The liver has a body—A Cook's tour

Just as there are fashions, fads and fancies in Art, Music, Literature and Dress, so there are in the more academic pursuits of Science, Economics, Engineering and Architecture. Even Medicine is vulnerable to the vagaries of the vogue. “Fashion” sneered Ambrose Bierce cynically, “is a despot whom the wise ridicule and obey.”1 In Physic, a prime practice that has swung like a pendulum in and out of fashion is the performance of a physical examination as part of the diagnostic algorithm. Now, perhaps more than ever, with the availability of elaborate laboratory tools to analyze bodily fluids, the perception of high resolution imaging with sonic and electromagnetic vibrations, and the intimate glimpses afforded by microscopic, ultramicroscopic and molecular dissection of the tissues of the body, there seems to be little room for the tradition of inspection, percussion, auscultation and palpation. Auscultation of the heart has yielded to echocardiography; percussion of the chest to computer-assisted tomography; careful evaluation of the neural network with flashlight, pin, cotton wool, tuning fork and tendon hammer to magnetic resonance imaging of the brain and spinal cord; and inspection and palpation of the abdomen to endoscopic invasion of the gastrointestinal tract by flexible light-emitting tubes that propel charge-coupled devices, and with wireless capsules that relay their reconnaissance by radio transmission to the examiner. Whereas no one regrets the passing of gustation of sweat and urine in the diagnosis of jaundice and diabetes, respectively, is it any wonder that residents and fellows show little fascination or even interest, let alone respect, for the visual, auditory, tactile and olfactory examination of the patient. This lamentation is not expressed to imply that an extensive meticulous physical examination has always been the bedrock of clinical diagnosis — far from it, as we shall see. Rather it is an expression of nostalgia, that emotion of longing for temps perdu, which for several centuries was thought to be a truly disabling disease of young people forced to live far from their homes2 but now is a prerogative and a proof of senescence. But we digress, for the purpose of this exposition is to remind the reader that the physical examination not only has an illustrious pedigree but is still rewarding in hepatology, as it can indicate the presence of liver disease, assess its severity and, together with the patient’s history, give some intuition as to its cause. Physicians of the Ancient World, in the East and the West, did not have the virtually unlimited access that we have today to the patient’s body, except perhaps at the time of the “ultimate physical examination.” Nonetheless, by carefully scrutinizing the accessible, i.e., the face, hands, body posture and movement, the rhythm and noise of breathing, behavior, demeanor and mood, together with some limited intrusive approaches, like feeling the pulse, inspecting the tongue, hearing the rumble of the abdomen and even shaking the patient, they made many astute observations.3 Witness Hippocrates and his facies, fingers and succussion.4,5 Hippocrates recognized jaundice and hepatic coma, and he could hear the succussion splash of fluid moving in the pleural space in his patients with pleurisy, whom he jolted to make the diagnosis. Galen, in 2nd Century CE Rome, could fill 16 volumes with his writings on observations, interpretations and prognostications of the pulse, a practice incidentally much favored in Ancient China too.6 Wang Shuhe, who lived during the Western Jin dynasty in the 3rd Century CE, compiled all available knowledge on pulse diagnosis in his manual on the pulse, Mai Jing. Galileo timed his pendulum from his pulse and vice-versa, while his Paduan contemporary Sanctorius Sanctorius (who had also improved on Galileo’s thermometer and dabbled in paracentesis) invented the pulsilogium, a pulse-watch dedicated to that purpose.7 The pulse, tongue, eyes, nails and skin were favorites of the Ayurvedic physicians too, dating from the early centuries of the current era in India, but here great emphasis was placed on the patient’s age, constitution, body proportions, and capacity for food and exertion, which were evaluated chiefly to allow them to estimate life expectancy.8 Yet though the practice of medicine in most cultures was vaunted as relying on the five senses, physical examination literally remained at a superficial level, by and large, until well into the late 18th Century.9 As Richard Gordon has sardonically remarked, the 17th Century physician was useless but decorative.10 With his satin giltdecorated coat, buckskin breeches, silk stockings and buckled shoes, lace ruffles and full bottomed wig, he swung a long cane with a hollow gold head filled with Marseilles vinegar that he sniffed repeatedly to ward off infection.10 To Richard Mead (1673-1754), physician to Queen Anne and George II and Fellow of the Royal College of Physicians, the gold-headed cane was a badge of office to be carried with pride. To caricaturists, like Thomas Rowlandson and William Hogarth, it was an icon with which to identify individuals with medical pretensions, as in Hogarth’s 1736 cartoon “The Company of Copyright © 2005 by the American Association for the Study of Liver Diseases. Published online in Wiley InterScience (www.interscience.wiley.com). DOI 10.1002/hep.20597