhe and moan
some more. There was no position that was comfortable. After

(03:10):
several bouts of dry heaving, I started to cough of blood.
Maybe it's an ulcer, I thought, so I texted my
close friend who had an ulcer and told her my symptoms. No,
she said, I've never experienced any of that. You should
go to the hospital. I can't drive right now, I
told her, I can't even sit up. Then call a friend.
She texted back, you know I don't have any of those,

(03:31):
I replied, I had moved to a new state recently
and making friends is hard. Well, then call an ambulance.
She said, that seems like overkill, I told her. Plus,
the dog would lose his mind and I am in
no state to control him right now, and so I
lay there alone, hoping the pain would subside as it
had before, but it did not. My husband arrived home
around eleven PM, having had to rent a car from

(03:53):
the airport since I had texted to say I would
not be there to pick him up as planned. He
also wanted to take me to the hospital, but since
I still couldn't sit up, I dreaded the thirty minute
car ride and a long wait in the r waiting room.
I promised him i'd go in the morning, when I
planned to be feeling better. I spent the night on
the couch without sleep, though the pain did start to
lessen in the morning. He reminded me of my promise,

(04:15):
but I still wasn't feeling up to the trip. I
renegotiated the terms such that I would go to urgent
care when I was capable of sitting upright, which happened
around noon. At this point, I was actually feeling almost normal,
so I insisted on taking myself and I told the
check and staff my symptoms. I was told they could
not see me at urgent care, I'd have to go
to the er. I called my husband from the parking

(04:36):
lot and bated whether to wait until Monday morning to
see a doctor rather than going to the er, where
I truly waste time. But he was sufficiently worried that
I relented and drove over to the ar. To my surprise,
if you tell the check and nurse that you are
experiencing sharp stabbing pain just under your ribs, there is
basically no weight. I was called back to a little
curtained room almost immediately and blood and urintests were taken,

(04:58):
as well as an X ray. The doctor came to
tell me my results a couple hours later. My liver
function tests were off the charts. He suspected my gall
buttter had to come out. They kept me in the
hospital overnight. I had an MRI to confirm Coli societis
the next morning, and then laparoscopic surgery the next and
I went home that same day. After three days of recovery.

(05:20):
I felt great, and I promised everyone in my life
that the next time my gall butter goes, I'll go
straight to the hospital.

Speaker 2 (06:12):
Oh my gosh, Maria, Maria, Maria, I mean disclosure. I
have heard this story a couple times now, and every
time I'm just like I am enthralled and horror spired
at the right parts and believed at the right parts

(06:33):
and laugh at the right parts. It's just yeah, it's
a great story. It's a great story. And I'm glad
you're okay.

Speaker 3 (06:43):
Set of circumstances.

Speaker 2 (06:44):
Yeah, yeah, thank you, Maria, Yeah.

Speaker 3 (06:48):
Thank you for thank you reliving that yet again for
us and everyone who's listening.

Speaker 2 (06:55):
Yeah. Hi, I'm Aaron Welsh and I'm erin on an
Updike and this this podcast will kill you.

Speaker 3 (07:01):
Today we're talking about the gallbladder.

Speaker 2 (07:03):
Just the gallbladder, the gallbladder, the golfbladder.

Speaker 3 (07:07):
I almost texted you multiple times to be like, it's
just gallbladder, right, We're not doing like a specific part.
It just it's gallbladder, a specific part of the gallbladder.
Like we're not just doing like golf gullstos or like.

Speaker 2 (07:19):
Or like gallbladder cancer or like.

Speaker 3 (07:21):
This didus Holy, Yeah, we're doing gallbladder.

Speaker 2 (07:25):
Yeah.

Speaker 3 (07:26):
I can't wait.

Speaker 2 (07:27):
I mean, And and the reason that if you had
texted me that my answer would have been like, I
don't know, I don't know what these things are so whatever,
we could do anything you want to do our podcast.

Speaker 3 (07:40):
We've promised this for a while now we have. I'm
really excited to finally be doing it.

Speaker 2 (07:47):
I mean, of all of the organs to start with.

Speaker 3 (07:52):
Is this the first like organ episode?

Speaker 2 (07:56):
Yeah?

Speaker 3 (07:57):
Isn't it? Yeah? Yeah? Is that right? I feel like
we've talked about doing like the heart, We've talked about
doing other organs.

Speaker 2 (08:06):
I can can you think of other organs?

Speaker 3 (08:09):
I mean, the uterus is the first one I think
of it. We've done a lot of like uterus right,
the discussions, but we've not just like done a whole
episode on the uterus.

Speaker 2 (08:19):
Nope, not yet. Well, gallbladder here we are here. We
are celebrate the gallbladder and also chastise it for the
things that it does poorly.

Speaker 3 (08:29):
I can't wait. I'm really really excited. I have no
idea what you have in store for me, Aaron, but
I it's gonna be fun.

Speaker 2 (08:34):
I know that we'll see before we get into all
of that thought quarantine any time, quarantin any time. What
are we drinking this week?

Speaker 3 (08:45):
We're drinking on the stones, like on the rocks.

Speaker 2 (08:50):
We're going to do gall of stone.

Speaker 3 (08:52):
Oh I thought we said Oh no, you're right.

Speaker 2 (08:55):
We did do on the Stones.

Speaker 3 (08:57):
Okay, we have a lot of ideas.

Speaker 2 (09:00):
We did well, we had two at least so and
in on the Stones we're actually doing a classic cocktail
which I've always heard of but never knew what was in.
It's a Harvey.

Speaker 3 (09:11):
Wallbanger, not to be confused with Wait wait wait, Harvey
Wahlberg isn't a person, is it.

Speaker 2 (09:19):
There's Mark Wahlberg, right, and then there's Donnie Wahlberg and
I assume other Wahlberg's.

Speaker 3 (09:25):
I don't know why that was the first thing I
thought of when you said Harvey Wallbanger, you did?

Speaker 2 (09:31):
You were like, what's in the what's in the the
Harvey Wahlberg, I'm like, excuse me?

Speaker 1 (09:37):
What?

Speaker 2 (09:37):
Yeah, okay, in the Harvey Wallbanger or on the Stones
is orange juice vodka a like a yellow kind of
vanilla e liqueur called galliano or guyano Guyiano I'm not
sure how you pronounce it, and a marishino cherry delish. Yeah,

(09:58):
it's delish. The reason we chose this too is because
I when I was like thinking of the quarantine, I
was like, Okay, well it's got to be yellow, because
that's what bile is, and then I told you and
you were like, yeah, but bile's not yellow. I mean
what we're going with it anyway.

Speaker 3 (10:15):
It's yellow. It can be yellow. It ranges from like
yellow to green or black is not a good color
for bile, but sometimes so it's a spectrum. I think
we think of it in our minds as more bright
yet like more on the light yellow spectrum than it.
It's closer usually to the darker side of the spectrum.

Speaker 2 (10:35):
But you know what, already learning things, already learning things.
We will post the full recipe for on the Stones
on our website this podcast will Kill You dot com,
as well as on all of our social media channels,
so check it out.

Speaker 3 (10:48):
Check it out. Also check out on our website, our
merch our bookshop, dot org affiliate account, and our good
Reads list our music by Bloodmobile, who's also on Instagram,
Treon page, transcripts, sources from all of our episodes, and
so much.

Speaker 2 (11:05):
More, so much more. We're on YouTube.

Speaker 3 (11:10):
We're on YouTube, follow you exactly right network, subscribe to
it all. We're on what do you call It? iHeart podcasts,
Now and Apple Podcasts and all of the other ones.
Thanks for listening.

Speaker 2 (11:24):
At the end and now over to the beginning.

Speaker 3 (11:30):
I'm going to talk us through what the heck is
the gall bladder right after this break Aaron. You know
those like old timey water skins, like I think they're

(11:53):
probably made out of like animal organs, but you see
them in like old movies, like old westerns, like you
put it on a saddle bag and then you drink
water out of this. Yeah, okay, So your gallbladder.

Speaker 2 (12:04):
Oh oh af to an unusual start.

Speaker 3 (12:07):
Is kind of like a little water skin kind of okay, okay,
it's like it shaped a little bit like that, like
what I what I think of it as those little
water skins. It's like this seven to ten centimeter so
it's quite a bit smaller than those water skins. So
two and a half to four inches long.

Speaker 2 (12:25):
I'm a little so little pouch.

