Is Seeing Believing?

Isn’t it interesting that some of us can look at a forest and miss the wind riffling through the leaves, while others see the moon as a ‘ghostly galleon tossed upon cloudy seas’? What determines what we see? Does it have to relate to something we’ve seen before -patterns that we recognize? Is our apprehension of reality an expectation? A sorting through the chaos and discarding what we don’t understand -the noise– until something more familiar emerges? Why do we not all see the same thing?

If patterns are what we are evolved to see, if they are what we use to make sense of the world, are there always patterns everywhere? These are things I wonder about, now that I have time to wonder. Now that I am retired, I suppose I can wade more thoughtfully into the turbulence I once found swirling about my days. Clarity is certainly not a common property of old age, but occasionally it descends as softly as a gossamer thread, and then as quickly drifts away leaving only traces of its presence. Doubts about its visit.

Are these mere hints of what the gifted see? Is peering beyond the horizon just a gift, or is it fleeting and unstable unless learned? There was an interesting essay in Aeon, an online offering that touched on the subject of insightful examination, by Gene Tracy, the founding director of the Center for the Liberal Arts at William and Mary in Williamsburg, Virginia: https://aeon.co/essays/seeing-is-not-simple-you-need-to-be-both-knowing-and-naive

‘When Galileo looked at the Moon through his new telescope in early 1610, he immediately grasped that the shifting patterns of light and dark were caused by the changing angle of the Sun’s rays on a rough surface. He described mountain ranges ‘ablaze with the splendour of his beams’, and deep craters in shadow as ‘the hollows of the Earth’. […] Six months before, the English astronomer Thomas Harriot had also turned the viewfinder of his telescope towards the Moon. But where Galileo saw a new world to explore, Harriot’s sketch from July 1609 suggests that he saw a dimpled cow pie.’ And so, the question must be asked, ‘Why was Galileo’s mind so receptive to what lay before his eyes, while Harriot’s vision deserves its mere footnote in history?’ But, as the author notes, ‘Learning to see is not an innate gift; it is an iterative process, always in flux and constituted by the culture in which we find ourselves and the tools we have to hand. […] the historian Samuel Y Edgerton has argued that Harriot’s initial (and literal) lack of vision had more to do with his ignorance of chiaroscuro – a technique from the visual arts first brought to full development by Italian artists in the late 15th century. By Galileo’s time, the Florentines were masters of perspective, using shapes and shadings on a two-dimensional canvas to evoke three-dimensional bodies in space. […] Harriot, on the other hand, lived in England, where general knowledge of these representational techniques hadn’t yet arrived. The first book on the mathematics of perspective in English – The Art of Shadows by John Wells – appeared only in 1635.’

But is it really as fortuitous as that? As temporally serendipitous? Tracy makes the point that, at least in the case of Science, observations are ‘often complex, contingent and distributed.’ And, ‘By exploring vision as a metaphor for scientific observation, and scientific observation as a kind of seeing, we might ask: how does prior knowledge about the world affect what we observe? If prior patterns are essential for making sense of things, how can we avoid falling into well-worn channels of perception? And most importantly, how can we learn to see in genuinely new ways?

‘Scientific objectivity is the achievement of a shared perspective. It requires what the historian of science Lorraine Daston and her colleagues call ‘idealisation’: the creation of some simplified essence or model of what is to be seen, such as the dendrite in neuroscience, the leaf of a species of plant in botany, or the tuning-fork diagram of galaxies in astronomy. Even today, scientific textbooks often use drawings rather than photographs to illustrate categories for students, because individual examples are almost always idiosyncratic; too large, or too small, or not of a typical colouration. The world is profligate in its variability, and the development of stable scientific categories requires much of that visual richness to be simplified and tamed. […] So, crucially, some understanding of the expected signal usually exists prior to its detection: to be able to see, we must know what it is we’re looking for, and predict its appearance, which in turn influences the visual experience itself.’

‘If the brain is a taxonomising engine, anxious to map the things and people we experience into familiar categories, then true learning must always be disorienting. […]Because of the complexity of both visual experience and scientific observation, it is clear that while seeing might be believing, it is also true that believing affects our understanding of what we see. The filter we bring to sensory experience is commonly known as cognitive bias, but in the context of a scientific observation it is called prior knowledge. […] If we make no prior assumptions, then we have no ground to stand on.’

