Masters of their fates?

Sentience is the present participle of the Latin verb sentire –‘to feel’- but what is it? What does it imply? Consciousness? Thought? Or merely some form of awareness of the surroundings, however indistinct and vague? Is avoidance of a noxious stimulus enough to establish sentience, or does it have to involve an understanding that it is harmful?

How about pain itself, then? What kind of a nervous system can feel pain -not just avoid damage, you understand, but feel it? Because surely feeling pain assumes some sort of an I who perceives it as pain rather than simply moves away reflexively… Are we back to consciousness again?

I suppose it’s easy to posit sentience in something like a dog, or a wary squirrel in whose eyes one can easily see that there is something/someone behind them looking out at the world. It’s more difficult as you move down the phylogenetic chain (if one even can, or should, assign direction or rank to changing phyla): easier with, say, lizards or crocodiles; more difficult with flies and mosquitoes; and impossible -for me, at least- with, oh, tapeworms or amoebae and their ilk.

Yes, and then there are the plants which react to stimuli, often in a purposive fashion -what do we do with them? What constitutes a feeling of pain -especially since they do not have what most of us would consider a nervous system (although their root structures and associated symbiotic fungal networks might qualify). Do plants feel some sort of proto-pain -and if they do, so what? The buck, if I may be allowed to paraphrase the sign on the previous American president Harry Truman’s desk, has to stop somewhere

So where do we draw the line with sentience? Is it entirely subjective (ours, at any rate)? Should it be confined to those things we would not think of stepping on or swatting? Or is it enough to be alive to merit consideration -different from a rock, for example?

I don’t know why I worry about such things, but I obviously do -especially when I come across essays like the one in Aeon written by Brandon Keim. https://aeon.co/essays/do-cyborg-cockroaches-dream-of-electric-trash

It was entitled I, cockroach, and delved into whether insects felt pain, or were conscious. The question occurred to him after reading about Backyard Brains, ‘a Kickstarter-funded neuroscience education company.’ The company’s flagship product is apparently RoboRoach, a ‘bundle of Bluetooth signal-processing microelectronics that’s glued to the back of a living cockroach and wired into the stumps of its cut-off antennae. Cockroaches use their antennae to detect objects; they react to electrical pulses sent through these nerves as though they have bumped into something, allowing children to remote‑control them with smartphones.’

I have to admit that I am appalled at this -although I suppose I would think little of swatting a cockroach crawling across the kitchen floor. The difference, I suspect, is somewhat akin to what Keim discusses: using a living creature as a tool in what might be -for the cockroach, at any rate- similar to some higher being wiring us up for whatever questionable purpose to change and study our behaviour and -who knows?- maybe change our reality. It’s hard not to sound overly anthropomorphic in describing my feelings about this, but there you have it.

‘A note on the company’s website does reassure customers that, though it’s unknown if insects feel pain, anaesthesia is used during procedures on cockroaches, and also on earthworms and grasshoppers involved in other experiments.’ But as I’ve already mentioned, and as Keim discusses, ‘You can’t experience pain unless there’s a you — a sense of self, an interior dialogue beyond the interplay of stimulus and involuntary response, elevating mechanics to consciousness. [And] such sentience is quite unlikely in a bug, says Backyard Brains.’ Really?

Even the likes of Darwin wondered about cognitive states in ‘lower’ creatures. In his final book, The Formation of Vegetable Mould Through the Action of Worms, with Observations on Their Habits (1881), he describes in great detail ‘how earthworms plug the entrance to their burrows with precisely chosen and arranged leaf fragments, and how instinct alone doesn’t plausibly explain that. ‘One alternative alone is left, namely, that worms, although standing low in the scale of organisation, possess some degree of intelligence.’

And no, as the more observant of my readers will no doubt have noted, worms are not cockroaches. Then how about honey bees as insect stand-ins for roaches? How about their waggle dances: ‘the complicated sequence of gestures by which honeybees convey the location and quality of food to hive-mates’? As Keim notes, ‘scientists have assembled a portrait of extraordinary cognitive richness, so rich that honeybees now serve as model organisms for understanding the neurobiology of basic cognition. Honeybees have a sense of time and of space; they have both short- and long-term memories. These memories combine sight and smell, and are available to bees independent of their immediate environments. In other words, they have internal representations of their worlds. They can learn to recognise patterns, and also concepts: above and below, same or different. They have simple emotions and beliefs, and apply those memories and concepts to their decisions. They likely recognise individuals.’