Speaker 3 (12:27):
Yeah, And it sits just on the underside of your liver,
and your liver hangs out in the right upper quadrant
of your abdomen. It just like a butts against your diaphragm,
which is what separates your abdomen from your thorax or
your chest.

Speaker 2 (12:41):
The liver is always so much higher than I think
of like for some reason, I just think of the
chest cavity as empty, and all my organs are somehow crowded.

Speaker 3 (12:49):
At the very bottom, your chest cavity is empty, not
like your well, my heart.

Speaker 2 (12:55):
That's okay, loves you heart, and then well there's anything
else until like my until the bottom.

Speaker 3 (13:01):
Yeah, the liveries weigh the heck up there, way up there.
And this little pouch sits just there's like a little
a little groove, a little divot that it basically sits in.
And it is part of what's called our biliary system,
which is basically a series of tubes like a I
think of it as like the branching plumbing system that

(13:23):
the super Mario brothers travel through. Some of these tubes
come from the liver they're called the hipatic ducts, and
then they join together with the tube from the gall bladder,
which is called the cystic duct, and those all joined
together into what's called the common bile duct. And then
another branch comes over from the pancreas. I don't know

(13:46):
why I went this way, because it's coming from your
left side, and these all together empty out into our duadnum,
which is the first part of our small intestine. So
you have this series of duct work that connects our liver,
our pancreas, and then there's this one branch that ends
in a blind pouch, and that blind pouch is the
gall bladder. To better illustrate this.

Speaker 2 (14:07):
Oh, do we have props?

Speaker 3 (14:09):
We have props today. I made a billiary tree, Oh
my gosh, out of some pipe cleaners and a balloon.
So if you're just listening, imagine thank you. I tried
to get my kids to help, and they were like, nah,
I'm good.

Speaker 2 (14:25):
But minecraft to watch exactly.

Speaker 3 (14:30):
So I made this. Imagine if you're just listening, I'm
going to talk you through it. Basically, we've got two
pipe cleaners that come together in like a y shape.
These are our two hepadict like left and right hepadic ducts.
These are what are bringing the bile which is made
in the liver down into the common hepatic duct. This pouch,

(14:52):
which is a balloon, a squeezy balloon, is the gall bladder.
It's connected to this whole system by the cystic duct here. Okay,
then we have the common bial duct. This branch coming
out towards the left, which is really quite skinny, connects
really close to the bottom of the common bial duct,
and that is what connects the pancreas. That's the pancreatic duct.

Speaker 2 (15:14):
Okay, the blues the pancreas, got it.

Speaker 3 (15:16):
And then it lets out in a sphincter. So there's
a muscular sphincter here called the sphincter of odie, and
it is what allows flow out into the duadnum or testin.

Speaker 2 (15:32):
Hold on, where's the liver again?

Speaker 3 (15:34):
The liver here is up there, okay, Okay, So the
liver is what's covering the top part of this, and
then your gall bladder sits just underneath the liver just
kind of poking out. Got a day, okay, And so
the gall bladder it's essentially a storage unit or really
like a storage and handling unit. Okay. Our liver is

(15:54):
producing bile, and it produces something like a leader a day,
which is more than I realized. But it produces this
bile I know, right. It produces this bio at different
rates depending on whether we are eating or whether we're fasting, right,
in response to hormone signals that it gets when we're eating.
And then this bile is traveling ultimately to the duadnum. Right,

(16:18):
It has to get into our intestine because it's going
to help us digest our foods. But because there is
this muscular sphincter at the bottom, it's regulating the flow
of bile, So the bio is not just free flowing,
gushing all the time into our duadnum. So depending on
the timing pre meal, after a meal, if you're snacking

(16:40):
and the pressure of this sphincter, bio will either flow
outwards into the small intestine or it gets diverted into
the gallbladder.

Speaker 2 (16:52):
Okay, so if you're like, we don't need to digest
right now, just hold on to this until for a little.

Speaker 3 (16:59):
Bit, then boop the pressure Like that sphincter's closed, so
the pressure builds up here and then bloop, that fluid
gets diverted into our gallbladder. Something like ninety percent of
the bile that's produced during times that we're not actively
eating or digesting our food ends up going into the
gallbladder for storage. But while it's there, it's not just

(17:19):
sitting there. Our gallbladder is doing a job, and that
job is concentrating this bile. You can think of it
kind of like a barrel that's aging your fine wine,
right yeah, some of I'm really going hard on the
analogies here today.

Speaker 2 (17:37):
I like it.

Speaker 3 (17:38):
So, if you have wine in a barrel, like some
of that wine soaks into the barrel, right, so the
wine that comes out after a certain amount of time
is a little bit different than what went in. It's
the same thing here. So the bile that exists in
the gall bladder is more concentrated because there's all these crypts.
It's not like a smooth wall on the inside of
the gall bladder. It's got like folds and layers and

(17:59):
these cryps. So you actually even end up having like
layers within the gallbladder of this fluid, this bile where
the most concentrated stuff is deep down in the crypts,
this inner lining, and then there's less concentrated stuff on top.
So after a meal, and depending on how big that
meal was, how much fat was in that meal, like

(18:20):
a lot of different components, how much hormones are being
secreted out, how well your gallbladder squeeze is to begin with,
our gallbladder will get to work squeezing and pushing that
concentrated bile out the cystic duct, which will mix with
stuff coming from the liver. That's free flowing still, and
then we'll eventually travel while mixing also with enzymes from

(18:42):
the pancreatic duct out through that sphincter into our duodenum
so that we can digest our fat burger.

Speaker 2 (18:50):
Two questions give it to me? How is it concentrating?

Speaker 3 (18:55):
Like?

Speaker 2 (18:56):
And number two, what is bile?

Speaker 3 (19:00):
I knew you were gonna ask that question, So my
literal next part is what the heck is bile? So God,
when we work together, Well, the way that it's concentrating
is basically there's like, you know, a bunch of transporters,
like ion transporters and different things in the wall of
the gall bladder itself, like in that intestinal lumin or

(19:21):
not intestinal, but in that bile lumine. And so it's
going to be like soaking up like basically taking back
some of that water and maybe other parts of what's
in the bile and leaving a more concentrated bile behind.
If that makes it. Yeah, So bile, great question. So
glad you asked. Is this yellowish greenish liquid that's made

(19:44):
in our liver and it's made up of a bunch
of different things. It's a combination of bile acids, which
is the most kind of active part and probably one
of the more important parts of bile and bile acids
are We've talked about them in one of our pregn
the episodes when we talked about cholestasis of pregnancy. But
these are made from cholesterol. So our liver is making

(20:08):
cholesterol and then through a process of a whole bunch
of enzymes converting that cholesterol into bile acids. And then
what it also does on top of that, there's another
thing called biol salts, and that's just a fancy name
for the liver will take these bio acids, combine them
with other amino acids to make them more hydrophilic so

(20:31):
that they're more soluble in water, because cholesterol is fat
and fats don't mix well with water. So our liver
makes these cholesterol products called bio acids, then makes them
into something that's more hydrophilic that we call a bio salt,
and that's a big, huge component of our biole It
also contains bilirubin, which is a byproduct of like red

(20:53):
cell breakdown. It also has other phospholipids. There's probably just
some like plain processed cholesterol in there. There's water, and
then there's other salts and minerals. What bile does, especially
these bile acids or bile salts, our help in the
digestion of lipids or fats in our gi tract. They

(21:17):
are helping to emulsify and facilitate the absorption of our
fats and things like fat soluble vitamins. Okay, they also
are going to grab onto and help eliminate cholesterol from
our body by grabbing onto it and then essentially like
we'll poop it out, so they'll like block some absorption

(21:38):
of cholesterol. And because these are made in the liver
and then traveling via this biliary system maybe pit stopping
in the gallbladder, and then being re secreted after they're
in our digestive tract and they're doing their jobs, they
actually get reabsorbed through our intestinal wall later on in

(22:00):
our small intestine, then re enter what's called our entero
hepatic circulation, go back into our liver where they can
be reprocessed, re secreted and used again.

Speaker 2 (22:12):
Okay, so we recirculate bile.

Speaker 3 (22:16):
H Yeah, most of our bile is recirculated. Our liver
is always making more, but we need way more bile
than it's making in a day, if that makes sense,
so we recirculate it.

