Different Flavours

There are more things in heaven and earth, Horatio, than are dreamt of in your philosophy –so says Shakespeare’s Hamlet. I suppose as one ages, there is a tendency to become, if not indifferent, then less surprised at the plethora of variations that exist when they are sought, less amazed at the range of combinations just waiting for discovery. Like ice cream, the world does not come in only one flavour.

But perhaps it is not just the array that so bedazzles, but that we could ever have presumed to define what is normal in anything other than in a statistical way. A Bell Curve distribution confronts us wherever we look –reality is a spectrum no less than the rainbows we all profess to admire. So, then, why is it that in some domains we are less than accepting of mixtures, less tolerant of difference? Why is there the overwhelming need to categorize things as either normal or abnormal? Natural, or unnatural? A macrocosm of only us and them?

Is it just the benefit of retrospection that allows me to notice that no one of us is the same? Or a corollary of Age that lets me thank whatever gods may be that it is like that? That not only do we differ in our tastes and thoughts, but that the discrepancies in our appearance, if nothing else, allow us to recognize each other?

At any rate, I have to say that, as a retired gynaecologist, I was pleasantly surprised to rediscover a world I thought I had left behind –intersex. It was an article in the BBC News that caught my attention: http://www.bbc.com/news/world-africa-39780214 In my day, however, we still hewed to the label ‘hermaphrodite’ if both male and female gonads were present, or even more insensitively, to something like ‘disorders of sex development’, with the medical community taking it upon itself to assign and surgically ‘correct’ the anatomical features at variance with some of the more prominent features of the melange. All this often before the person was able to decide whether or not to identify with either or both traditional sexes. I don’t for a moment believe that this was done malevolently, however, and I think we have to be careful not to apply current sensitivities to another era. Historical revisionism is always a temptation…

But the spectrum of variation is so wide in both anatomy and physiology, not to mention time of discovery, that assignation of gendered roles is fraught. For some, the worry has been that of acceptance –acceptance of any divergent anatomy, any dissonance, by society at large, but also acceptance by the individual themselves (even pronouns become problematic –assigned as they usually are by gender).

It is common nowadays (UN Office of the High Commissioner for Human Rights) to use the (hopefully) neutral term of intersex to define people who ‘are born with sex characteristics (including genitals, gonads and chromosome patterns) that do not fit typical binary notions of male or female bodies. Intersex is an umbrella term used to describe a wide range of natural bodily variations. In some cases, intersex traits are visible at birth while in others, they are not apparent until puberty. Some chromosomal intersex variations may not be physically apparent at all.’

Of course attitudes are as disparate as societies themselves. Not all have been as tolerant or accepting of difference as one might hope. The BBC article, for example, describes the attitude in some rural areas in Kenya that a baby born with ambiguous genitalia should be killed. ‘Childbirth is changing in Kenya. Increasingly, mothers are giving birth in hospitals, rather than in the village. But not so long ago the use of traditional birth attendants was the norm, and there was a tacit assumption about how to deal with intersex babies. “They used to kill them,” explains Seline Okiki, chairperson of the Ten Beloved Sisters, a group of traditional birth attendants, also from western Kenya. “If an intersex baby was born, automatically it was seen as a curse and that baby was not allowed to live. It was expected that the traditional birth attendant would kill the child and tell the mother her baby was stillborn.”’ The article goes on to say that ‘In the Luo language, there was even a euphemism for how the baby was killed. Traditional birth attendants would say that they had “broken the sweet potato”. This meant they had used a hard sweet potato to damage the baby’s delicate skull.’

‘Although there are no reliable statistics on how many Kenyans are intersex, doctors believe the rate is the same as in other countries – about 1.7% of the population.’ But the thrust of the article was really to discuss how  Zainab, a midwife in rural western Kenya defied a father’s demand that she kill his newborn baby because it was intersex. She secretly adopted the baby –and indeed, even a second one a couple of years later. ‘In Zainab’s community, and in many others in Kenya, an intersex baby is seen as a bad omen, bringing a curse upon its family and neighbours. By adopting the child, Zainab flouted traditional beliefs and risked being blamed for any misfortune.’ But she represents a slow, but nonetheless steady change in attitudes in rural Kenya.