In his opinion, there is a thrust and parry between learning to see, and seeing to learn. I have no trouble with that, but I have to say that Science is only one Magisterium in a world of several. Science is neither omniscient, nor omnispective.

I happened across a friend standing transfixed in the middle of a trail in the woods the other day. A gentle breeze was coaxing her hair across her face, but her eyes were closed and she was smiling as if she had just been awarded an epiphany.

At first I wondered if I should try to pass her unannounced, but I suppose she heard my approach and glanced at me before I had made up my mind. Her eyes fluttered briefly over my face for a moment, like birds investigating a place to perch, then landed as softly as a whisper on my cheek.

“I… I’m sorry, Mira,” I stammered, as surprised by her eyes as her expression. “You looked so peaceful, I didn’t want to disturb you…”

Her smile remained almost beatific, rapturous, but she recalled her eyes to brief them for a moment before returning them to me. “I was just listening to that bird,” she said and glanced into the thick green spaces between the trees to show me where, “when I felt the breeze…” I have to say, I hadn’t noticed anything -I hadn’t even heard the bird. “…And it touched my forehead like a kiss,” she said, and blushed for describing it like that. She closed her eyes and thought about it for a moment. “I can’t think of another word,” she added, and slowly walked away from me with a wink, onto a nearby path.

I don’t think that what she was saying was Science, or even meant to require a proof, and yet I felt far better knowing there are people like her in my world. I think I even felt a brief nuzzle by the wind as I watched her disappear into the waiting, excited fondle of the leaves.

 

 

 

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To Have, or not to Have

There are two worlds out there, two Magisteria. Two contrasting inclinations that pass each other on the street without a wave. Strangers who sometimes know each other well. They sit, unwittingly close to each other, in the waiting room of my office. They chat and smile obligingly, trusting that their ignorance of the other is no impediment to friendship, however brief. Indeed, there is no barrier, only a perspectival boundary: Weltanschauung.

And yet, I don’t want to make too much of the difference; it is often in flux, and can mutate even as we watch –Time has a way of adjusting viewpoints,  justifying decisions. We all try to vindicate ourselves in the end. Validation requires exculpation, does it not? Absolution in the eyes of those who matter…

So the stronger the tradition, the societal apologue, the more the justification and guilt assigned to those who stray from it. There is a sort of canniness in the collective –or at least strength. Acceptance… And it is easier to regress to the mean, than defy the group. Especially when it comes to attitudes towards pregnancy –or more specifically, the decision whether or not to have a baby.

I’ve just read an incredibly powerful  book, whose title captures some of the agony and guilt attending those who dare to deviate from societal expectations: Selfish, Shallow, and Self-Absorbed. It is a collection of 16 well-written and generally thoughtful essays -13 from women, and 3 from men- about choosing not to have children. None are from paedophobes; and only a few are from those who decry the notion of pregnancy in others. They are not outliers –except perhaps on a carefully constructed Bell Curve- nor could they be construed as deviant. Each has merely made a personal decision not to accept the tyranny of the Norm.

The essays took me back to the early days of my practice, when, as a newly minted obstetrician, the very idea that someone would not want to have a child at some stage in her life, was anathema… Well, perhaps curious would describe it better –memorable, at any rate. And yet, it was not unknown. It was always a difficult decision in those faraway times to accede to a request for sterilization in a young woman. Contraception, yes, and although this closed the door effectively, it did not lock it. We were suffocatingly parental in those days: we knew she might change her mind –she was young and inexperienced, after all. Like a child, she had to be protected; it was our responsibility to keep her future mutable and open. We –society- were the guardians of that door…

But there are surely two issues at play here. It is one thing to criticize a decision made prematurely –before the kaleidoscope of life has fully displayed, when the future is more chiaroscuroid, more obscure and uncertain- and another developed in that fullness of time when a considered, even retrospective analysis of the factors leading to the choice can bear fruit.

