The Bicameral Mind

Time to unwrap the Jeremiad again, I’m afraid; I’m getting tired of this. Really tired. I know it’s an American thing, but stop it will you? Or can you? Every time there’s a bicameral shift it tears the fabric a little more and unravels what I want to believe about your country. Yes, I’m Canadian and watching with unvetted eyes I guess, and yet sometimes it is good to hear from the other side of the mirror. To listen to the indrawn breath and pause to look around. Sometimes acumen travels in disguise: the dusty traveller leaning on the fence, the unwashed face of Vishnu. Wisdom does not always wear a flag.

One of the things I’m referring to, of course, is the perpetually probationary status in the United States of both family planning and pregnancy termination. Women’s rights seem contingent upon the prevailing ideology, their status as stable as the government in power -guaranteed only conditionally, and as changeable as the pen that underwrites them.

As a non-combatant, I suppose I should only listen with firmly closed lips; perhaps the border should be a closed curtain so I cannot see through. And maybe I should apologize for being so critical, but when is this vacillation going to stop? I accept that there are valid differences of opinion, and that any decision is inevitably temporally adjudicated. Times change, and so do populations and their ethnic and cultural compositions. It’s happening to us all. But surely the answer isn’t to retreat behind the doors and barricade the walls.

And defunding organizations that seek to address the issues of involuntary overpopulation would seem unduly parochial and even internationally misunderstood. It is the special duty of an enlightened nation to accept that there are many roads and many destinations. It has, it seems to me, the burden of reasonable neutrality, grounded observation, and judicious guidance.

The issue, I think, should be one of choice not fiat. Conscience, not doctrine. To offer alternatives is not to coerce, nor to prejudice the selection; it is surely to achieve the goal for which the options were offered in the first place. Not all things are equally acceptable; not all choices are politically or culturally permissible, to be sure. So a variety of solutions might have a greater likelihood of admissibility. A greater possibility of success.

Several years ago, I travelled to the States to attend a gynaecological convention and discovered that not only was pregnancy termination still an inflammable topic for many delegates, but even the provision of Family Planning counselling for whoever requested it. I found this hard to understand, especially at a meeting of specialists in the field.

I remember questioning one of the doctors I met there and she rolled her eyes at my Canadian naïveté. “Do you remember that fable of Aesop called ‘the Belly and the Members’?” Now I felt really naïve because I had to shake my head.

She seemed surprised. “Well,” she said, after interrogating my face for a moment to make sure I wasn’t kidding her. “The version my daddy told me when I was young went something like this. One day, after carrying the body through a long day of heavy work, the feet complained that they seemed to be the only ones in the body who had to work. Of course the hands argued with them that they were the ones who should complain -the feet may have carried the body, but they had to carry and even balance the load. The only thing they could agree on, after a long argument, was that although the four of them worked all day, in the end it was the stomach who got all the food.

“So, they devised a plan. The feet refused to walk to the stove, and the hands refused to pick up any food.”  The doctor smiled at this point and pierced me with her eyes. “And you can guess what happened after a while… They all got weak and finally had to agree to work together. Only the stomach could give them the strength they needed.”

She giggled at the end and touched my arm playfully. “I can’t believe you didn’t know that one, doctor.”

I hate it when a colleague calls me ‘doctor’, but I let it pass. “And I take it the fable is telling us that we all have to work together, no matter that we’re different? And that we can all have different opinions?”

Her expression changed and a puzzled look crept onto her face. “Never thought of that, actually… My daddy said it meant that we all have our jobs, but need someone –something- watching over us to give us strength and direction… Reminding us of what we should do. He said the Stomach was our Conscience… But I think he really meant the President… Or maybe the Lord…” She shook her head in apparent disbelief at my interpretation. I blinked, because it didn’t make sense to me. I wondered if she’d remembered it wrong.

“You must have similar fables even up there in Canada…” I could tell she was trying to understand my confusion. Transcend boundaries.

“Well,” I started, just like she had, “I do remember one about chopsticks…” She smiled at my multiracial example –so Canadian. “It was something one of my Chinese patients told me after giving me a little gift for delivering her baby. She said her father had told her this when she was a child.

“’There was an old man,’ she said, ‘who was close to death, and worried about what would happen after he died. He decided to ask the wise village elder if he knew what it would be like in Hell. The elder smiled and told him to imagine a large room filled with people. ‘They are all thin and hungry,’ he said ‘even though there is food everywhere.’

“’Then why are they so thin,’ the old man asked?

“’Because their chopsticks are each ten feet long,’ was the answer.

“The old man thought about it for a minute. ‘And Heaven,’ he asked, ‘What’s it like in Heaven, then?’