‘These days, the Ten Beloved Sisters leave delivering babies to hospital midwives. Instead, they support expectant and new mothers and raise awareness about HIV transmission. But in more remote areas, where hospitals are hard to reach, traditional birth attendants still deliver babies the old-fashioned way and the Ten Beloved Sisters believe infanticide still happens.’ But, ‘It is hidden. Not open as it was before’.

I suppose it is progress… No, it is progress –however slow, and frustrating the pace may be, as long as there are people like Zainab there is hope. But it still leaves me shaking my head.

For some reason Robert Frost’s poem, The Road Not Taken, springs to mind, in a paraphrase of its last verse: I shall be telling this with a sigh somewhere ages and ages hence: two roads diverged in a yellow wood and she, she took the one less traveled by, and that has made all the difference

Please.

Facing up to the Medicine

There is something magical about a face. It is at the same time familiar and yet mysterious. And although it contains many parts with disparate functions, these are somehow secondary. We see the face as a unit, then judge the components; it is a face first, and only subsequently an aggregation of details. It is the whole which imparts meaning, stirs emotion, engenders response. Only then do the ingredients surface. As St. Jerome said: ‘The face is the mirror of the mind, and [the] eyes without speaking confess the secrets of the heart.’ So I suppose it should come as no surprise that development of reliable facial recognition technology is considered so important. http://www.bbc.com/news/technology-33199275

But there are other domains in which it matters, too. Less technical perhaps, and yet more intriguing. Sometimes it’s not just the perpetuation of facial patterns enabling recognition from encounter to encounter that garner attention so much as a metamorphosis of something far more elusive, far more difficult: the ravages of age. There is something about a face that transcends Time itself. We are recognizably who we are despite the years: My comfort is that old age, that ill layer-up of beauty, can do no more spoil upon my face, as Shakespeare has King Henry V say.

Of course we all suspect we have escaped; daily visits to the mirror cannot see the change any more than frequent glances at a clock can spot the hour hand’s slow progress. Whatever we suppose Time to be, and however we conceive of its passage, barring the before and after of catastrophic events, its gait is not fixed, nor its effects on us often noted from day to day. We mostly live our lives in relative time, and adjust our expectations so gradually they are only apparent to others who happen upon us after long and unexpected intervals. And even then, unless confronted, go unspoken by and large -undescribed, unless in favorable terms.

*

The woman on the other side of my desk looked familiar -in the way some new patients seem to do; I could almost place her. Almost… I see a lot of people –some more frequently than others, to be sure- and yet after a few months or years of absence, even those with whom I’ve had extended exposure tend to generify. Recognition often requires initiation on their part. Prodding. Reminiscing… The encounter often ends with embarrassment or pretense on my part, disappointment on theirs, degenerating into an inadvertent charade for both of us. I don’t wish it so, but alas, I have not been blessed with an eidetic memory of faces past.

Of course, it’s easier to recall some people. They adopt a position on a chair that begs for remembrance, or a way of holding their head that is unique. With Sally -the name on my computer daysheet- it was her face. I tried to analyse what made it so memorable, as I sorted through some papers on my desk. Her eyes? They were brown and calm –they did not seem hunters at the moment, nor imprisoned behind long lashes; not deep set in shadows, not  hiding behind thick distorting lenses. In fact they were far from striking or even distinctive. Her nose was neither large nor mishapen, and her mouth seemed to sit comfortably in its alloted place and smiled only when appropriate, if infrequently.

She noticed me sneaking glances at her as I pretended to play with the keys on my computer, and sighed. “You’re trying to remember, aren’t you, doctor?”

Her voice, too, was familiar, and yet only vaguely so. She was like some book I’d read years ago, whose style and mood, were immediately recognizable, and yet the story, and the ending, were obscure. Tantalizingly close, but so far irretrievable.

“You haven’t changed at all from the first time I met you,” she said, painting my face with her eyes. “Hardly any grey in those curls, still no wrinkles, and that unmistakable look of innocent puzzlement whenever the focus is deflected back onto you.”

Why would anybody remember that? I smiled to diffuse my discomfort.

“Same smile, too,” she whispered, sitting back in her chair triumphant in her recollections. I was evidently who she expected to find -the one she had remembered. Her memory had served her well so far and her face was celebrating.

Who was this anyway?