This, too, can seem arbitrary, I realize. Is there a difference between a thoughtful twenty-five year old woman who -in her mind at any rate- has weighed the risks and benefits of having a baby and decided against it, and a forty-five year old who, on looking back at the way her life has unfolded, is grateful and reconciled to never having a child? It is a vexing question on several levels, I think.

In these days of autonomy and non-maleficence when it is considered medically paternalistic and politically incorrect to suggest that a decision need not be vetted by experience, we forget the other ethical duty of a health care provider at our –her- peril: beneficence –serving the best interests of the patient. It seems to me that this entails both a mature and non-directive dialogue and a list of other, more malleable options that would not only adequately serve her needs, but would also allow for change at any stage. Some form of reliable and non-intrusive contraception, for example, might respect her desire to avoid pregnancy, and yet enable some flexibility should she change her mind, or harden her decision for a permanent solution.

But I have to confess that I am still troubled. On the one hand, it seems to me that wisdom is the ability to judge a situation based both on knowledge of what it entails, as well as experience of how it usually turned out in the past. It is why elders were revered in the days before the plethora of information technology that assails us today. I am trying not to be Ludditic here but what the elders contributed, that Google often does not, is digestion. Analysis over time and place. Evaluation. Information can be coloured by current trends and bent by traditional assumptions –but of course so can needs. We must not forget that.

I have always been leery of ‘facts’ divorced from context. Are they then still facts or do they inhabit some terra incognita we have yet to fully occupy? A territory of collation, a thesaurus that is able to list endless variations on whatever theme we decide applies to us, so we can pick and choose the reality we prefer?

It is not the decision to have, or not to have a child that should preoccupy us, but rather the reason it has been chosen. And for such an important life-changing resolution, the depth and –dare I say- maturity of  thought that has gone into the consideration is paramount. It is not, nor should be allowed to fall under, the purview of political correctness and thereby escape a more cautious and examined approach. There is no correct answer, no unquestionable myth that can justify any position. We may have a spur to prick the sides of our intent, to paraphrase Hamlet, but it is a different one for each of us. We must take care that we, and those we counsel, are not –Hamlet again- hoisted with our own petards.

The Goddess of Small Things

Every office needs a goddess. Every doctor needs to see one now and then to keep things in perspective. Separate the two Magisteria.

I have a goddess –not self-professed to be sure, but in a pinch, self-acknowledged. She comes to see me once a year or so, for reasons that are not at all transparent.

It began about fifteen or more years ago. It was a surprise; the referrral letter from her doctor said nothing about a goddess. It didn’t even mention her powers, as I recall. It merely said “Infection!!”  and although the writing seemed laboured, reluctant –scrawled perhaps describes it best- the exclamation marks were clear enough. In fact, they were several times the size of the writing, and burrowed deep into the page, breaking through the paper in one particularly enthusiastic area as if to justify their mission.

Judith did not come across as your average goddess at all. In fact that first time she seemed rather shy and dressed as background; I didn’t even noticed her sitting in the already crowded waiting room until she stood up when I mis-called her name. A short woman with matching short dark hair, she was wearing a dress that seemed at once plain, and at the same time almost camouflaged against the other dresses in the room. Quite a trick, really. She only stood out when she moved across the room to correct my shortening of the Judith part of her name to Judy.

She spoke, or rather commanded my attention, as soon as I closed the door. I couldn’t place her accent, but it seemed an unusual one. “I require only one thing of you, doctor, so we can dispense with the usual history taking.”

I hate it when they do that. I’m a specialist; I’m supposed to take a careful history and solve their otherwise intractable problems with the benefit of my esoteric knowledge base.

She studied my face for a reaction and, obviously satisfied with the engendered confusion, proceeded to enlighten me. “I’ve been to several specialists already, but they all seem unwilling –or perhaps unable- to help me.” I don’t know why, but I felt like a PhD candidate about to defend an assertion in his thesis. I was being examined.

“I have a recalcitrant case of Mobiluncus mulieris in my parts.”