Speaker 2 (22:31):
That's really fascinating. And this is, like you said, a
leader a day at least. Yeah, that's such a huge
amount of Okay, yeah, when you're we talked about this
a little bit, but just again to go over it.
When you're barfing and you get to the point where
you're just barfing up like a little kind of gummy, sticky,

(22:52):
snotty liquid that's bright yellow, Yeah, is that ever bile
or is it just stomach acid?

Speaker 3 (22:57):
It could or it could not be bile. Okay, really
billious vomiting is like considered pretty bad. So like that
would mean like something is pretty wrongs.

Speaker 2 (23:08):
Have to be like from your small intestine backups through
exact stomach, so like that should not that's a one
way path.

Speaker 3 (23:14):
It should be a one way path. And so that
tells us that there's something going on that's causing that
much of a backup, So we think of that with
maybe something like a small bowel obstruction or something like that.
That doesn't mean that it's impossible to barf up bile.
We definitely like people barf up bile, you know for sure,
But most of the time when you're doing that, like
dry heaving, and then you get out just a little bit,

(23:34):
it's probably mostly just your stomach contents and like the
stomach acid that's left in there, that's what leaves that
really terrible taste in your mouth and things.

Speaker 2 (23:41):
Okay, yeah, I feel like I have a lot more questions,
but they're all related to the things that can go wrong,
and I agree with feelings. That's what you're going to talk.

Speaker 3 (23:49):
About, that is how can things go wrong? Oh so
I mentioned already that a big part of what your
gallbladder is doing is concentrating this bile. Anytime that you
have a liquid that's not just like say pure H
two O water, but you have a solution that gets
more concentrated, the solutes in that solution are at risk

(24:12):
of precipitating out. And that is essentially what happens when
you get gallstones there where.

Speaker 2 (24:20):
Now the stuff precipitates out.

Speaker 3 (24:23):
Yeah, it's not like perfectly as simple as that, but
that's the simplest way to think about it. Because gallstones,
there's a few different types of gallstones, but something like
eighty to ninety percent of gallstones are cholesterol stones, so
they're basically a solid mass of cholesterol from these bile
acids that essentially crystallizes as well as calcium other proteins.

(24:44):
And then these things called musins, which are produced by
our gall bladder and can kind of act as if
you've ever made like rock candy. Have you ever made
rock candy?

Speaker 2 (24:56):
I've eaten rock candy.

Speaker 3 (24:58):
If you're gonna make rock candy, you make us supersaturated
solution of sugar water, and then you have to take
your stick or your string or whatever and roll it
in sugar crystals and dunk it in there, and those.

Speaker 2 (25:11):
Sugar crystals kind of exactly domino crystallization exact.

Speaker 3 (25:16):
Actually, yeah, And so these musins are something produced in
the gall botty that can act as one of those
crystal formations. They kind of are like that, not a catalyst,
but they are that first thing where your cholesterol crystals
can start to precipitate out and then eventually form a gallstone.
There are other types of gallstones, So pigment stones are

(25:36):
mostly made up of bilirubin, and so those can happen
if you have an over abundance of bilirubin in the bile,
which we might see in something like a hemolytic disease
or some other kinds of medical disorders, but those are
much less common. Most gallstones are cholesterol gallstones. You can
also have mixed gallstones, and.

Speaker 2 (25:54):
That's just where the cholesterol is falling out of solution
and kind of like.

Speaker 3 (25:58):
Making little chunkies. Okay, so we're big chunkies.

Speaker 2 (26:01):
How common are gallstones and then how common are gallstones
that cause a major problem?

Speaker 3 (26:08):
Great question. Gallstones are quite common. It's estimated that like
ten to fifteen percent of adults in the US and
in Europe where we have the best data, but I
also saw some studies out of China that were like
around twelve percent, So like ten to fifteen percent of
adults have gallstones. Eighty percent of people with gallstones totally asymptomatic,
never even know that they have them unless they happen

(26:29):
to get a right up or quadran ultrasound and we
see them huh, okay, not so bad until they go
really wrong. And there are a lot of risk factors
for gallstone formation, and we really, in all honesty, you
just don't really understand them. Like maybe poor gallbladder motility
might have a role to play, because we see that

(26:49):
in conditions like pregnancy, which we talked about, where everything
slows down, things aren't contracting as much, and so then
you can get stasis. And if you have stasis, you
have increased concentration of this solution, and then you have
more precipitation. We can also see that in diabetes, because
diabetes can cause a slow down of the GI tract.

(27:10):
Side note, GLP one medications are friends like ozeen pic
slow down the GI tract and have been associated with
an increased risk of gallstone formation.

Speaker 2 (27:19):
Very interesting.

Speaker 3 (27:20):
There's also probably genetic predisposition to things like excess musin
production or just slow gut transport in general, or differences
in the way that bile salts are metabolized and reabsorbed
because you can end up with more or less hydrophobic versions.
So some that might just be more likely to precipitate

(27:43):
to begin with, if that makes sense, they're just not
as good at dissolving in water. There's probably microbiome considerations.
Estrogen my play role. There's a lot and we don't
fully understand it. But most of the time gallstones just
hang out there in your gallbladder and don't really cause
any problems. But if they're going to cause problems. Most

(28:03):
of the time. The first presentation if someone is symptomatic
is what's called billiary colic, and that is this kind
of I mean good example that Maria gave us an
herb perstent account. Unfortunately, it's this post pran deal. So
after eating, about an hour or so after eating, this
episode of really severe usually right upper quadrant, because that's

(28:27):
where your liver and gallbwater are. Pain that can be
very severe, very intense, lasts for maybe an hour, maybe
a few hours, and then eventually resolves on its own.
That is the classic description of biliary colic. We think
that usually this biliary colic is caused by a stone

(28:49):
or what's sometimes called sludge, because sometimes you don't get
like a full on stone formation, but you just get
sludginess where it's like really thick, concentrated stuff that gets
lodged some where in this biliary system, right, whether it's
in the cystic duct or somewhere else in this biliary system,
and then it causes irritation and inflammation and pain because

(29:10):
it's activating our like visceral sensory nerves. More than ninety
percent of people who have one attack will have a
recurrent attack of biliary colic within ten years. A lot
of them will have a repeat episode within two years. Okay,
but these type of attacks, this kind of biliary colic
is usually considered self limiting, right, it's not necessarily causing

(29:33):
an emergency, it doesn't need intervention necessarily. But these gallstone
blockages can also cause a number of more severe complications,
which all have various idis names because they're associated with
a lot of inflammation. We can get acute colycystitis, we
can get bacterial cholanngitis, we can get pancreatitis. Gallstone are

(30:00):
also a very well known risk factor for gallbladder cancer
down the line. So I want to kind of talk
through how each of these processes happen, because they're kind
of all actually the exact same process. It all just
depends on where in this biliary system a stone is
getting lodged. Basically anytime that you have a tube in

(30:25):
your body, but especially when you have a blind tube
right like this pocket where there's no exit on it.
When that tube gets blocked, you're going to increase pressure
behind that blockage. So in your gallbladder especially, this increase
in pressure is going to cause swelling, which especially along

(30:46):
with this supersaturated bile that's already present in your gall bladder,
will cause further inflammation. And inflammation in our body comes
with edema or swelling, which will further increase this pressure.
So acute coly sostitis is when you have a gallstone
that has blocked the cystic duct and then causes this

(31:08):
increase in pressure and inflammation and swelling in the gall
bladder itself. Eventually, this can lead to the wall of
the gall bladder not being able to get enough blood supply.
So then parts of the tissue because of just there's
so much like edema and swelling, so then the blood
can't flow there well, and so then the tissue will
start to die, so we can see necrosis, and with

(31:31):
necrosis you can see hemorrhage right because you're going to
have bleeding from where this tissue is dying. That can
eventually lead to perforation of the wall and the gall bladder,
which would cause it to spill out its contents into
the peritoneal cavity. And that's super concentrated bile acids that
they're supposed to digest stuff, So that can be really severe. Okay,

(31:52):
but even if it doesn't perforate, as you continue to
have all of this edema and sell death and necrosis,
you eventually can get a purulent phase where you get
a lot of white blood cells. Inflammation, bacteria can get
into this system, whether they're coming from the GI tract,
whether they're kind of they're already but not causing problems

(32:12):
until they proliferate. They make their way in there one
way or another and then cause a bacterial infection on
top of this. So that can happen in any part.
If it happens near the pancreatic duct and blocks here,
you can get inflammation in the pancreas, and that's called
a cube pancreatitis. Fifty percent of cases of that are

(32:35):
caused by gallstones. Okay, you can get a stone that
lodges somewhere in the common bile duct itself right so
below the gallbladder, but before the pancreatic duct, and that
can cause what's called coolanditis. It's usually bacterial colanditis, and
that's really severe because this is a relatively small tube,

(32:56):
so a small increase in pressure you could potentially have
a perforation that could be a lot more severe. So
we see people really really sick when that happens.