She straightened up in her chair and sat forward slowly. Deliberately. “I know I’m just here for a pap smear, and you’re a busy man, doctor, but given our history, would you mind if I asked you a personal question?”

I hate it when somebody says that. A polite request usually demands a courteous acquiescence -especially when an unrecalled ‘history’ is offered as a reference.

I nodded, but tried to indicate by my expression that I was only doing it to be –what?- polite. My forehead, I’m sure, made my point.

She noticed, and a tiny smile escaped, ran across her lips, and disappeared on the other side. I could see her amending her question on the fly. “I’m sorry, I didn’t mean to embarrass you. It’s just that you look so much the same as I remember from that first time… It’s uncanny, really.” She leashed her eyes for a moment to study my reaction. I could feel them trying to peel information off my face as they sat, hooded and dangerous on the edge of her thoughts. “I’ve been trying to figure out what it is.”

“Probably the scrubs I always wear,” I said, trying to be funny I suppose.

She shook her head and tried out another smile. “No… I don’t think so.”

Something about the varying texture of her smiles and how they each pulled differently at her eyes, caught my attention and a memory –a shadow, really- flitted like a ghost just out of reach.

A new smile, thin and toothless –an unasked question smile- appeared like a figure glimpsed through a thick gauze curtain, only to disappear again before adequate identification. She was beginning to unnerve me. But suddenly, like opening a gate, everything rushed out.

She took a deep breath and straightened herself on the chair as if she were about to answer a question in class. “I… I asked to see you for a reason, doctor. The pap smear was just an excuse…” She looked past me to stare out the window for a moment, obviously uncomfortable. Embarrassed.

“My midwife sent me to you for an urgent consultation twenty-two years ago. It was my first pregnancy and I wanted so much for everything to go smoothly –you know, home delivery, no pain killers… Anyway, one day Maryanne told me I had to see a specialist. I wanted to see a female, but for some reason I ended up with you.” She glanced at me to see how I was reacting, and then, reassured, continued. “I remember you were very nice, but you said there was not enough fluid around the baby and that it wasn’t growing so you wanted to induce labour right away. You asked me if I had any questions, but I was only thirty-two weeks along in my pregnancy then so I panicked and ran out of the office. I phoned the midwife and she assured me you had a great reputation but I didn’t believe her. I couldn’t. I was sure you were a fake, so I drove back to Surrey where I used to live. I wanted to think it over. But that night I went into premature labour and they had to deliver Melissa there by Caesarian section.

“She was quite sick when she was born –she spent more than two weeks in their nursery,” she said, wringing her hands as if it had all happened yesterday. “And you know, for some reason I blamed you. Like, if you’d decided my midwife was wrong, everything would have been okay…” She sighed and wiped away a tear. “Weird, eh? Hormones, I guess, because then they had to hospitalize me for depression. I was so paranoid I couldn’t think straight for months…”

She took a deep breath and another, different, expression surfaced. “Have you read any Oscar Wilde, doctor?” She asked, her eyes suddenly cold.

I nodded –but carefully. I had the uncomfortable feeling I was being led into a trap. “The Portrait of Dorian Gray?” she asked, her voice now soft and apologetic.

I steeled myself. It was the story of a hedonistic and dissolute man who remains handsome and young while his portrait –stored in the attic- ages and reveals all the evil he has committed.

“At the time, I thought of you as Dorian Gray,” she said, now inspecting her hands tightly kneading her lap. “All show, pretending to be kind, but all the while not caring what I really wanted… Really needed.” She shook her head slowly –maybe she did that when I saw her that time so very long ago. I don’t remember. “I apparently phoned all my friends and told them to stay away from your office… I hated you when I was sick… I tried to spread rumors…”

Well, at least it was Dorian Gray and not Jekyll and Hyde she’d read… Small comfort, I suppose.

Suddenly she sat up and leaned across the desk to grasp my hand. “But it was my portrait that was up in the attic, wasn’t it? It was me all along that was the fake.

“You know I’ve waited all these years to tell you about it -to apologize… but I was afraid.”

I squeezed her hand as a tangible acceptance of her apology and sat back trying to think of something to say to diffuse the mood. “And Melissa? How’s she doing now?”

