Wednesday, February 14, 2007

Liverly


Ever soaped your sweetie in the shower? Or, to be less (so I've been told) disturbing: have you held a piece of hardwood, turned and sanded smooth as glass, oiled and rubbed until it's like hot ice; passed your hand over the surface, thrilled at its silkiness, its undulating shape? Did you find it stunningly beautiful? If so, you have an idea of what your liver feels like. But really, because it's warm and taut and alive, the first question conjures it more closely. In terms of touch.

Surpassingly smooth, firm and full as a biker's buttock (I ride a Trek 5500), resolutely protected by the ribs and sealed snugly -- by surface tension and suction -- under the diaphragm, the liver releases itself with a certain reluctance. To explore it, you must make it come to you, but its barely-moist slipperiness resists exposure: you have to insinuate your latexed fingers gently between its lower edge and the underside of the ribcage, usually far to the left, while bending your wrist back to get the angle right. Then, as you glide upward and over, feeling the corrugation of the ribs across the back of your hand, you can guide yourself all the way to the dramatically domed apex.

There's not much space; what little there is tightens rhythmically with each breath. By pulling gently but insistently downward you precipitate a releasing of suction, and the liver falls partly toward you, not always silently, an exhalation. Too forceful, and the capsule could tear into the substance, like what happens sometimes when pulling the membrane off a boiled egg. You sweep over a mass larger by far than your open palm; chunky, chocolate, yet feeling as if it could shine in the dark. Nearly luminous; like a living agate. Sometimes, in order fully to free the liver, you need to slide your hand all the way across the top surface; in doing so your hand is more than full, and with it, your senses. The glide, the only slightly-yielding thickness, the meaty heat, the landscape as it moves your palm up and down, the fingers together and apart. Close by, separated by the thinnest part of the diaphragm, beats the heart; its throb is on the back of your hand, and under it. In some people, the pattern of the ribs is inverted onto the surface of the liver, making furrows and waves.

This is beauty a lucky few are privileged to experience. I've said it before: to me it's exhilarating. A gift given only to some, it is in no way based on worthiness. Which is why it's also humbling. And why I keep trying to convey the feeling: to give everyone the amazement I've been lucky to know. Once more I find myself using sensual terms, sounding sexual. But other than enabling transcendent joy from physical sensations, it really isn't; not like that. Not any more than being overwhelmed at the sight and smell and sound of the ocean, feeling like you could fly. The insides of the human body have awed me, filled my senses. I'm trying to let you in on it.

The liver, for its bulk, in its bastion, seems to preside over it all. To the ancients, it -- not the heart or the brain -- was the seat of the soul. And, while literally sensational to me, it's also terrifying. A dark crystal ball, the liver truly augurs your future. Unlike the soothsayer, it doesn't misinform. As delightful as it is in perfection, so are its imperfections portentous. Nothing in the operating room savages me more than when that sliding hand finds its way to something awful. It augers unwell for life. Searching the abdomen for signs of trouble when operating on cancer, -- say, of the colon -- feeling it in the liver sinks the heart, deflates hope, robs you of a job well done. It changes the climate with the suddenness of a thunderstorm; forces into your head terrible truths, from which there's no escaping the need to be told.

In the injured person brought rapidly to surgery, my hand goes first to the liver, over the top; and when a finger finds its way to a crack, and falls in, my pulse rises faster than the patient's, fearfully. Broken, the liver can defy every effort to put it back together. Fractured like a melon, it bleeds in a way that wells up and overflows, too fast to see into the depths, defying attempts to stanch it. Silent and relentless, it's the most dire sort of bleeding there is. (Some lacerations are very simple to care for, actually. Big, deep, and stellate, however, they often aren't.)

Nor does the liver lightly suffer indiscretion. Hammer-hard and knobby as knuckles, transformed from a lovely earthy purple-brown toward ghastly gray, the liver of an alcoholic rejects its most crucial blood-flow, forcing it back to the gut whence it came, pressuring veins till they might burst. Or, filled with fat by dietary excess, it morphs to mournful mush -- red-specked and muddy yellow; sick and squishy, like putrid paste.

Makes you want to step back into the shower, alone.

24 comments:

Ali said...

The insides of the human body have awed me, filled my senses. I'm trying to let you in on it.

I had the good fortune of volunteering with a program that let me scrub in on a few surgeries in college. It was exactly that feeling of awe and exhilaration that I couldn't forget and drew me back to medicine.

SeaSpray said...

Yet another moving post Dr. Schwab!

I have been anxious to read it but the boys are home from school with a snow day today. So, I wanted to wait until later when I am not competing with the sound of war games. However, I just had to read it anyway. :)

My cinnamon hot chocolate and marshmallows and I will come back later, when all is quiet, to savor this post and then I will comment.

Once again, thanks for the interesting trip into the OR allowing us to see through your eyes, think through your intellect and feel with your feelings. :)

Hmm.. I guess that I did just comment. However, in case no one has noticed - brevity with words is not my strong suit. ;)

Dr. Charles said...

i must say that you have gravitas writing about the liver on valentines day when the rest of us are spouting cliches about the heart. awesome post.

Bohemian Road Nurse... said...

If you had written my textbook, I would have done much better in anatomy class!

Sid Schwab said...