I have to confess that I blinked involuntarily at the words. Was she a nurse? A doctor in disguise, sent by the provincial medical association to check on my competance? I had to think fast –she had just named one of the several microorganisms thought to be responsible for a rather malodorous vaginal problem. “Bacterial Vaginosis can be very difficult to treat…”

She was silent for a moment and then sat down in a chair across from my desk, a smile incipient, hiding in full view. “Very good, doctor.”

“Did I pass?”

The smile blossomed on her face like a rose opening in the morning sun; her eyes twinkled with mischief. She sat back in the chair, finally relaxed. “I had to know…”

I didn’t ask.

But from that moment, she seemed to bond –with me, with the room, with the Gestalt… And, no doubt it was my imagination, but she suddenly surfaced from the background, like a picture focussing. She shook her head like a fairy might and blinked back at me from somewhere deep inside her head. “You will be my doctor,” she said simply and then stood up.

The interview was obviously over, the threshold attained and crossed, but she stopped at the door and turned to me. “I will not come with problems I cannot solve, merely with problems I wish to discuss.” The now-famous blink again. “Is that all right?” she said, already knowing it was as she turned and left.

She would appear from time to time and tell me of her trips to places I had never heard of. Sometimes it was cloaked in the pretense of needing a pap smear, or a culture for some totally esoteric sexual disease, but we both understood that these were excuses. Dissimulations to cloak her need to connect. It was as if, when she disappeared each time through the door, she ceased to exist –much like Brigadoon –the famous musical about a town that exists for only one day every hundred years.

I told her the story of Brigadoon on a visit when she suddenly appeared in the waiting room, after not seeing her for what seemed like several years. She disappeared behind her eyes for a moment in surprise and when she surfaced again, she was a pixie. She shrugged mischievously, as if caught with a hand in the cookie jar. “I travel a lot,” she said, but not convincingly.

I realized how little I actually knew about her and when she sat down, I decided to find out more. But I suppose she could read my expression and shook her head almost imperceptively. “Magic lies not in what you can see, but in what you can’t quite make out, don’t you think?” she said innocently enough.

I smiled to conceal my embarrassment at being caught about to probe a past which, by some unwritten, unspoken understanding we had agreed should remain hidden. “My secretaries think you are a…” –I hesitated to continue, fearing she would take even the substitute word that I had decided to use the wrong way. An unintended, pejorative way. One secretary –the younger one- had actually said ‘witch’, but the other, the older worldly-wise one, a more sexually-innuendoed word.

But she merely smiled; her eyes told me she already knew what I wanted to say. “You were going to disguise their guess, weren’t you?”

“I…”

“Or change it into something more… polite?” her face twinkled playfully. I have to confess I blushed at her seeming prescience. She leaned towards me over my desk. “Some have called me fey…” She thought about the word for what seemed an eternity. As if she wasn’t sure how much to disclose. “There are many words they use,” she whispered and then sat back. “Witch, enchantresss, goddess… Weird things like that, because, like you, they don’t know much about me.” She stared at me for a full minute and then at something over my head –or so it seemed. “Because I only appear long enough to influence some part of their everyday lives and then vanish, there is a touch of mystery to me, I suppose.”

The skin on her face relaxed and she suddenly seemed older. Wiser. Ancient.

She got up slowly and walked to the door. “But it’s not like that, you know. Not really…” Even from the door I could see her sigh. “No matter what they think, I don’t do very much for them.” A final blink before she turned. “I am the Goddess of small things,” she said over her shoulder as if to the wall. As if, as it turned out, I would never see her again.

Pregnancies can be Miracles

The older I get, the more I wonder at the different Magisteria in which we become entangled. I am using the word in a metaphorical sense to mean sacred domains: sacrosanct issues rarely subject to closer interrogation -things we know because it is how we were raised, how our society apportions its sanctions and which, confirmation biases in tow, we could, were we so inclined, verify for ourselves with our own investigations.

Miracle, I suppose is another such metaphor. Its etymology is from the Latin mirari: to wonder at. Drawn as I am to Shakespeare, I remember Hamlet’s words to Horatio very early in the play: There are more things in heaven and earth, Horatio, than are dreamt of in your philosophy. It is Hamlet commenting on the ghost of his murdered father; and perhaps Hamlet commenting on the limitations of the human mind as well…

So when I assert that in the course of my long career in obstetrics and gynaecology I have seen the occasional miracle, I do not want it misconstrued as religious, New Age, or even anti-scientific. With all the retrospective obfuscation that memory affords, I mean it in the original sense: something I wonder at.

