No humour

Many people consider Hippocrates the father of Western medicine. More than 2,000 years ago, his beliefs and teachings focused on human beings having a body and a soul, and for the first time, illness was to be rooted in an imbalance of bodily fluids, rather than the result of displeasing the gods or other supernatural forces. According to Hippocrates, in order for someone to be free of illness, these fluids—collectively known as the four humours (derived from the Latin word “humour,” meaning fluid)—needed to remain in balance. The four humours are blood, yellow bile, black bile, and phlegm.

Approximately 500 years later, Galen, a prominent Roman physician, developed many of Hippocrates’ teachings into a comprehensive typology of temperament in his dissertation, De Temperamentis. He describes four temperaments that corresponded to one of the four humours: sanguine (blood), courageous and hopeful; choleric (yellow bile), easily angered and bad-tempered; melancholic (black bile), sleepless and irritable; and phlegmatic (phlegm/mucous), calm and unemotional.*

The association between yellow bile and anger holds true today as it relates to diseases and injuries of the biliary tree. Many physicians have come across, at one time or another in their career, either a raging cholangitis, gangrenous cholecystitis, or serious hepatobiliary injury. These patients tend to be quite ill and have increased morbidity and mortality. Fortunately, traumatic injuries of the biliary tree/gallbladder are relatively rare occurrences. A recent retrospective review over a 12-year period at a single trauma center revealed 33 injuries in 30 patients (0.1 percent) out of 26,014 trauma admissions. There were 10 injuries to the gallbladder and 23 injuries to the biliary tree, with a median injury severity score of 25, a median length of stay of 19 days, and a 10 percent mortality rate.†

Hospital discharge status

Hospital discharge status

To examine the occurrence of biliary tract injuries in the National Trauma Data Bank® (NTDB) research dataset for 2010, admissions medical records were searched using the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM). Specifically searched were diagnosis codes 868.02 (injury to other intra-abdominal organs without mention of open wound into cavity, bile duct, and gallbladder) and 868.12 (injury to other intra-abdominal organs with open wound into cavity, bile duct, and gallbladder). A total of 413 such injuries were uncovered; 397 records contained a hospital discharge status, including 277 patients discharged to home, 54 to acute care/rehab, and 19 to skilled nursing facilities; 47 died (see figure). These patients were 80.2 percent male, on average 33.1 years of age, had an average hospital length of stay of 17.3 days, an intensive care unit (ICU) length of stay of 9.3 days, an average injury severity score (ISS) of 21.8, and were on the ventilator for an average of 9.3 days. The mortality, hospital length of stay, ICU length of stay, ISS, and ventilator days for this group represent one of the highest subsets reported in this column to date.

The incidence of injury, overall severity, length of stay, and mortality in the NTDB review was similar to that of the study mentioned in the previous paragraph. These patients were seriously injured and required significant hospital care. The injuries may result in a leakage of bile, but there is “no humour” in a biliary tract injury.

Throughout the year, we will be highlighting data through brief reports in the Bulletin. The NTDB Annual Report 2011 is available on the ACS website as a PDF file and as a PowerPoint presentation at In addition, information regarding how to obtain NTDB data for more detailed study is available on the website. If you are interested in submitting your trauma center’s data, contact Melanie L. Neal, Manager, NTDB, at

Statistical support for this article has been provided by Chrystal Caden-Price, Data Analyst, NTDB.

* Renouard PV. History of Medicine: From Its Origin to the Nineteenth Century, with an Appendix, Containing a Philosophical and Historical Review of Medicine to the Present Time (Google eBook). Comegys CG, trans. Moore, Wilstach, Keys & Company; Cincinnati, OH: 1856. Available at Accessed September 25, 2012.

Thomson BN, Nardino B, Gumm K, Robertson AJ, Knowles BP, Collier NA, Judson R. Management of blunt and penetrating biliary tract trauma. J Trauma Acute Care Surg. 2012;72(6):1620-1625.

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