Dr C: actually, I was going to post a bit from my book about stabwounds to the heart, but I realized I'd already done so, a few months back. But, as I said, the ancients considered the liver the seat of the soul, so it seems like a valentine, if an oddly shaped one.

Anonymous said...

with the imagery created by the almost musical fluidity of that first paragraph (is it hyperbole to think this a written equivalent to a rachmaninov piano concerto? a Dvorcek symphony?).....whew, all I can say is if you are half a good a surgeon as you are a writer then the ailing world is poorer for your retirement. (But the reading world is so much enriched!)

Laurie said...

PS - I guess your stab wounds to the heart are not those that originate from Cupid's.

I guess that wouldn't be "loverly"....

Bongi said...

once as a intern after working in obstetrics for a few months and having only done caesarian sections (although many) i got the chance to assist in a general surgery operation. half way through the procedure i realised my heart was racing and i felt almost euphoric. i can't remember what the operation was but i remember the exillaration it ellicited in me. it was at that moment that i knew what i wanted to do with my life. the next week i went to see the surgery prof. still every time i do an operation i'm overwhelmed by what i'm actually doing. to cut a fellow human being open, and that with their permission??? i doubt it will ever lose it's magic for me.

Lynn Price said...

Your gifts for communicating awe over an organ remain unsurpassed. I have a particular scene I'm writing in my novel about a liver operation. Since I haven't witnessed a surgery in person, your post brings brilliant perspective to what was a mundane scene.

I'm also enjoying the heck out of your book.

Sid Schwab said...

Bongi: I can tell from your writing that you'll never lose thrill. I never did, even hernias. As you said, it's not just the act of operating per se, which is thrilling enough, but that we're allowed to do such a thing at all...

Lynn Price: I now have this fantasy of reading your book some day and finding a spot where I can say, wow, I think my writing had a little part in this...

Lynn Price said...

"Lynn Price: I now have this fantasy of reading your book some day and finding a spot where I can say, wow, I think my writing had a little part in this..."

Sidney, Sidney, what lovely words those are. While you're waiting for book 2 to get to the editor, feel free to read the first one. It's definitely medical fiction with a twist, and, given your temperment, I think you'd find it definite food for thought.

Alexandra Lynch said...

This is beautiful, Sid. I am always fascinated to read your prose on the body and sickness and health. Living with them every day, we forget what an amazing thing our bodies are, and how wonderfully they work. When I was younger, I considered medicine for precisely that reason.

I hope that the next surgeon to work on me has the reverence that you feel for the body and its fundamental beauty.

SeaSpray said...

I never did get that hot chocolate!

Awesome post - so well written. It causes me to wonder how my own surgeon views surgery and how about the OR staff?

Does it ever get so routine that "some" just take it for granted - you know - if you have seen one you've seen them all, even though the variables are going to be different each time?

Some years back, a patient was brought into the ED with what seemed to be minimal injury. The person was joking, etc, but later after being transferred out to a larger facility it turns out they died in the OR because of serious liver damage that they couldn't repair.

About a week before Christmas this past year, I almost lost a good friend because (literally died in the ED) she had an esophageal rupture while at home which came from the liver damage that she knew nothing about.

Is fatty liver reversible?

By the way I love my liver even more now. Dr. Schwab - your causing this girl to fall in love with her internal organs. Do you have any sweet talk about the kidneys? ;)

Erica said...

I never thought of the liver as beautiful before. But your imagery is so vivid, I can't help it. Wonderful read. Thank you.

Kathleen said...

hey doc??? I am have been looking for more info on the liver. I'm thinken' when I do the CP/ICT, that's gonna put a lot of responsibility on my liver. I'm kinda concerned about putting all of my eggs in one basket, so like, when I do this and say, hypothetically, if my liver conked out somewhere down the road...I want to know what that really means, other than some of the obvious...can you please direct me where I can find that info please? Thanks! Kat

beajerry said...

Good stuff.

PixelRN said...

Why do I suddenly find myself craving foie grois...

Anonymous said...

Amazing, thank you so much for the insight.

Susan said...

Dr. Schwab,
In Indonesian, a term of endearment uses the "liver". Eg: you're my sweet"heart" would be my sweet"liver" in word per word translations.
:)

TBTAM said...

Having had the experience of palpating the liver myself, I must say that you have captured the feeling beautifully. Great post.

Magpie said...

Beautifully written. Once upon a time, I had a laparoscopy of the pelvic area - at the followup, my doctor showed me the pictures and there was the edge of my liver, looking just like...a liver. It was strangely thrilling, and more interesting than my ovaries or endometriosis.

Nurse Practitioners Save Lives said...

Beautiful description. Makes me regret not going into surgery as a specialty.

dave said...

Thanks for writing this, and your "Deconstructing an Operation" series. I have undergone two liver transplants due to PSC, and so I try to learn all I can about the liver, the biliary system, and the details and process of the transplant operation itself. (I actually asked Dr Busuttil to have my first surgery videotaped so I could watch it afterwards, but I don't think he took me seriously as I was 17 years old at the time!)

kellie said...

This was an excellent read. Your words are so descriptive that I can draw a picture in my head. I love it! I know it might not be as dramatic as human medicine but, being a veterinary technician and scrubbing in on animal surgeries can be awe inspiring as well .. so, I think I can relate (if only a little bit) to what you mean in this. :)