Very early in my career, when I was wet with knowledge but experientially dry, I was on call for a colleague at the hospital. Those were exciting times when the textbook in my mind came alive. When the scenarios envisioned in the explanations blossomed into three dimensional reality, complete with an angst no writer ever mentioned. These were real people -real situations, jammed with emotions and consequences. An inaccurately assessed situation, an inexpertly performed procedure, an inability to decide on an appropriate course of action in what might seem to someone else as the blink of an eye, could be catastrophic. They were bewildering times, actually.

I was asked to see a woman -a patient of my colleague- in heavy labour who seemed to be making no progress. The cervix was not opening despite strong and regular uterine contractions, and the baby’s heart was beginning to show some signs of distress. There is a pattern and a progression to labour, and when things begin to deviate, the caregiver’s antennae begin to lengthen. We look for clues in the disparity: the fetal heart rate patterns associated with contractions, the mother’s condition, the amount and type of pain relief she both needs and received, the contractions themselves… Sometimes what clues exist are hidden -like they had minds of their own and did not want to be found. It can take patience to unearth them. Analyse them. Act on them. And that discovery time is sometimes fraught with danger to the mother – but more especially, to the baby. Occasionally the need to act, the need to intervene, is difficult to define and so difficult to explain to the parents. And yet it needs to be done. In older clinicians, there is probably an intuitive grasp of the situation -and not only a feeling that things are not right, but the vocabulary to explain it. I was not an older, experienced, battle-weary clinician. I did not yet have the words to justify my unease to the parents.

But I had to decide, and given her lack of progress in labour so far, I made the only decision I could under the circumstances: a Caesarian Section. She was only in her early twenties, as I recall and it was her first pregnancy. She and her partner saw the look on my face and readily agreed to the surgery.

I had done many Caesarian sections in my training -it is one of the operations with which most new consultants feel at least mildly comfortable. The procedure, though complicated and one requiring skill and good assistance, is simple enough in principle. One must gain access to the uterine wall by cutting through the abdominal skin and then separating the abdominal muscles to create enough space to see the uterus. Then the uterine wall is cut, the internal cavity entered, and the baby removed. But then the work begins: things have to be repaired -put back in place. And to do that, the placenta -the organ that has been feeding the baby until now- has to be removed. Normally, it is attached to the inner surface of the uterus like glue and comes free either with a little traction, or more commonly nowadays, by the anaesthesiologist adding something to the intravenous to make the uterus squeeze it out.

Her baby, a little boy, cried as soon as his head cleared the incision and I breathed a sigh of relief at his obvious health. Better a well-timed Caesarian operation that delivers a crying newborn, than one performed too late that doesn’t! Now I just needed to extract the placenta and close the incisions. But the placenta wouldn’t come out! I tried every trick I had been taught, and so did the anaesthesiologist but to no avail. And she was continuing to bleed. Heavily! Because of the amount of blood being lost, I realized I had to act quickly. The placenta seemed firmly attached to the wall, seemed to enter the uterine muscle, in fact.

Sometimes the placenta attaches a little too strongly to that inner wall -penetrates it, even. And then the nightmare begins: the invasive quality of the placental attachment can take it right into, or even through the wall of the uterus so it can be seen on its outer surface.  And under those circumstances, there are very few options -especially if she’s bleeding uncontrollably. The medications to make the uterus contract do not work in the area of perforation of the placenta (called a placenta percreta in the instance I am describing ). It’s usually deeply attached over a large area of the lining, even though only a small portion of it may have managed to reach right through the uterine wall. So, if all attempts to stop her hemorrhage fail -as they usually do under these circumstances- the only thing that can stop her from bleeding to death on the operating table, is a hysterectomy.