In fact, ‘Cognition is only one facet of mental activity, and not a stand-in for rich inner experience, but underlying honeybee cognition is [a] small but sophisticated brain, with structures that effectively perform similar functions as the mammalian cortex and thalamus — systems considered fundamental to human consciousness.’

I don’t want to take this too far. Thomas Nagel, the American philosopher, in his 1974 essay What is it like to be a bat? argued that ‘an organism has conscious mental states, “if and only if there is something that it is like to be that organism—something it is like for the organism to be itself.” (A fascinating paper, by the way, and well worth the read). But, coming back to cockroaches, as Keim writes, ‘The nature of their consciousness is difficult to ascertain, but we can at least imagine that it feels like something to be a bee or a cockroach or a cricket. That something is intertwined with their life histories, modes of perception, and neurological organisation’ -however impoverished that something might seem in comparison to our own perceptions. Indeed, maybe it would be something like our state of awareness in doing ‘mindless’ tasks like walking down stairs, or picking up a cup of coffee -both purposive, and yet likely unremarked consciously…

There’s even some evidence that cockroaches have a richer social life than most of us might have imagined. According to ethologist Mathieu Lihoreau in his 2012 article for the journal Insectes Sociaux, ‘one can think of them as living in herds. Groups decide collectively on where to feed and shelter, and there’s evidence of sophisticated communication, via chemical signals rather than dances. When kept in isolation, individual roaches develop behavioural disorders; they possess rich spatial memories, which they use to navigate; and they might even recognise group members on an individual basis.’

Maybe the famous English biologist J.B.S. Haldane got it right when, in 1927, he wrote that ‘the universe is not only queerer than we suppose, but queerer than we can suppose’. Then again, I suspect we tend to view things as peculiar or even alien if we feel no connection to them -feel that, as humans, we are not really a part of their world. But remember the words of Gloucester as he stumbles around the moor after being blinded by Regan and Cornwall in Shakespeare’s King Lear: ‘As flies to wanton boys are we to the gods; they kill us for their sport‘.

Who’s world are we in, exactly…?

Is there really nothing new under the sun?

What has been will be again, what has been done will be done again; there is nothing new under the sun. The older I get, the more I understand the wisdom of that passage from Ecclesiastes. It’s not that I have experienced everything, seen everything, and I certainly haven’t thought of everything; I have no proof whereof I speak, and yet… And yet it seems to wear the ring of understanding, doesn’t it? ‘It is the province of knowledge to speak and it is the privilege of wisdom to listen’ as Oliver Wendell Holmes once said.

I suspect there’s something truly atavistic about touch. Something inescapable, at any rate. Birth, suckling, and rearing are universals –at least for mammals- and each involves contact, albeit a closeness that often diminishes with a maturity that adopts different forms of communication. Different types of connection. But its primacy never really disappears –whether in fighting, copulating, or even greeting, it lingers like a shadow never fully in the background.

I’ve written about it before, sometimes vicariously, with a soft brush, sometimes even with a gentle nudge, and once when I was moved sufficiently to address it as a subject worthy of a title: Touch  https://musingsonwomenshealth.com/2013/01/25/touch/ But somehow, it creeps back again and again as needful as a hungry child to be noticed.

Like the fabled Phoenix, it rose anew in an article in the CBC news, and as a still-unrequited lover, I have rushed to it again with open arms: http://www.cbc.ca/1.4363121 It’s amazing how such a basic thing as touch seems to require mention again and again – as if without the attention it would slip beneath the waves like a curious seal and be seen no more. As if we continually need the reminder to see our noses.

