At last she called a Huntsman, and said: “Take the child
out into the wood; I will not set eyes on her again; you
must kill her and bring me her lungs and liver.”
Little Snow White, Grimms’ Fairy Tales
BLOOD-TEST RESULTS tend to come by computer these days, but when I was starting out in hospital medicine they came up twice a day from the mail room on sheaves of pink, yellow and green paper. One of my jobs was to look through the papers, then sign them to acknowledge receipt. If the results showed that a change in antibiotic was needed, or that a patient’s kidneys had failed, it was my responsibility – as the one who’d signed the papers – to do something about it.
Pink was for hematology, listing the concentration, maturity and hemoglobin levels of the cells in each patient’s blood. Yellow was for microbiology, detailing every virus or bacterium the lab had managed to isolate. Green was biochemistry, and listed those substances that give an indication of liver, thyroid and kidney function, as well as body salt levels. Each was tabulated vertically on a grid, beside older results so that trends over the course of days could be discerned.
“Liver function tests” or “LFTs” could be the most difficult to interpret, and are misnamed – they don’t indicate much about the function of the liver. Instead they measure substances that are ordinarily contained within liver tissue, but that leak out into the blood in proportion to how irritated or inflamed the organ is. It would be more accurate to call them “liver inflammation tests.” One of these, “gamma glutamyltransferase” or GGT, rises in particular when the liver is inflamed by alcohol or gallstones. Another is “alanine transaminase” or ALT – more likely to rise in hepatitis or when drugs or the immune system attack liver tissue. The liver is a mysterious organ: essential to life, multifarious in its actions, its tissue unusual in being able to regenerate. It detoxifies the blood and discharges unwanted chemicals into the bile. Another of its many functions is to create proteins that the body needs: a measure of this is the level of “albumin” in the blood. Albumin shows how well the liver is managing to generate proteins, but also of how well nourished an individual is. If someone is starving, or their liver is failing, albumin levels begin to fall.
NIAMH WHITEHOUSE was in her late twenties, a small, neat woman with ink-black hair and pointed, puckish ears. I heard the story of her life, and her illness, from one of her work colleagues. She grew up in Edinburgh, an only child, and her father died when she was seven years old. At the age of fourteen her mother remarried and Niamh ran away from home – she subsequently lost all contact with her family. She had always loved to be outdoors, and after a few years drifting in London came back up to Scotland. She found a job as a junior gardener at a stately home and worked there happily for several years, rarely leaving the estate.
While digging among rose beds one day she scratched her hand on a thorn. The wound bled, but she thought little of it. The morning after the rose scratch she didn’t feel well – dizzy and unsteady, with a fever and aching muscles. She had to stop work early, and staggered back to her cottage. She wondered if she had the flu. When the head groundsman arrived the following day to allocate her work she could barely make it to the door. “Just stay in bed today,” he told her. Later he peered through the window and saw her slumped on the sofa. She didn’t answer when he rattled the windowpane so he broke down the door and called an ambulance.
I met her on the intensive care unit, paralyzed and on a ventilator, with plastic tubes going into her nose, mouth, neck, wrist, forearm and bladder. Her eyes were taped shut to protect her corneas, and she had wires on her chest to record each heartbeat. A plastic clip shone red light through the skin of her earlobe – it provided a continuous readout of the oxygen level of her blood. She lay amid a forest of drip-stands seeping a cocktail of antibiotics, plasma substitute, transfusions and heart-strengthening drugs. Her hair straggled across the pillow like a black halo. During the struggle to put needles into her, some crimson spots of spilled blood had dripped down her neck and onto the hospital sheets.
Bacteria on the rose thorn called staphylococcus had entered her bloodstream and begun multiplying. Toxins spilling out from the bacteria were laying waste to the normal, harmonious control of her body’s functions. Soon after she’d collapsed her blood became incapable of regulating how and when to clot: scarlet patches of hemorrhage bloomed across the skin of her trunk and limbs while other parts of her bloodstream began to clot off and starve her tissues of oxygen. Small clusters of bacterial growth began flying off into her fingers and toes, causing blackened smudges on her fingertips like the blight that browns the tips of leaves. Blood pressure is ordinarily maintained by tight seals along the lining of our arteries and veins, but chemicals produced by the conflict between her own immune system and the bacteria began to break down that seal. As a consequence her capillaries became leaky: her slim figure became as waterlogged with tissue fluid as a riverbank in flood.