“The elder laughed. ‘Imagine another large room. There is food everywhere, but the people are fat and happy in spite of their ten foot long chopsticks…’

“The old man was puzzled. ‘But… I don’t understand.’

“The elder smiled and put his arm around the old man. ‘In Heaven, they feed each other…’”

Perhaps, I thought, after watching my colleague’s reaction, perhaps there is something more profoundly different about our two countries than simply the colour of our mailboxes…

Biding the Pelting of this Pitiless Storm

Hubris –the extreme arrogance that was so offensive to the old Greek gods that they reacted with punishment and an exile from grace- is that what this is? I’m not sure anymore… It’s not, perhaps, so obvious as the vaulting ambitions of a Macbeth or the arrogance of a Caesar, nor even the overweening pride of an Oedipus in the Sophoclean plays, and yet… And yet, viewed from a distance, it’s hard not to notice the similarities that inhere in the attitude that End justifies Means, that intentions trump consequences, that methodology is the servant of results –however narrowly beneficent we define them. And it’s important that we not be so blinded by those touted benefits that we ignore other, perhaps less harmful routes, to achieve them.

And what, you may reasonably ask, prompted this jeremiad? It was a study reported in the New England Journal of Medicine (NEJM) on the addition of a second and possibly more powerful prophylactic antibiotic during non-elective Caesarian Sections to reduce post-operative infection rates: http://www.nejm.org/doi/full/10.1056/NEJMe1610010?query=gynecology-obstetrics -certainly a worthy aim, to be sure. Who could possibly take issue with that? Well, in this era of increasing antibiotic resistance, and the unfortunate dearth of replacement antibiotics in the wings, I think not only the study, but also the idea demands more than a cursory analysis. This is not to criticize the intent, so much as to explore alternative roads to the same destination.

Few would argue that antibiotics, when they are deemed necessary, should be used according to the infecting bacterial sensitivities if they are available –or considered expectations as to sensitivities if they are not. It’s why we can no longer use penicillin for everything –not all infections would respond. Surgical prophylaxis (where there is not yet an infection) is one of the few exceptions, and even there, the antibiotics are chosen in anticipation of the type of bacteria that might reasonably be expected in the surgical field (although there are some who believe that their effect is merely that of decreasing the total bacterial load in the area whether or not the expected ones have been targeted). But, nevertheless, we toy with resistance at our peril.

I’ve chosen to link the editorial rather than the study itself because of the insights it offers. The full-length study to which it refers can be accessed via a link in that editorial, however.

As I mentioned, the study by Tita and colleagues, in a randomized trial, attempted to reduce post-operative infections by adding another broad-spectrum antibiotic (Azithromycin) to the usual antibiotic (cefazolin) in non-elective Caesarian sections (i.e. there was some condition in mother or baby that required urgent delivery) where the current infection rate was 12% -and it worked! Compared to the usual group that just received the cefazolin alone, they dropped the infection rate to 6.1% -not zero, but at least an improvement. And, ‘Neonatal outcomes, which were tracked up to 3 months, were similar in the two trial groups.’

But on closer analysis, 73% of the population in the study was obese -and that, plus the fact that the Caesarians were unplanned, certainly added to their risk of infections. So far, so good.

But, as the editorialist wonders, could the fact that these women were obese have meant that the usual dose of cefazolin was inadequate: ‘[…] should the potential pharmacologic benefit of higher doses of cefazolin alone be evaluated further before the addition of a second agent?’

Another consideration leading to the study of adding azithromycin to the regimen, was that it may be useful for eliminating a potentially  infective organism in the vagina –ureaplasma– that cefazolin doesn’t touch. Unfortunately, there are no prospectively adequate data for the contention that the organism was even present in the studied women.

And finally, the azithromycin was more beneficial in those women whose incisions were closed with staples, and there seems to be evidence that staples, themselves, may increase the post-operative infection rate.

So why, you may ask, have I chosen to comment on this rather obscure study –especially since it seems to have demonstrated the benefits it expected? First of all, I think we have to be careful that we don’t lose sight of the forest as we wend our way through the undergrowth. There do seem to be other options that could be explored before the addition of yet another antibiotic –and indeed should be anyway, given the non-zero infection rate even with the addition of azithromycin. Such things as more ‘stringent adherence to infection-control protocols’, avoiding the use of staples in this high-risk population, or even re-calculating the dose of the standard prophylaxis (cefazolin) to account for differing patient weights before deciding to add the new antibiotic.

I don’t mean to be the new Cassandra, issuing thundering prophesies of doom that will not be heeded anyway, or aspersing well-intentioned attempts to improve our lot… And yet we must not forget that consequences follow actions, not precede them. To be fair, we do try our best to anticipate and thereby avoid, or at least minimize them, but history is riddled with examples of unintended outcomes. The road to disaster is paved with should’ves –only seen with clarity, after arrival.