Speaker 2 (33:04):
And so, but like, no matter where the stone or
the obstruction is happening, the gallbladder will continue to be
backed up and swell. Or is it only when that
stone is at the opening of the gall bladder.

Speaker 3 (33:16):
Yeah, it kind of just depends. So you can definitely
get pancreatitis without having any gallbladder swelling, like without having
colicicitis on top of it. Colicystitis. Acute colicstitis is specifically
when it's blocked at the neck of the gall bladder somewhere,
so it's the gall bladder that is most affected.

Speaker 2 (33:33):
Like the hotel California of gallbladder issues, you can check,
you can go in, but you can never come out.
It's like the worst It's all I can think of
is like you can you can Yeah, you can't leave.

Speaker 3 (33:46):
Yeah, you can't leave exactly, nothing can leave. Yeah. The
same is true though, like if you get if you
get a stone blocking somewhere else, it just depends on
how long it's there, how severe it gets, whether it's
ever able to pass. You could certainly get inflammation, like
you can end up with an infection in the gall
bladder or inflammation in the gall bladder when you also

(34:06):
have colandritis in other places, in other places, and at
the heart of it, the problem ultimately is the gallbladder
itself in any case, right yep. And so for a
lot of these cases, though I will say not all
of them, Like especially not when we're talking about pancreatitis.
The treatment for that is potentially different. But especially when
we're talking about acute colis istitis, when it's this inflammation

(34:30):
of the gallbladder itself, treatment is usually take out that
gall bladder, cut it the heck out, cola systectomy.

Speaker 2 (34:40):
So what are the consequences of this? What is the
deciding factor? So obviously if like if it's severe enough, yeah,
what do we ever just remove the gall stone?

Speaker 3 (34:54):
You absolutely can. Yeah, there's a number of procedures that
you can do to just remove the gall stone. There's
also medication that you can use. We use it definitely,
like in pregnancy when it's the colistasis of pregnancy, which
is different, that's like it's a different process. See our
pregnancy episode we talked about it. But so there is

(35:16):
a medicine that we can use that helps to kind
of break up these gallstones. Themselves, but it's not necessarily
like all that effective long term and prevention of complications.
But that is one option. We used to do a
lot more of like what we do for kidney stones,
which is like go in and like ultra sound wave

(35:37):
them somehow and break them up. That's not really done anymore.
So another option if someone is really really sick with
acute coalisistitis, so this infection inflammation in the gall bladder
and they cannot have a surgery, because ultimately surgery to
remove that gall bladder is the treatment, especially for acute
cola sisiitis. Okay, if someone cannot have that surgery because

(36:01):
they are too sick or they cannot have that surgery,
then sometimes we'll put a drain in it, so that
would come from the outside, and that's called a percutaneous
collisystostomy tube, and so that's just going to drain all
of the infected fluid, all of the pus, everything, all
of the bial But it's sort of just a temporizing measure.
Eventually you're going to have to do something more permanent.

(36:24):
So yeah, I mean, it really does depend though on
what the presentation is. So if somebody just has that
biliary colic that we talked about. They may or may
not decide to get their gallbladder removed. If they do,
a surgeon is probably going to want it to be
at a time when there's not any issues going on,
because then everything is calm and cool, and it's easier

(36:47):
to remove because you don't have irritation and inflammation.

Speaker 2 (36:51):
I have a question about diagnosis though, So, like you said,
this is a These attacks are fairly characteristic. It's like
right upper quadrant debilitating pain. Like I've heard some people
that I know I've had it describe it as like
they're like, yes, I've had children, and this is worse
than unmedicated child birth. Yeah, which is wild to think about.

(37:11):
And and but it like you said, it's it's self limiting.
It's it does go away eventually unless there's doesn't more
severe unless it doesn't. And so if that goes away,
and then you go to your doctor a week or
two later and let's say there's no gallstone, yeah they
can find, so then what what do you do.

Speaker 3 (37:30):
Yeah, it's a great question. It kind of depends, Okay,
it depends on if it comes back most of the time,
Like most of the time you see something whether that's sludge, right,
so you might not see a stone. If you had
a small stone and it passed, you know, during that episode,
then we might only see sludge. But even just sledge

(37:52):
itself can cause billiary colic, right if that sludge get
pressed up against and then ends up causing irritation. But yeah,
I mean, it all just is going to depen and
on that specific presentation on how often it's happening. There
are other things, of course that can mimic this, so
I don't have an easy answer for that.

Speaker 2 (38:11):
All right, So but what if you get your gallbladder out?
Obviously this happens a lot. Yeah, yeah, what happens.

Speaker 3 (38:19):
It depends some people they don't even miss it and
they have no issues whatsoever, and then they live their
life without gallstones, and isn't that great news. But a
lot of people can have post colo systectomy complications and
that can really really range estimates. I saw most of
them were around forty percent on the high end. Some

(38:41):
were a lot lower, and I'm not sure that I
believe that just based on all of the other papers
that said anywhere from like five to forty percent. So
I think there's a pretty huge range of looking at
different studies, but the symptoms can also range, and I'm
not talking about like acutely. There are of course complications
from surgery that can happen, right have injury to the
bile duct, you could have leakage things like that. But

(39:04):
outside of that, like just postop period, some people can
have acid reflux that they can get after a procedure
like this. We don't fully understand. Some people get persistent
right upper quadrant pain, so like they still end up
having pain in that area where they were having pain
from their gallbladder. Some people very commonly end up with diarrhea,

(39:26):
and that has a lot to do probably though we
don't fully understand it. With the changes in how you
now are getting bile acids into your GI tract, right
you're no longer having these concentrated bile acids, but you
are having more of a constant free flow of less
concentrated bile acids into your GI tract. And it's thought

(39:48):
that this likely changes the gut microbiome, which will then
shift how these bile acids are like conjugated or unconjugated,
or what they're conjugated with when they go through processing
and all of that kind of stuff. So there's a
lot of potential changes that happen after a close etectomy,

(40:08):
and yet you can function and your GI tract can
function just fine without your gallbladder.

Speaker 2 (40:14):
You just kind of snip it, snip snip.

Speaker 3 (40:19):
Yeah that's the end. Oh okay, Aaron, Oh wow, tell
me about this, would you.

Speaker 2 (40:30):
Maybe we'll see, we'll see what what I come up with. Okay,

(40:50):
have you ever heard someone described as like having the
goll to do something? Yeah? Like what goal he has
to suggest that?

Speaker 3 (40:58):
Don't tell me that that has to do with GOLs.

Speaker 2 (41:00):
Tones, of course it does.

Speaker 3 (41:02):
I don't know why I thought it was the gallbladder.
I know, but I this is so embarrassing, I'm not
going to say it out loud. I thought it was
like the glants are like, no, like the birds. Oh goal, Yeah,
I thought I had something. I mean, I knew it
was gall but I don't know why I just assumed
that it had something to do with birds.

Speaker 2 (41:21):
I mean, I would say, goals do have a lot
of goll.

Speaker 4 (41:25):
I would agree, because it's like usually it's like you
know someone who's bold hands exactly the goal, the gall
on that goal, the audacity based on what it is.

Speaker 2 (41:38):
Yeah, I love it. It's it's such a great word.
It's like a little pearl clutching word. I don't think
we use it enough. I let's use it for the
goal and it comes Yeah, it comes from the gallbladder.

Speaker 3 (41:50):
Okay, Like why what does the.

Speaker 2 (41:52):
Gallbladder have to do with personality or temperament or daring?
So today we may not think that often of our gallbladder,
except for the subset of us who have been at
the mercy of our organ because of gallstones or coally
systectomy or some other reason. Like how many of you
out there listening knew what the gallbladder did or could

(42:15):
locate it on a diagram before this episode? I could
not at all. Yeah, I mean you could do it.

Speaker 3 (42:21):
Yeah. We don't think about it very often. We don't.