At first the infection proliferated only within her bloodstream, but then some imbalance sent it whirling out into her other organs. Messenger proteins from her immune system began to confuse their targets, and liver cells became caught in the crossfire. I watched the progress of this collateral damage on the green biochemistry sheets. Albumin began to fall; as the cells in her blood broke apart, the hemoglobin within them was metabolized to a waste product: “bilirubin.” Her failing liver couldn’t process the bilirubin into bile, or discharge it the usual way into the gall bladder, so the concentration of it within the blood began to rise. The bilirubin yellowed and stiffened her skin with jaundice, as if her body was embalming itself from the inside. Her GGT and then ALT began to rise, first to double the normal limits, then quadruple and beyond.
Twice a day on the ward round I’d gather with my seniors to peer at the grids of figures, trying to predict her path of recovery, or gather some hope from their trends. As she lay in bed it seemed as if she was in a state of suspended animation, but in truth every day brought her closer to death.
BEFORE IT WAS KNOWN that the heart was a pump, it was widely believed that blood was created in the liver, and flowed from there to the heart in a torrent driven by the force of its own generation. In the heart it was blended with vital spirit from the lungs then dispersed out to the tissues where it was consumed. As the source of blood, and thus of life, the liver was a symbol of power and mystery – examining it was thought to yield secrets about the future. It’s a vast, solid organ, the biggest of the abdominal viscera, with wide-bore connections into the heart’s ventricles and the intestinal system – no wonder it was thought to hold the secret to life. For Shakespeare, the quantity of blood in your liver said something about the strength of life within you: “if he were opened, and you find so much blood in his liver as will clog the foot of a flea, I’ll eat the rest of the anatomy.”
As far back as ancient Babylonia the livers of sacrificed animals were examined for their power to predict events. This method of divination is well documented in the Bible: the Book of Ezekiel describes a king planning his next move by it. A priest who predicted the future from examining the liver was known as a haruspex: “For the king of Babylon stood at the parting of the way, at the head of the two ways, to use divination: he made his arrows bright, he consulted with images, he looked in the liver.”
Another Near Eastern myth, that of Prometheus, seems to have recognized that the liver is the only whole organ capable of regeneration. Prometheus’s punishment for having stolen fire from the gods was to be chained to a rock and have eagles tear at his liver, thus attacking the origin of his life. Every day it regrew, prolonging his torture.
The practice of divining the future from the liver wasn’t confined to Mediterranean and Near Eastern cultures: the Roman historian Tacitus wrote in his Annals of the way northern Europeans sacrificed human beings, sometimes examining the “palpitating entrails” to predict the future – they weren’t averse to eating them either. Even today “I’d l
ike to eat your liver” is a term of endearment from the eastern reaches of Iran as far west as the plains of Hungary. There may be echoes of cannibalism in the speech of Iran and Hungary, but in northern Europe the tradition that Tacitus reported on has largely gone from the vernacular. It didn’t disappear entirely, however: in the folk tales gathered by Jacob and Wilhelm Grimm there are echoes of eating the liver, as well as of using entrails to predict the future.
IN THE STORY OF LITTLE SNOW WHITE, the first version of which was published by the Grimm brothers in 1812,* it’s not the examination of entrails that grants supernatural knowledge but a magic mirror – reminiscent of the Babylonian king’s anxious consultation with “images.” In the earliest versions Snow White is just seven years old when her beauty surpasses that of her mother, the Queen. “Whenever she looked at Snow White,” the story goes, “her heart heaved in her breast, she hated the girl so much.” She orders a hunter to take her daughter out and kill her, bringing back entrails – the lungs and liver – as proof of the murder.
The first version in 1812 was intended for a largely academic audience. For the second edition some tales were sanitized (for example, cannibal “mother” replaced by “stepmother”) and explicit references to sexuality and pregnancy were removed.