It seems to me that, wherever possible, we should be exploring options that reduce the likelihood of incurring bacterial resistance. And the answer may not lie in the reliance on new antibiotics -new guns for our on-going war with the microscopic world. It’s a battle in which we cannot hope for more than a temporary truce while we search for peace. Without that, as the map makers of old were said to write on unexplored regions, Here be dragons.

 

Aphantasia?

We are a culture of categorists. Slotists. Namists. It is a society of Nomino, ergo sum. It’s as if we can sleep more securely knowing we have named and categorized everything we have seen that day –no matter how bizarre, no matter how unimportant. No matter, even, how mistaken the belief that by so doing, we have added something of substance to the world at large. I suppose what concerns me, though, is when to stop the naming? How finely do we divide the gradations before asking if we are really labelling something different?

And, does the act of naming something reify it –make it a real thing, in other words? Or does it merely select it from an otherwise amorphous background where it existed all along? Or, to identify yet another permutation, is it more like taking a shape, say, from a Rorschach ink blot and privileging one interpretation as gospel?

We are all different in many ways –some, interestingly so, others not as noticeably until pointed out by otherwise underemployed taxonomists. I accept this, but still question whether each variation from a norm is deserving of a separate name. Might we put ourselves in greater danger of muddying the water the more we stir it? Losing what we could previously identify in its depths? And for what? Are there really ‘more things in heaven and earth, Horatio, than are dreamt of in your philosophy? as Hamlet might have asked – More things requiring unique and quirky names?

So, what provoked this mini Jeremiad? Well, I suppose I am as much to blame as the taxonomists in my relentless search for novelty. As I poked and prodded my way through –what else?- the BBC News app, I came across an article on Aphantasia. http://www.bbc.com/news/health-34039054 At first, I wondered if it was a reminiscence about that Disney film which was set to classical music. I was about to scroll past it, but the ‘Ph’ spelling aroused my etymological curiosity.

It turns out that Aphantasia is a neologism that borrows from both Greek and Latin roots: a –meaning ‘without’, and phantasia –meaning ‘image’, or even ‘a making visible’. It refers to the inability to produce a voluntary mental image of something when it is not actually present. So remembering a mental picture of a face might be a problem for someone with aphantasia, although they would still be able to remember non-visible facts about the face –things that stood out, perhaps, like a large nose or a patch over an eye… Attributes, not images.

It may well be a spectrum of loss, however, as Professor Zeman, at the University of Exeter, points out in his study: ‘..the majority of participants described involuntary imagery. This could occur during wakefulness, usually in the form of ‘flashes’ (10/21) and/or during dreams.’ http://medicine.exeter.ac.uk/media/universityofexeter/medicalschool/research/neuroscience/docs/theeyesmind/Lives_without_imagery.pdf  I find this interesting; their capacity to form the internal visual memories is not lost apparently –more the ability to retrieve them at will.

But the very acknowledgement –and naming– of this edge of the normative Bell curve set the neuroscientists scurrying to find its other perimeter and they found it: hyperphantasia –perhaps more easily described as hyper-imagination. I have less faith in this category as a distinct entity, though –I would suspect it wanders terribly close to the edge of more classically defined psychopathology, as in the outer border of bipolar disease, for example, or the imaginative excesses often found in schizophrenia.

So, what has this study purported to identify? Boundaries. After all, up to a certain point, we classify difference as merely a variation from the mean –a quirk of behaviour. A nuance, not an epiphany. And yet boundaries are slippery and once determined, are heavily scented with unintended consequences. As the BBC article pointed out, ‘One person who took part in a study into aphantasia said he had started to feel “isolated” and “alone” after discovering that other people could see images in their heads.’ After all, a boundary had obviously not existed until it had been defined, and then, sadly, the person found that he was on the wrong side of it. What is normal and unremarkable to one, is alien, or at least unexpected for another.

But all of us are on one side or another of some line, aren’t we? Our very uniqueness requires it. It is something to celebrate, something to admire. And yet, not to appear unduly Cassandroid, there are dangers in names –in difference– unless Society learns to honour the mosaic. Cherish it for the montage it weaves into our cultural fabric. Accept the ever changing clothes despite any unwanted flesh it may expose.

I may sound like I’m against the free and unexpurgated pursuit of scientific curiosity -I’m not. Against the inductive method of interrogating nature -again, I’m not. Nor am I content to drift with the tide, happy to land wherever wind and water direct. But curiosity is a watchful cat that lurks in our shadows with hungry eyes and eager claws. It needs to be fed and nurtured constantly, but sometimes carefully. Respectfully.