Speaker 2 (42:24):
We don't. But this sort of backseat, overlooked role that
the gallbladder now plays is actually a relatively recent one.
For centuries, the gallbladder, or maybe more precisely, the substance
that it stores, was a star. It was famous among
the organs, or among the substances produced by organs, crucial

(42:47):
for how it affected not only your health and well being,
but also your outlook on life? What and that is
the story that I want to tell today. Okay, I've
touched on it in other episodes of the podcast, but
it's not one that I've ever really told or thought
about in full. And so what better time to discuss
the humoral theory of disease? Yes? Eight years into this? Yeah,

(43:15):
so you might be thinking, Okay, well, what do we
care about an outdated and disproven model for understanding human
health and disease? Fair enough, I care, I mean yeah,
but I asked myself, why is this really the right
thing to do? It doesn't give us a ton of
accurate info about our bodies inner workings, but it does

(43:37):
give us insight into how the world was perceived in
past centuries and how that perception actually lingers today in
a surprising way, long after the humoral theory of disease
was supposedly discarded in favor of germ theory and other
concepts of modern medicine. Okay, but before we get too

(43:58):
deep into the humors, I figured I should at least
share some fun gallbladder facts that get collected.

Speaker 3 (44:04):
Give it.

Speaker 2 (44:05):
The largest gallstone removed laparoscopically was twelve point eight centimeters
long and seven centimeters wide, So that's five point one
inches two point eight five point one by two point
eight inches.

Speaker 3 (44:20):
Yeah, that's hefty.

Speaker 2 (44:21):
It's hefty. It's like a smallish avocado, is what I
would say, like a quite small avocado.

Speaker 3 (44:27):
Just stitting in your gut.

Speaker 2 (44:30):
That was a laparoscopic removal for Yeah, the largest removed
in a traditional surgery, at least like documented in recent times,
was sixteen point eight centimeters long and seven point eight
centimeters wide, so it's like six point six and a
half by three inches. It's like it's large avocado, good
sized avocado. Avocado. And also they kind of art were avocado.

Speaker 3 (44:52):
Shaped because the gall bladder is a little alike.

Speaker 2 (44:55):
It's avocado.

Speaker 3 (44:56):
Yeah, pair shaped, avocado shaped.

Speaker 2 (44:58):
That one weighed to one and seventy eight grams or
zero point six pounds. Wow, it's a large avocado lot.
I've got citations for those, But this next one comes
from a more questionable source. So I googled like largest
gallstone and then found the ones that are like in

(45:18):
you know, medical journals. But then the Guinness Book of
World Records of course has an entry stop it quote
the largest gallstone reported in medical literature was one of
six point two nine kilograms or thirteen pounds fourteen ounces
removed from an eighty year old woman by doctor Humphrey
Arthur at charing Cross Hospital, London. Okay, yeah, okay, no

(45:43):
citation provided for this, so I hunted it down. I
read the original paper titled a Large Abdominal Calculus by
Humphrey Arthur. Couldn't find anything in that paper that was like,
this is a gallstone. I made you read.

Speaker 3 (45:55):
It, huh?

Speaker 2 (45:55):
And I was like, do you see anywhere that they
tie this to a gallstone they identify as a gallstone.

Speaker 3 (46:01):
And it doesn't sound like a gallstone either, doesn't sound
like a bladderstone.

Speaker 2 (46:05):
Yep. In the paper it's not a gallstone. So someone
has got to notify Guinness to say, you know, sorry,
that ain't a gallstone.

Speaker 3 (46:14):
Listen, Guinness, wrong, are you hearing this? Can someone at
them right now, right now, right this minute? You have
your largest gallstone? Wrong?

Speaker 2 (46:23):
Yeah? Wrong? I mean the largest one I could find
in the literature was point six pounds. That's not thirteen.

Speaker 3 (46:29):
Pounds fast difference, fast pounds. Yeah.

Speaker 2 (46:32):
So anyway, I.

Speaker 3 (46:33):
Will say, don't you remember at the Sturgical Science museum
in Chicago. They had some hefty gallstones.

Speaker 2 (46:40):
There had so many gallstones. Yeah, it's highly recommended, such
a great museum. Yeah, let's go back. Okay, Okay, gallstones
have been found in ancient Egyptian mummies.

Speaker 3 (46:53):
Of course.

Speaker 2 (46:53):
There is a bronze model of a sheep liver and
gallbladder from the second century BCE that was found in
a field in Italy, and the first gallstone removals began
in the late nineteenth century, led by German surgeon Carl
Langenbuk who reasoned that some mammals don't have a gallbladder,
so that probably means that humans can survive with that

(47:16):
one that but like they were like, eh, that's probably fine.

Speaker 3 (47:21):
That's probably fine.

Speaker 2 (47:23):
Previously, surgeons would treat gallstones or like any gallbladder complaint
primarily by like creating kind of an opening like you described,
like a fish Jula's what they described, to excess and remove.

Speaker 3 (47:35):
Stones, remove stones.

Speaker 2 (47:37):
Yeah, okay, what else we can add acute coalesistitis to
the list of things that allegedly killed Alexander the Great. Oh,
I think we've covered like poisons on this before, or
some infection, whether it was typhus or typhoid. Who knows.

Speaker 3 (47:55):
I mean, you can have poisons, so you can get
colosistitis from not gallstones, like ten percent of cases are
called a calculus. So maybe in fact it was both
a poison and a cute could be?

Speaker 2 (48:08):
Could be. The famous American surgeon William Stewart Halsted performed
surgery on his mom to remove gallstones in eighteen eighty one,
prolonged her life by a couple of years, And in
September nineteen sixty five, President Lyndon B. Johnson had his
gallbladder removed. Okay, you know, laparoscopy helped cut down complications

(48:33):
and speed up healing time, and the first laparoscopic coali
systectomy was performed in nineteen eighty five. And now we've
got robotic assisted coally systectomies. Yeah, pretty pretty cool. Revolutionary
healing time is yeah, it's it's neat. It's neat stuff.
That's the end of my gallbladder facts.

Speaker 3 (48:51):
Love it.

Speaker 2 (48:52):
Let me know if you out there have more for me.
That's really all that I could find for this. Go
onto humoral theory.

Speaker 3 (48:59):
Okay.

Speaker 2 (49:02):
In the fifth century BCE, our old friend friend of
the pod Hyppocrates, along with his buds put together the
revolutionary medical texts that would come to rule Western medicine
over the next two thousand years. In it, they described
a person's health, their psychology, character, behavior, preferences, and appearance,

(49:24):
and how all of this could be traced back to
the balance or imbalance of four substances in the body.
The humors. Quoting from Galen, who was a few centuries later,
quote to begin at the beginning, The elements from which
the world is made are air, fire, water, and earth.

(49:44):
The seasons from which the year is composed are spring, summer, winter,
and autumn. The humors from which animals and humans are
composed are yellow bile, blood, phlem, and black bile. End quote.

Speaker 3 (50:00):
I love it, He's like listen, it's four four four, okay.

Speaker 2 (50:04):
Four four four. There's a symmetry that is beautiful, undeniable, undeniable.
The humors were related to the elements of the world,
like air and blood, water and phlegm, fire and yellow bile,
earth and black bile interesting, and also to temperature and moisture.
So blood was hot and moist, phlegm was cold and moist.

(50:28):
Yellow bial was hot and dry and melancholy or black bile.

Speaker 3 (50:33):
Was cold and dry, okay, interesting, too.

Speaker 2 (50:36):
Much of one humor could be deadly. Your death could
be caused by excess phlegm, like that would be on
your death certificate. Let's say you maybe ate too much
of something or drank too much of something that gave
you that excess phlem. That was what led to it,
and treatments were advised based on the precise imbalance. If
it was an excess of blood, bleeding was your best

(50:58):
course of action. If it was yellow or black bile
that you had too much of, you should probably take
some laxatives or emetics, something to make you throw up.
And if it was phlegm that was bothering you, like
it clearly is bothering me. Nothing better, Nothing is better
than something that caused you to sweat or expectorate.

Speaker 3 (51:18):
Quick question. Sure is phlem back then the same thing
as phlem today?

Speaker 2 (51:26):
I think so, But it's kind of this is where
it gets a little bit weird, because what the heck
is black bile?

Speaker 3 (51:34):
Yeah, that's what that was gonna be my next question.

Speaker 2 (51:36):
Yeah, it's we'll get a little bit more. No, we'll
get a little bit more into it. But like I
think that we have to suspend our our perception of
we have to see what these substances are and where
they're coming from, because a lot of it was not
in how they're coming out of your body, but just.

Speaker 3 (51:55):
This like idea of how they exist in your body. Yeah, okay,
I feel like I always thought of flem as like lymph,
and I know that they didn't really know that that
was the thing, but like in my brain act like
that's what it is.