And each time it surfaces in a different place than we expect. ‘In the past 20 years, scientists have discovered that our hairy skin has cells that respond to a stroking touch. It’s a trait we share with other mammals. Now psychologists in England say their work shows, for the first time, that a gentle touch can be a buffer against social rejection, too. […] The study builds on previous ones showing that receiving touch from loved ones after a physical injury is supportive.’ -a coals-to-Newcastle study you may ask? I mean, really… But I suppose that statistical validation is a way of indicating that it is a conclusion once-removed – that the findings are hopefully divorced from any possibility of emotional contagion. Still…

It continues, ‘Pain is ubiquitous across medical disciplines. Yet touch has been shown to improve outcomes in people with rheumatoid arthritis or fibromyalgia and in pre-term infants, the study’s authors said.’ Once again, the older and wiser amongst you might have to fight against the urge to roll your eyes. Of course touch is important, I hear you whisper, as you move on to another, less flagrantly transparent article.

There was a point to underlining the glaring intuitively common sense observations, however –but not, alas, until the nether end of the article. ‘Our brains are attuned to combining information from our five senses. And when much of our time is spent engaging with social media, which relies on visual and sound cues alone, it’s easy to forget the power of touch.’ This, in an era of proxy reaching, and touching a friend online -‘just “liking” a post or texting an emoji.’

Maybe it’s more obvious to those of us who didn’t grow up with a smartphone in our hands or a screen in our face, but it still needs repeating: Of course touch is important! So is actual eye contact. And body language. There’s something about proximity that facilitates communication and realistic interpretation.

A study at St. Francis Xavier University in Nova Scotia –one of undoubtedly many of this type- tracked ‘100 mothers and babies over four years [and] they found mothers who used skin-to-skin contact reported breastfeeding for a longer period, less postpartum depression, and a closer relationship with their babies compared with mothers who did not use the method.’ Without re-stating the obvious, the contention was that ‘Because the baby is being held so close to the mother, the mother learns the baby’s signals…’ And, of course, then the usual self-evident trope that ‘It’s not just newborns who benefit from skin-to-skin cuddling — moms do, too’ with the requisite reductionist explanation ‘For the mother, the close contact stimulates the hormone oxytocin, which helps to promote maternal feelings’ as if a physiological justification for the observation were required to bolster the issue… Just in case.

Surely we know all this, though. Surely, if we look around us we can see touch in action -even in a downtown shopping mall.

I rarely go to malls -I find the crowds of strangers annoying- but every so often, the anthill instinct surfaces, and I dip my foot in the colony just for the experience.

I am usually wary of casual contact and, as on a busy sidewalk in the city, there is an unconscious dance to avoid touching strangers. It’s not a fear thing, nor a dread of pestilence; I do not feel uneasy for myself or my property, so much as that my closeness, however accidental and unintended, might be misconstrued. Touch can be therapeutic and welcomed, for sure, but it can also be unwarranted -misunderstood by a stranger – frightening or threatening if unrequested.

I picked the wrong time to test the mall, I think. It was noon and filled with casual shoppers, their eyes on window displays, and bags akimbo, they wandered aimlessly from store to store, depending on a mall-acquired skill to avoid the Brownian motion alive around them. Me? I felt more dizzy from the chaos than innately protected, and found myself leaning rather self-consciously on a pillar near a bank of seats, watching for a vacancy to rest. I admit I shouldn’t have let down my guard, but I am basically a visiting country mouse -a mall virgin, I’m afraid.

Still, I didn’t expect to be knocked down by a distracted shopper –a thin, middle aged woman at that- but I suppose that anybody, if hit unawares, would go down as quickly. At least that was my embarrassed conceit on my way to the floor.

The woman, a business executive by the look of her dark-blue pant suit and blindingly white blouse, was mortified and stooped to help me up. I must have looked confused –I’m sure I was- at the sudden horizontality of my position when she first extended her hands to me.

“Are you alright, sir?” she said, her eyes leaning heavily on my face. “I’m so sorry… I don’t know how I managed that…” she added, her words thick with remorse.