It’s curious that the liver and lungs were chosen as evidence, rather than the girl’s head or heart, or even her corpse. I asked Marina Warner, a distinguished academic who works on myth and fairy tale, why she thought entrails and in particular the liver were chosen in the original version of the Snow White story. “Entrails give signs,” she told me, “and the witch-like aspects of the wicked queen are enhanced by her closeness to a pagan haruspex in this, perhaps.” The huntsman couldn’t bear to kill Snow White, of course, so presented instead the organs of a pig. According to the original Grimms’ tale the Queen inspected them, was satisfied, then ate them “salted and cooked.” With a better knowledge of comparative anatomy, or even of animal butchery, the Queen would have known she’d been tricked – pig livers are lumpier than ours, the lobes of which are relatively smooth.
When the wicked Queen finds out that Snow White is still alive (and living with seven dwarfs) she dresses as an old crone and delivers three poisonous gifts. The last of these is an apple, Eve’s downfall: symbol of knowledge in the Genesis myth (and on the flip-top of personal computers). Snow White eats the poison and falls down comatose – almost as if she were suffering from blood poisoning.
This time the dwarfs can’t revive her, though “she looked still as if she were living, with her beautiful blooming cheeks.” They put her in a glass casket in order that they could go on admiring her, and because it seemed a pity to bury such a beautiful, lifelike girl.
Snow White is one of many “sleeping beauties”: beautiful young women who fall asleep as if dead in European fairy tales and myths. The earliest sleeping beauty is found in a fourteenth-century French tale, Perceforest, and just as the original Snow White tale is far darker and more disquieting than the versions we’ve come to know, so is the original Sleeping Beauty, in which the girl is raped while in her coma, then gives birth without waking up. In a seventeenth-century Neapolitan version Sleeping Beauty gives birth to twins named for the Sun and Moon, one of whom rouses her by sucking a poisoned thread from her fingertip.
In Snow White the girl’s coma is broken not by the traditional prince’s kiss, but by dislodging a piece of the poisoned apple from her throat. It’s as if the poisoning and her coma have been a time of adolescent transition; she throws off her glass casket and, like a butterfly breaking out of a chrysalis, emerges into womanhood and promptly agrees to marry the prince.
There’s an enduring, puzzling fascination with stories of these passive, comatose, beautiful girls. The tales are heavy with symbolism about the maturation of sexuality, though the meanings ascribed to the girls’ sleep seem to shift with time. They are continually being retold and updated for the new generation whether in film or animation. Marina Warner has written of how the Disneyfied retelling of these myths no longer have “sweet, biddable girls: in family entertainment, heroines have become fast-talking, athletic and indomitable; they take on all-comers, especially would-be lovers, and they show no sign of falling in love.” These heroines may be dynamic, but an appetite persists to have them fall unconscious and emerge transformed from their sleep. In 2014 Sleeping Beauty was reworked by Disney as Maleficent: a dark, gothic fantasy in which an adolescent girl pricks her finger, falls comatose, and is awakened by a kiss of maternal, rather than matrimonial love – the redeeming kiss is given by the repentant dark fairy who issued the curse.
Recently I watched Disney’s take on Snow White again: Snow White & The Seven Dwarfs. When it came to the scene where the girl was laid in a casket of glass, it reminded me of an isolation cubicle on an intensive care unit.
NIAMH’S BOSS LOOKED through her cottage and found an old address book in one of the drawers. He began phoning around to find anyone who knew her family. After a few false starts he turned up an old school friend who gave a number for Niamh’s mother. He phoned it, broke the news, and a couple of hours later she arrived at the hospital.
She was like a rococo cathedral: high, stately and with an expensively dressed façade. Her voice tinkled like money. I explained as clearly as I could that Niamh had suffered septicemia – blood poisoning – and that her liver and kidneys had partially failed. The crimson spots blooming over her skin were caused by the infection. Her heartbeat was weak, her liver was failing, and we were giving her transfusions and maximal doses of antibiotics. The mother’s eyes were wide, scanning me, as if my face held the key to the future rather than just relating some details about the present. “We don’t know whether she’ll survive,” I said, “but the next few hours could be critical.”