Speaker 2 (52:08):
Yeah, right, and maybe it is. You know, sometimes these
did come out like you could see maybe flem is
you know, snot or whatever. Blood obviously is more visible,
but like there's blood. Wasn't necessarily blood if that makes sense.

Speaker 3 (52:24):
Oh my god, it doesn't, but I'm going to go
with it.

Speaker 2 (52:26):
You know, like, well there was like the blood that
you bleed, and then there was the blood that was
like a part of your core that beat was different, Yeah,
which really I mean we got to just try to
think in their in their minds. Yeah. And so what

(52:46):
you what you wanted to do with treatment was basically
treat with opposites, so like allopathy as opposed to homeopathy,
which is like like with like and so guided by
these general principles, people suffering from whatever ailment didn't necessarily
have to seek the help of a physician only in
extreme cases, but they could concoct their own remedy or

(53:07):
buy a home remedy. Poultices, aenem syrups, potions, powders, pills, ointments, antidotes, fomentations, inhalations, infusions.

Speaker 3 (53:16):
Lots of options, less possibilities yep.

Speaker 2 (53:19):
And the quality of the treatment was determined not by
its efficacy necessarily, but generally how rare or expensive the
ingredients were or how complicated it was to put together.
But even for the healthy person, there were general guidelines
for how to live your life under the humoral theory
of disease. Eat less in the summer and more in

(53:41):
the winter. Beer nourishes provokes urine has a laxative effect,
causes gas truth vinegar induces melancholy. I'm not sure about
that one.

Speaker 3 (53:57):
For me.

Speaker 2 (53:58):
Ye, blood letting is best in springtime and only for
those older than seventeen. Baths are not recommended during the
summer months, which is also a time to eat cold
food and avoid lovemaking, Oh dear, which might be related
to the baths. Okay, sideline, I'm not sure, but alongside

(54:21):
temporary imbalances. Rocking the boat people tended to have a
certain humoral imbalance, which determine their personality. Those with more
yellow bile or collar colar were choleric, achievement oriented, driven, bold, decisive, independent, argumentative.
These this yellow bile was associated with or people of

(54:44):
this temperament was associated with summer and adolescence or youth.
If you had an excess of black bile, you were
of the melancholic personality, sensitive, indirect, detail oriented, loyal, associated
with maturity and audit, and a tendency to delirium or depression.
A phlegmatic person or phlegmatic person had more. You guessed

(55:08):
at phlem and they tended to be calm, steady, introverted, agreeable, indirect,
slow to action, associated with winter and old age.

Speaker 3 (55:18):
Okay.

Speaker 2 (55:19):
And then finally, more blood led to a sanguine personality, optimistic, social, serene,
fun loving, extroverted, active, associated with springtime and childhood. And
there's like diagrams that you can see that have like
these different colors. So like red is sanguine, obviously, black
biles black. I'm pretty sure yellow bile is yellow, and

(55:42):
then phlegm, I think is orange or not orange blue. Interesting, Yeah,
and it has like it's like an idiogram. Yeah, I
don't know if there are like wings and whatever. And
I was like thinking in my head, like, oh yeah
that you know, yellow bile, the choleric personality really sounds
kind of like an eight or a three, And then
like yeah, but then I was like, I can't these

(56:04):
are not one to one.

Speaker 3 (56:05):
Yeah, obviously obviously, but yeah.

Speaker 2 (56:08):
So the humoral theory of disease provided a framework to
understand not only a person's health or disease, but also
their emotions and personality, linking the two. And it drew
connections between the environment, diet, and just inborn temperament to
not only explain a disease, but also to provide a
prognosis how the disease was expected to play out, guided

(56:32):
by adjustments to humoral balance. And more than this, the
humoral theory of disease represents a revolution in how people
understood the world to work. Rather than divine intervention or superstition,
there was a physical basis for every phenomenon of the
human body and a corresponding explanation. All you had to

(56:55):
do was closely observe your patient, maybe take a case history,
which led you to a diagnosis than prognosis than treatment.
This approach to medicine was really the first to resemble
the scientific one that we use today to some extent.
Interesting because instead of there being one answer to every

(57:17):
question of why, which would be because God decrete it,
there could be a multitude of answers. This framework of
humoral theory had its own logic, even if that logic
is not based on our current understanding of anatomy and physiology,
and it allowed physicians to, you know, do all of

(57:39):
these things in order to care for their patient. And
the humoral theory of disease persisted for centuries despite the
you know, the lack in our eyes were like you
kidding me, what even is black bios like, what is that?
What is it? Based? Not based on fact or on
what we know? It's still persisted because it gave meaning

(58:03):
to the world. It answered these unanswerable questions, and I
think it provided some form of certainty, and we know
how much people hate uncertainty. Yeah, and so in this way,
the humoral theory of disease was deterministic, like everything including
behavior and mood, could be explained as it related to humors. Oh, well,

(58:24):
of course you have this, you know, like and I
imagine that would be both satisfying and also like very irritating, right, Like, no,
I'm not upset because I ate hot soup and my
bile is up. I'm upset because you borrowed my toga
and you stained it. But you have a sanguine temperament,
so of course you wouldn't understand. But at the same time,

(58:50):
people couldn't use their humoral imbalance as an excuse for
bad behavior, like if an imbalance represented a diseased, unnatural
state of being, they should try to act against it,
to use their rational mind to make decisions and take action, like.

Speaker 3 (59:05):
You're supposed to overcome this kind.

Speaker 2 (59:07):
Of yeah, yeah yeah, and to not overcome it, to
be beholden to your inborn temperament was kind of like
viewed as a weakness like you know better, Yeah, fascinating, okay.
And so the order and explanatory power that the humoral
system provided is really what helped it survive for so

(59:30):
many centuries because it could be folded into any religion
like this is how whatever deity you believed in created humanity.
It could explain any illness or any state of mind,
and it was adaptable. Like if you needed to add
a little bit more color to your diagnosis, you could
just say, well, you know, it wasn't just an excess
of blood, but it was the type of blood, how

(59:52):
viscous it was, where it came from, which organ or
like part of the body was it concentrated in.

Speaker 3 (59:58):
Could get really really neat gritty with you could your
various humors yep.

Speaker 2 (01:00:04):
So like smallpox, for instance, was believed by one ancient
physician to be the result of retained menstrual blood by
the fetus. So like you got smallpox as a fifteen
year old because as a fetus there was retained menstrual
blood in your mom's womb.

Speaker 3 (01:00:21):
Oh like not okay, yeah, oh okay, like okay exactly.

Speaker 2 (01:00:28):
So like there's there's no limit to the mental gymnastics
that you can do.

Speaker 3 (01:00:32):
Yeah wow, okay, just come up with an idea and
then you could say you could you could humor it.

Speaker 2 (01:00:40):
There you go.

Speaker 3 (01:00:43):
Uh.

Speaker 2 (01:00:43):
Infectious inheritable diseases also fit nicely into this, since miasma
explained how could it could be transmitted from person to person,
like humors and humoral temperament could be transferred from parent
to offspring.

Speaker 3 (01:00:57):
MM naturally.

Speaker 2 (01:01:00):
Were also less about curing someone than they were about
guiding someone through their natural course of disease and doing
their best to get the best outcome, and with things
like diet and then later on herbal remedies. So this
left more wiggle room for physicians who weren't expected to
cure their patients. So it wasn't like you don't know
what you're talking about because this person's not getting better.

(01:01:23):
It was just like, this is the destiny, and I'm
trying to do my best to fix things, but I'm
you know, I can only do so much.

Speaker 3 (01:01:32):
I'm limited.

Speaker 2 (01:01:33):
I'm limited. Yeah, And the basic principles of humoral theory
were also fairly easy to grasp, Like if you could
remember each of the humors and what season or moisture
they were associated with, and then various foods and their
you know, moisture or heat levels, yeah, you could make
a good guess as to what your disease was and

(01:01:54):
how to manage it, even if you had no formal
training or education.

Speaker 3 (01:01:57):
Okay.

Speaker 2 (01:01:59):
The other thing that let humoral theory rain was that
autopsies were not permitted for a good chunk of this time.
That excess of black bile was based on external observations
of just like someone's symptoms, and as we'll later see,
fact checking would undermine the credibility of humoralism.

Speaker 3 (01:02:21):
Once they tried to find out what the heck is
black bile, then they were like, there is no such thing. Okay.