Yet another smile surfaced briefly, changed its mind for a moment, and then re-emerged as a gigantic grin. “You delivered her baby a couple of  years ago, doctor. I was sitting in the far corner of the delivery room in the shadows for most of it, afraid you’d recognize me. I remember you kept looking over at me –wondering why I wasn’t standing beside my daughter. I didn’t quite know what to do. I kept trying to smile, but I was so ashamed, the smile kept disappearing…” She looked at me quizzically for a moment. “Did you recognize me?” Her face knotted up. “I have to know…”

It was my turn to smile this time. “No…” I said slowly, unable to suppress a blush at my failing memory. I hope that made her feel a little better. And yet, although I hadn’t recognized her then, I realized what had puzzled me about her today: she was wearing the face of a woman I’d come to know quite well; she was her daughter but through a glass darklyThe time is out of joint- O cursed spite, that ever I was born to set it right!” said Hamlet. It felt like that…

The Mystery of Pain

Obstetricians and midwives are, at times, unavoidable witnesses to pain; they wade through it, explain it, try to alleviate it, but never experience it because the physical sensation of pain cannot be transferred to anyone else. It is the one constant attendant in the labour room, the uninvited guest that, welcome or not, arrives early and departs late. It is the ghost in the room, invisible to all but the patient. Unsharable. Unprovable. Indescribable except by metaphor, analogy – it is like something: a drill, a knife, a pressure… We all realize it is there -but there, not here. We do not share in the pain; we have to believe it exists because we are told it does. It is not an objective thing, pain; it is entirely subjective –an owned phenomenon.

In a way, pain has no voice. As Virginia Woolf put it [and here I will use Elaine Scarry’s paraphrase and elsewhere, quotations from her extremely helpful book The Body in Pain]: “Physical pain does not simply resist language but actively destroys it, bringing about an immediate reversion to a state anterior to language, to the sounds and cries a human being makes before language is learned.”

It is a cruel proof of the Theory of Mind: although I realize that you may have different thoughts and feelings from what is in my head, I can only guess what they are; I can never know what they are. Scarry again: “For the person whose pain it is, it is effortlessly grasped (that is, even with the most heroic effort it cannot not be grasped); while for the person outside the sufferer’s body, what is “effortless” is not grasping it (it is easy to remain wholly unaware of its existence; even with effort, one may remain in doubt about its existence …).” And indeed, “… if with the best effort of sustained attention one successfully apprehends it, the aversiveness of the ‘it’ one apprehends will only be a shadowy fraction of the actual ‘it’”.

We can only know something of what the other person is feeling if they can verbalize a suitable metaphor that we all can understand. And given the difficulty of descriptions in the setting of ongoing pain, these can be hard to find, let alone verbalize. Pain Clinics will often use aids such as the McGill Pain Questionnaire that suggest words that do other than merely measure intensity: moderate, severe, or number on a scale of ten, for example. So their vocabulary offers a choice of qualitative descriptions as well as quantitative.

But for most of us following a woman in labour, such questionnaires are unhelpful -and except for the vocabulary, almost useless, in fact. We are still left standing on the outside, trying to sense the existence of something we do not apprehend. It is not like Nietzsche calling his pain ‘Dog’ and saying “it is just as faithful, just as obtrusive and shameless, just as entertaining, just as clever as any other dog –and I can scold it and vent my bad mood on it …” For us, the attendants, this is sophistry.

Pain –the verbal reaction to pain, at any rate- seems to have different ways of expression in different languages, different cultures, even different geographical regions. As Scarry notes: “… a particular constellation of sounds or words that make it possible to register alterations in the felt-experience of pain in one language may have no equivalent in a second language.” And yet it is really all about the same thing, and serves to “… confirm the universal sameness of the central problem, a problem that originates much less in the inflexibility of any one language or in the shyness of any one culture than in the utter rigidity of pain itself: its resistance to language is not simply one of its incidental or accidental attributes but is essential to what it is.”

Empathy, which is as close as an outsider can get to the pain experienced, will have to suffice. Or -far better phrased- Shakespeare’s opinion:

A wretched soul, bruised with adversity,

We bid be quiet when we hear it cry;

But were we burdened with like weight of pain,

As much or more we should ourselves complain.