A caesarian hysterectomy is far more difficult than a more routine hysterectomy done at some temporal distance from a pregnancy. The tissues are more edematous and vascular for one thing -everything bleeds. And the anatomy is obviously altered and deformed by the size and shape of the just-pregnant uterus: rather than fist-size, it is basketball-or-bigger-size. And it bleeds uncontrollably until all of the arteries supplying it (with the same amount of blood it needed to nourish the baby) are cut and tied off. Lumps and bumps that would be easily recognized as fibroids (benign local overgrowths of muscle tissue) in the non-pregnant state often loom as large swellings sometimes indistinguishable from the rest of the huge mass of bleeding tissue that is a uterus in such distress.

Things were difficult, but controllable. I managed to find the requisite blood vessels supplying the uterus and systematically addressed them one by one to cut and tie them off. But just as I was about to tie one of the major ones, I noticed an unusual lump that, in the mad scramble to stop her hemorrhage I must have ignored. Now it seemed important. I hesitated to clamp the blood vessel on that side of the uterus, and instead examined the lump more closely. It didn’t seem to be a fibroid, or anything else I could think of. And then I saw the Fallopian tube. A normal uterus has two -one exiting from either side. Each one is charged with connecting the ovary to the uterine cavity. Charged with allowing sperm to travel along it to find an egg in the ovary, fertilize the egg, and then facilitate its way back to the uterus to implant in the inner wall as a pregnancy. The lump had a Fallopian tube attached to it.

She had, I guessed, what is commonly called a double uterus, joined to its baby-carrying twin at the cervix -sharing it, in fact. It hadn’t grown as large as the other side because it didn’t have a baby to accommodate. Of course I had never seen one before, but it looked like what I would expect it to. Actually, I’m not really sure what I expected one to look like, but on the spur of the moment, I decided to save it. To work around it. To take its bleeding, placenta-carrying sister out without its shared cervix and hope that the bleeding would stop.

The bleeding did stop and I finished the operation and then spoke to her frantic husband who was waiting in the lounge. We had asked him to leave the operating room when the bleeding had started because we’d had convert the spinal anaesthetic -with which we’d started for his wife- to a general anaesthetic to deal with all of her problems. I explained the need to remove her uterus to save her life and how close we’d come to losing that battle. Almost as an afterthought I mentioned the little nubbin of tissue I’d saved. He smiled wanly, probably not really understanding anything I’d said except that although his wife would live, they would not be able to have any more children. I don’t think he really understood how close she’d come to dying -after all, she was young and healthy and had only come to the hospital because she’d been in labour. People didn’t die in labour in this country. Nobody had mentioned it in their prenatal classes…

I suppose the reason I have come to regard this as extraordinary, is that after subsequent investigations, that little lump did turn out to be a uterus, albeit only half of what had been intended. But it did have its own Fallopian tube and an ovary. And she recovered well from the surgery. There’s always a silver lining if you look hard enough.

I subsequently lost track of her over the years. I’d heard from her family doctor that her menstrual periods had eventually returned, but as time and circumstance dictate, I eventually forgot about the incident.

And then one day she appeared in my office for a consultation. I didn’t recognize her at first, but I did remember her broad, engaging smile. She was one of those rare individuals who can make you feel both welcome and happy just by looking at her face.

I was obviously delighted to see her again, but puzzled by her visit. She looked well -radiant, in fact. Her face was ruddy, and her gait… familiar. She had a contented aura -almost visible- that extended far beyond her expression. Her eyes twinkled, as she sat on the other side of the desk and stared at me. Her face almost cracked with the smile.

“I didn’t get a note from your family doctor,” I stammered, not quite sure if I could believe what I sensed. I was no longer a neophyte. No longer an inexperienced beginner in my specialty.

“I told her not to,” she managed to say through the smile, and reached for my hand across the too-wide desk and across the vast bridge of time that separated us from our last meeting. She blinked slowly and contentedly and her face -her being– seemed to glow. “But you know, don’t you?” she added contentedly, softly – electricity travelling along her hand into mine.

My smile was no match for hers, but it was as big as my face could handle. I nodded, my eyes now locked on hers. “You’re pregnant, aren’t you..?” And we laughed together, like two children who realized they had shared the same secret.

I delivered a vigorously crying little girl four months later by another Caesarian section -a bit premature to be sure, but apart from being miraculous in both our minds, otherwise rather routine…