Speaker 2 (01:02:31):
And this isn't to say that humoral theory remained unchanged
until the seventeenth and eighteenth centuries. You know, there were
scholars like the famous Persian physician Avicenna who added his
flare to it, and overall interpretations became more complex, as
did the mental gymnastics that were required to come up
with these explanations. So, for instance, a combination of heat

(01:02:54):
and the liver weakness of the spleen, external cold and
a long disease history could lead to a heightened amount
of black bile in the organism.

Speaker 3 (01:03:01):
Okay, how do they know what is a liver and
what is a spleen if they're not yeah, and animals okay,
animals okay, And then they they really do okay.

Speaker 2 (01:03:13):
Yeah, they would do autopsy or not autopsies, dissections on
animals and then like make assumptions like that must be
what the human coralate is.

Speaker 3 (01:03:23):
Yeah, so do we even know if yellow bile is
what we call bile today?

Speaker 2 (01:03:30):
I think it was because I believe that Hippocrates thought
it was produced by the liver or not not the liver,
but a he thought it was produced actually by the
gallbladder by we're going to attach to the liver, got it.
So I do think that it was related to the bile.

Speaker 3 (01:03:46):
That we we have at least those coralates, and phlem
might be really phlem and then black bio is the
real question mark here.

Speaker 2 (01:03:52):
Yeah, I had a little bit about black bile, but
now I have forgotten what it was. It was just
sort of like, we don't really know it a certain
type of blood, is it? I don't know.

Speaker 3 (01:04:03):
Interesting so interesting arin.

Speaker 2 (01:04:05):
Yeah, And humoral theory, it's not like it remained super
popular during this entire time, so it fell out of
favor occasionally, like in the Middle Ages when Christianity was
on the rise and treatment was thought to like corrupt
the soul and go against like God's wishes, or when
an epidemic exhausted the explanatory power of humoral theory, like

(01:04:29):
when the Black Death struck Western Eurasia in the mid
fourteenth century. You can't explain away a third to a
half of the population dying because they all took a
bath in the summer.

Speaker 3 (01:04:39):
Like that's that's just can't do that.

Speaker 2 (01:04:42):
Yeah, yeah, So that was a crack in the certainty
that humoralism had provided, and that crack just widened over
the next centuries as people tried out alternative frameworks to
understand the world, you know, magic, religion, alchemy, homeopathy, anatomy.
By the seventeenth century, humoralism was under threat, with the

(01:05:04):
taboo against dissections slowly breaking down. You had anatomous like
Visalius publishing intricate drawings of the human body, and artists
like Michelangelo celebrating the naked form. People were gaining a
clearer insight into structure and function. And then you have
microscopes allowing a view of the world as it had

(01:05:25):
never before been seen. What these new perspectives revealed was
that humoral theory simply did not hold up under scrutiny.
The vena cava was not connected to the liver as
Galen had claimed, nor were the lungs simply there to
cool the heart. Oh, I mean, there were entire humoral

(01:05:45):
structures missing.

Speaker 3 (01:05:48):
Wow.

Speaker 2 (01:05:50):
I mean, yeah, we've talked about breath before and how
it was not understood why.

Speaker 3 (01:05:55):
Breath was what breath was.

Speaker 2 (01:05:56):
Yeah, yeah, because we didn't know about oxygen. And yeah.
Anatomical dissections ironically were permitted because they were supposed to
support humoral theory and provide more detail, not dethrone it,
and so Visalius's findings were quite an unwelcome shock to
the medical establishment of the mid sixteenth century, which had,

(01:06:18):
you know, still was adhering to Galen's teachings. But you
couldn't uncrack that egg, and this marked the beginning of
the end for humoralism. Observable evidence obtained through experimentation became
the gold standard for establishing new laws of nature and
guidelines for practicing medicine, just empiricism basically, but there was

(01:06:41):
no concept of health and disease that could immediately replace
humoral theory, and so it was a slow decline. It
didn't help that humoralism was literally embedded in language, not
just for physicians or scientists, but for everyone, Like it
was how you understood yourself, it was how you understood
the way you moved about the world. Blood wasn't just

(01:07:01):
blood it could be invigorating or excessive, pure or corrupt.
But that connection grew thin as scientists discovered that blood,
well was just blood, and the human body actually bore
a closer resemblance to the machines that engineers were inventing,
rather than the mystical being imagined by the ancients. The

(01:07:25):
feeling was that everything would eventually be figured out in
short order, and for many things that was true. The
nineteenth century saw germ theory oust miasma, The circulatory system
was fully mapped, the beginnings of hormones and vitamins were
starting to be understood, and there were effective treatments developed
for a myriad of illnesses. Bit by bit, body part

(01:07:47):
by body part, medicine was laying claim to distinct areas
of human health. The one realm that seemed stubbornly opaque
was the brain and nervous system. Still true, neurology as
it was born in the late eighteen hundreds wasn't explicitly
modeled after humoralism, but it certainly paralleled it. Hysteria was

(01:08:11):
associated with excess fluidity okay, and was thought to be
impacted by diet exercise. Too much of this, too little
of that some of which might have a trace of
truth to it, right.

Speaker 3 (01:08:21):
I think that's what's so interesting about I mean, like,
you know, not to the extreme of like don't do
this in summer, don't do this in winter, but like
so much of it is like still, like we should
move our bodies makes sense?

Speaker 2 (01:08:36):
Is common sense? A lot of it is just common
sense advice. Yeah, but then there were Yeah, things like
neurasthenia also had associations that were very like humoral in nature.
Melancholy remained pretty much unchanged in its conception. It was like, oh,
black bile cooled the brain, it makes you depressed.

Speaker 3 (01:08:54):
Interesting.

Speaker 2 (01:08:56):
The psychiatrist of decades past, just like those today, have
sought to bridge the gap between the brain and the mind,
and part of that bridge has really been constructed with
the concept of temperaments, Like why do we respond the
way we do to certain events? Do certain individuals tend

(01:09:17):
to be affected by this disease or that disorder, whether
these are mental health illnesses, or whether these are like
physical illnesses, people who are high strung, they are thought
to have higher blood pressure and all these things.

Speaker 3 (01:09:31):
Why.

Speaker 2 (01:09:33):
The reason is because humors have not left the building.
The traces of humoral theory can be found in the
language that we use, like sanguine, like melancholy, good, humored,
bilious gall In Greek, the word coli means bile. Melon
means black, So melancholy black bile, Like that is directly

(01:09:53):
what it comes from. Isn't that fascinating?

Speaker 3 (01:09:56):
Wow? I didn't know that.

Speaker 2 (01:09:57):
Yeah huh. But the humoral theory has also lingered beyond linguistics,
like we still seek balance in our lives, whether it's
our work life balance, getting the right the balance, diet,
enough exercise and relaxation. We feel like we should eat
certain foods in certain times of year, right, like warm

(01:10:21):
and hearty soups in the winter. We take ginger for
nausea and humoralism ginger is warming, and so that was
supposed to help to combat whatever it is, phlem or something. Yeah, yeah,
eucalyptus for stuff sinuses like, also straight from humoral theory.
We're only now recognizing the role that diet might play

(01:10:44):
in a myriad of things that we just kind of
had discarded previously, like mental health, maybe via our microbiome.
This would not have surprised humorists at all, which I
find really fun and interesting.

Speaker 3 (01:10:57):
It's all a circle.

Speaker 2 (01:10:58):
It's all a circle.

Speaker 3 (01:10:59):
Yeah.

Speaker 2 (01:11:00):
Today, scientists and medical practitioners operate under a framework that's
been refined by decades of observation and experimentation, and we
rely on these general rules to make sense of the world.
But when we discarded humoralism in favor of empirical science,

(01:11:21):
we also left behind perhaps what I think is like
the most important lesson of humoral theory, and that is
that each patient is a unique person, and you have
to first understand that individual and where they come from
and who they are in order to help them. So
like that's I don't know, that was something that I
was thinking about in terms of like just how the temperaments. Yes,

(01:11:45):
it is putting people in boxes, but it is also
acknowledging them as individual people right at the same time.
So I just thought that was an interesting little foray.
That's the lesson that I could draw from humoralism. I mean,
to be honest, just full disclosure. I wrote most of
this when I was sick, and so I like reading

(01:12:07):
it over. I was like, wow, this feels like a
fever dream. You can hear it in my voice to me.