I suppose it is the ‘why’ of some types of pain that is so puzzling. The etymological root of the word itself is poena: punishment. In the end, is that really what it is: nothing more than an  arbitrary abuse meted out by a blind and indifferent Nature?  We may understand the physiology of pain, the biochemical irritants that cause it, the nerve fibers that fire in response; we may even postulate the evolutionary protective purposes it sometimes purports to serve, and yet… And yet we are still left wondering about more than the physical nature of pain. As Scarry says: “… when one speaks about ‘one’s own physical pain’ and about ‘another person’s physical pain,’ one might almost appear to be speaking about two wholly distinct orders of events… Thus pain comes unsharably into our midst as at once that which cannot be denied and that which cannot be confirmed.”

It is a relief to find that I am not the only one who finds these disparate aspects of pain to be numinous -and the ‘why’ of pain as elusive to others as it is to myself. If the only way to describe one’s own pain, as I have already mentioned, is through metaphor, perhaps the only way to understand pain, then, is also through metaphor. Story. Literature.

Nietzsche once again: “Only great pain, the long, slow pain that takes its time… compels us to descend to our ultimate depths… I doubt that such pain makes us “better”; but I know it makes us more profound… In the end, lest what is most important remain unsaid: from such abysses, from such severe sickness, one returns newborn, having shed one’s skin… with merrier senses, with a second dangerous innocence in joy, more childlike and yet a hundred times subtler than one has ever been before.”

I do not understand Pain, but I do not discount it. I will merely rest my discomfort on another of Shakespeare’s observations: that maybe “Pain pays the income of each precious thing.” It’s a start anyway…

 

 

 

 

 

 

 

 

 

Midwifery

Perspective is a mysterious thing: a thousand people crossing a single bridge is a thousand people crossing a thousand bridges. We can only see the world through our own eyes; none of us is exempt.

When I first graduated, doctors were a cult, and immersed in it as I was, I would not have thought of it as such. We were doctors and they -everybody else- were, well, others. And at the time, I remember well that the very idea of entrusting the care and delivery of a woman to someone outside of the medical profession was anathema. We were the Guardians of science, and only we realized that things could go horribly wrong in a pregnancy if not guided by someone on a first-name basis with disease -someone not necessarily experienced with the vagaries of the process, but one who could at least recognize that it was going wrong and take an alternate path to its successful resolution: forceps, arcane manuevers, Caesarian Sections… Of course the obstetrician was never as threatened as the family practitioner because only we could perform the complicated stuff. Our training was longer, more intensive. Put another way, we were even more indoctrinated.

Why do we fear the other side? Why is there an other side? I suppose we mistrust those who come from different traditions -those whose perspectives do not entirely conform to what we have been taught. We are parochial creatures; it’s where our comfort lies. Seldom do we have the patience -or wisdom- to attempt to frame the world differently. And why should we, if we believe we possess the Truth, that we alone walk the Path? But of course we don’t. There are as many paths as there are destinations and how dare any of us assume we know the best one?

I am reminded of a patient I saw in consultation earlier in my career than I care to remember. She was in her second pregnancy and had been referred to me by a family doctor in town because she had required a Caesarian Section for her first child. She was only four feet ten inches tall and as the doctor had tried to explain to her, the first baby was too large for her pelvis, so the second would be as well. But she wanted to go to a midwife for her antenatal care. What was the harm? As she explained to me, if the second baby didn’t fit and the labour didn’t progress, the midwife would be able to refer her to the obstetrician on call and she’d have the Caesarian then: win-win.

“But doesn’t it bother you that you may go through all that work and distress for nothing?” I asked, incredulous at the very idea, and clearly insensitive to what she was trying to tell me.

I remember she sat up straight in the chair and stared at me, equally incredulously. “For nothing? Doctor, no offense, but do you see why I want to go to a midwife?”

I didn’t understand it for a long time. I had to mature enough to realize that although we both wanted the same thing -a healthy baby- there were different routes to the same place. One of my favourite poems describes it best, I think. Do you remember the one by Robert Frost: The Road Not Taken? It starts: Two roads diverged in a yellow wood/ And sorry I could not travel both…

And how it ends? Two roads diverged in a yellow wood, and I-/I took the one less traveled by,/And that has made all the difference.

I don’t mean to suggest that one of them is better, or preferable, or even less chosen, merely that I shall be telling this with a sigh/ Somewhere ages and ages hence.

I suppose I should have known…