“Well, I shall stay right here,” she said.
The next set of biochemistry results showed little change, but for the first time there was no deterioration in her liver function. The following two mornings I arrived to find Niamh’s mother asleep in a chair by the bed – it was as if she was making up for all the years that she and her daughter had been apart. I was more anxious than usual waiting for the following day’s blood tests to come back from the lab, and asked them to phone with the results: “Good news,” said the lab technician. “Her ALT is down, and her albumin has come up a little.” Another day, and there was further improvement in all the parameters we were measuring: the consultant thought we should try reducing her sedation. As we turned down the dose of anesthetic her eyes began to move beneath their taped-down lids, as if she was trapped inside a dream world. The following day she woke up.
She woke up and saw her mother, and her smile was like an upside-down rainbow. Later that day she whispered her first words: “I’d like to come home.”
NIAMH’S LIVER ALMOST FAILED – she came very close to dying because of her blood poisoning, and its consequent effect on her liver. But its tissue regenerated and brought her back to life. It was not some handsome prince that saved her, or any reconciliation with her mother – it was her own liver.
LFTs are among the most common tests I send to the lab; I look through grids of them every working day. Often they’re raised because of alcohol – even slightly more than the recommended amount can double or triple the blood levels of GGT. Sometimes it’s drugs: the statins that reduce cholesterol have a habit of sending liver tests awry. Gallstones block excretion of bilirubin, malnutrition drops the albumin, and sometimes a general inflammation revealed by the tests implies that cancer is darkly at work.
Occasionally I can’t find a reason for the liver’s inflammation, so I send the patient to a modern-day haruspex for a biopsy. Through a keyhole in the abdomen the high priests of techno-medicine extract a piece of liver tissue, examine it carefully, then pronounce judgment on the patient’s future. Even when their verdict is bleak, the liver can often regenerate; there’s always the chance of a fairy-tale ending.
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LARGE BOWEL & RECTUM: A MAGNIFICENT WORK OF ART
Midway, his last resistance yielding, he allowed his
bowels to ease themselves quietly as he read … Hope it’s
not too big to bring on piles again. No, just right.
James Joyce, Ulysses
HUMANS COULD BE DESCRIBED as tube-like animals, our skeletons and organs as elaborations to support a length of gut. From that perspective we’re not all that different from nematode worms, primitive organisms that seem to exist primarily to ingest and excrete. Food goes in one end, feces out of the other, and nutrients and water are extracted. In nematodes, it takes just a fraction of a millimeter to accomplish, but in us it’s between twenty and thirty feet. Our bowels are forced into loops and spirals in order to fit in the space they’re allocated; they squirm and twist constantly as they squeeze food and feces along. The rectum is the terminus of that tube, and isn’t free to move around – it’s stuck down to the back wall at the spine. Its name comes from the Latin meaning “straight”: as the bowel jinks its way out of the sigmoid colon it makes a straight run through the pelvis for the exit.
In terms of function, the rectum is really just a waiting room: a place for feces to accumulate until it’s convenient to let it out. Bowel habit comes to most as a birthright: morning or evening, regular or irregular, loose or firm, we grow accustomed to the way waste exits, and alarmed if its pattern begins to change. For the most part that’s with good reason: doctors are interested in changes to bowel habit because they can signal deeper disturbance. Diarrhea can be a sign of thyroid disease, constipation a warning of malignancy, and oily, floating feces suggest that your pancreas has packed in.
Just as a great deal of information can be revealed about someone’s state of health from asking about how often they open their bowels, there is a lot to be gleaned from checking the inside of the rectum itself. In men it’s the main way of examining the prostate, which can be felt by a (gloved) finger through the thin anterior wall. In women the cervix lies in about the same place, and in some women, particularly if they’ve never had sex, it’s more acceptable to check the cervix rectally rather than vaginally. If someone is passing blood, an examination is necessary to find out if the blood is coming from hemorrhoids, from a tear in the anal skin, or from a tumor – I’ve found several rectal cancers this way (the medical school aphorism goes: “If you don’t put your finger in it, you’ll put your foot in it.”)
Adventures in Human Being Page 13