Speaker 3 (01:12:13):
Maybe the humoral theory all is it is a fever dreamer,
so maybe it.

Speaker 2 (01:12:17):
Was a fever dream. Yeah. I had no idea what
I was going to do for gallbladders. I did not
expect to come down this path of funeral theory of disease,
but I thought it was fun Then I was like thinking, like,
what what humoral temperament? Temperament? Am I?

Speaker 1 (01:12:33):
Yeah?

Speaker 3 (01:12:33):
What are you?

Speaker 2 (01:12:36):
I don't know. I asked my sister actually, and she
said I was choleric, which is like the argumentative one I.

Speaker 3 (01:12:44):
Would I would agree with that, but I would say
I was going to guess myself is the same, So I.

Speaker 2 (01:12:51):
Think we might be. Yeah, we might be a mix
of of choleric and sanguine as well.

Speaker 3 (01:12:55):
I think on the border line there yellow and red,
perfect can optimistic also, right, yeah, sometimes, But that's all.

Speaker 2 (01:13:06):
I've got for gallbladder, which is really the humoral theory
of disease.

Speaker 3 (01:13:10):
I did not expect that journey, and I really quite
enjoyed it.

Speaker 2 (01:13:14):
I'm glad. I'm glad. What's what's going on with gallbladder
stuff today? Let's let's wrap this up by getting back
to where we started.

Speaker 3 (01:13:21):
Sure, let me tell you about it. I kind of

(01:13:54):
already told you about it, Aaron, Honestly, Okay, ten to
fifteen of adults in the US and in Europe, and
we don't have data on like across the whole globe,
but it's estimated on average ten to fifteen percent of
adults end up with gallstones. But luckily most people eighty
percent or so of people with gallstones are asymptomatic. The

(01:14:17):
other twenty percent may end up with complications at some point.
Ten to fifteen percent of those complications will be acute colisciitis,
so that is by and large the most common complication
of gallstones. There are pretty big differences in like prevalence
of gallstones, especially if you're looking at different like racial

(01:14:40):
or ethnic groups, like within the US, for example. But
it is not necessarily thought that this is genetic, Like
we haven't found genetic markers that clearly explain this, and
so the thought is maybe it's more related to say,
dietary factors in different like populations or different areas, which
my underscore that it's just a social construct after all.

Speaker 2 (01:15:02):
Of course, Okay, I did think though that like there
tended to be gallbladder like family history of gallbladder might
or gallbladder removal makes you more likely to have gallbladder there.

Speaker 3 (01:15:14):
Yeah, so there are some like familial clustering, but we
still haven't found any like genetic markers. So is it
microbiome where you know, you have similar microbiomes when you
live in the same households and things. I don't know.
We don't know, Okay, does it could also be genetic
and we just don't know it yet. Sure, people assigned
female at birth are more likely to have complications from gallstones,

(01:15:35):
although that's also less true in older populations, Like it
kind of evens out the older that you get. So
that's why it's maybe thought. Is it the estrogen that
we have higher levels of, especially you know in our
younger years prior to menopause. We don't. We don't know,
but those are some of the risk factors. There's also
other things. Sometimes higher BMI is associated with the higher

(01:15:57):
risk of gallstones, but also so is weight loss associated
with gallstones and complications. I mentioned diabetes and some of
our diabetes medications. And we know too that it's not
just a cute coli cystitis. The incidence of acute pancreatitis
is about forty per one hundred thousand each year in
the US. Okay, I should have aired mathat but I didn't.

(01:16:23):
But about fifty percent of those are from gallstones, and
gallstones are kind of the major risk factor for gallbladder cancer,
of which there are an estimated one hundred and fifteen
thousand or socases each year across the whole globe. So
that's my stats. Okay. According to most sources in the US,

(01:16:45):
there are about half a million Coli systectomies performed every
single year, So that means half a million gallbladders. Get
the bucket kicked? WHOA, I know it's a lot, right. Oh.

Speaker 2 (01:16:58):
I have a question, okay, if you have a liver transplant,
uh huh, is the gallbladder ever come with?

Speaker 3 (01:17:10):
I don't think so.

Speaker 2 (01:17:11):
No, Okay, I don't know why. I was just curious.

Speaker 3 (01:17:14):
That's an interesting question, I think so. No, okay, great question.
Do they take the gallbladder out? I don't. I feel
like I ought to know more about this, but they're like, yeah,
they're butts their pals. There's a little pouch for it. Yeah. No,

(01:17:34):
I don't know. Great question.

Speaker 2 (01:17:38):
I love that you abbreviated question. Great question.

Speaker 3 (01:17:42):
Listen, what are we doing in terms of research with
the gallbladder. Great question. I don't know, okay, okay, but
I did find a really interesting paper. It was like
real long and like deep in detail. So if someone
wants to get deep into this, I got some sources
for you. I underestimate just how important bio acids are

(01:18:05):
and how much of a role they serve outside of
just digesting are fats. They're important in like intestinal homeostasis.
They're important in like absorption. But if there's too much
of them that makes it to the colon, they can
end up causing diarrhea. If there's not enough, you can
end up with chronic constipation. So there's been like bio

(01:18:27):
acid dysfunction implicated in ibs. They're affecting our microbiome. That
might even affect the increases in risk in colon cancer.
And we've seen a lot about colon cancer lately and
increased risk especially in young folks. That might have something
to do with bio acids. We don't know, still up
for debate, And there's just increasing evidence of bio acid's

(01:18:49):
role in a myriad of other disease processes, and so
there's research ongoing into using drugs that target bio acid receptors.
Either black looking them or activating them as potential treatments
for a number of different diseases. We also do use
bile acid sequestrians, so that's like things that grab onto

(01:19:11):
bile acids and help us to just poop them out
rather than reabsorbing them, mostly to treat elevated cholesterol. But
we don't use them really often because they have quite
a lot of side effects, especially diarrhea and like bloating
and things like that. So yeah, none of that is
very gall bladder specific, but it's just I mean, but bile,
bile and bile acids so so interesting. So if you

(01:19:33):
want to read more, let us tell you about all
of our sources.

Speaker 2 (01:19:37):
Yes, if you want to read more about definitely something
that is not gallblader specific in any way, shape or form.
There is a book called Passions and Tempers and it's
about the humoral theory of disease by Noga Arika. And
then there's a paper which just has a few funt tedbits.

(01:19:58):
It's a book chapter actually called History of Medical and
Surgical Management of Acute Coalesistitis by Barry and Frank from
twenty fifteen. And I've got a few more sources, especially
on those big gallstones and you know, so Guinness Booker
World Records, get on this.

Speaker 3 (01:20:16):
Yeah. I also had a number of sources I used,
primarily also a textbook chapter. It was from the textbook
Comprehensive Physiology, and the chapter was called Functions of the gallbladder. Surprise, surprise.
I also used a bunch of other specific papers to
look at. For example, there was one from the Lancet

(01:20:37):
in two thousand and six called Cholesterol gallstone Disease. There
was a Gamma review from twenty twenty two called acute coalsistitis,
a review I've got one on gall bladder cancer, one
on pancreatitis, a few others on bile acids, both the
synthesis and their use in these other like the other
functions that they serve. You can find all of that
on our website, this podcast we Kill You dot Com

(01:20:59):
under the episodes tab.

Speaker 2 (01:21:01):
Certainly, Ken Maria, thank you so much again for sharing
your story.

Speaker 3 (01:21:08):
Yes, seriously, thank you so much, so much for telling
us that story and sharing it with all of our listeners.
We really appreciate it.

Speaker 2 (01:21:17):
Thank you to Blood Mobile for providing the music for
this episode and all of our episodes.

Speaker 3 (01:21:22):
Thank you to Tom and Leanna and Brent and Pete
and Jessica and everyone and exactly right for everything that
you do to make this podcast possible.

Speaker 2 (01:21:32):
Thank you, Thank you, and thank you to you listeners
and watchers fans of this podcast will kill you. We
really appreciate the time that you take to you know,
just support the show by watching it's and listening. It's
really it means the world to us. We do this
for you, It's true. So let us know what you
think of the gallbladder. What what temperament are you? What

(01:21:56):
you know hippocratic temperament or whatever are you?

Speaker 3 (01:21:58):
Let us know And as special shout out as always
to our patrons, thank you so much for your support
overround Patreon. We really appreciate it. It means so much
to us.

Speaker 2 (01:22:09):
We do well. Until next time, wash your hands

Speaker 3 (01:22:12):
You feel the animals