Sometimes, I think I look younger than my years –one gets used to the reflection in the mirror- but obviously she saw me in a different, more fraught light, and her expression melted as she mistook my surprise for fragility. Suddenly she hugged me –a brief, but reflexive attempt at apology. It couldn’t have lasted more than a fraction of a second, but it was as if, for that instant, she was not a stranger, but a caring person responding to the needs of another.

She blushed at my smile, then touched my sleeve as she walked away, her head disappearing in the crowd like a bird in a forest. But I have not forgotten that heartfelt touch. Some things are special –ordinary or not. Touch is a gift, and I felt unexpectedly blessed…

For my Pains, a World of Sighs

What does pain look like? An intriguing question to be sure, but one I hadn’t even thought to ask until recently. Pain is one of those things that, like St. Augustine’s quandary over Time, presents a similar difficulty in defining. The International Association for the Study of Pain made a stab at it: ‘Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage,’ but somehow, it seems to lack the immediacy of its subject matter –it stands, like an observer, outside the issue. Poets have done a better job, I think. Emily Dickinson, for example: After great pain, a formal feeling comes. The Nerves sit ceremonious, like tombs’; or Kahlil Gibran: ‘pain is the bitter potion by which the physician within you heals your sick self’; or even Oscar Wilde: ‘Pain, unlike Pleasure, wears no mask.

But I was reminded of another of Wilde’s observations -‘We who live in prison, and in whose lives there is no event but sorrow, have to measure time by throbs of pain, and the record of bitter moments.’- when I read a CBC article from November, 2016 entitled ‘Indigenous children, stoic about their pain, are drawn out with art’ http://www.cbc.ca/news/health/aboriginal-youth-art-pain-hurt-healing-1.3852646

‘”Aboriginal children feel and experience pain just like anyone else. It’s just that they express their pain very differently,” said John Sylliboy, community research co-ordinator with the Aboriginal Children’s Hurt and Healing Initiative.

‘”They don’t necessarily verbalize their pain, or they don’t express it outwardly through crying or through pain grimaces,” he told CBC News.’

‘These children are socialized to be stoic about their pain, to hold in their pain.’- Margot Latimer, Centre for Pediatric Pain Research, IWK Health Centre in Halifax. ‘”We noticed we weren’t seeing any First Nations youth referred to our pain clinic at the IWK hospital and wondered why that was so.”‘ It didn’t make sense, she thought — especially since research shows that chronic illness in First Nations communities is almost three times higher than in the general population. Aboriginal children are especially vulnerable, says Latimer, with higher rates of dental pain, ear infections, and juvenile rheumatoid arthritis.’

I found it very moving, and yet disturbing, that ‘[…] cultural traditions, and lingering effects from the residential school system, are some of the reasons Indigenous kids pull on their suit of armour against pain and hurt.’ But they’re children, and perhaps not yet completely shackled to all the subtleties of culture. ‘A group of Indigenous children and teenagers from four First Nations communities in the Maritimes were asked to paint their pain, to express their hurt through art. Researchers were hoping to tease out emotions from a population more inclined to show resilience to pain.’ But soon after, the children began to depict not just physical pain, but emotional pain as well. As Sylliboy points out, ‘”These kids told us about loneliness, sadness, darkness, bullying, hopelessness. It’s not the typical anxiety [or] depression. It is more complex than that.” “To these clinicians who are just asking about physical pain and not looking at emotional pain as well, it is important, because Aboriginal kids are showing us that there is no difference between emotional and physical pain”, said Sylliboy. “It’s just pain.”‘

And I learned another thing about pain –or maybe about children – ‘It’s all about creating a safe space for the children when they come to the hospital, says Latimer.  She says it’s about learning a bit about them and gaining their trust. “When they come to the health centre, or a physician or a nurse practitioner, they want to tell their story, but we do not train health professionals to assess pain that way.”’

It reminded me of a patient I first met in the Emergency Department at the hospital when I was the gynaecologist on call one night. Edie, an aboriginal woman arrived with heavy bleeding –she was  apparently in the throes of miscarrying an early pregnancy- and had brought her eight year old son to the hospital because she had no one to take care of him at home. The bleeding settled shortly after her arrival and an ultrasound in the department revealed that there was no further tissue left in the uterus, so fortunately we didn’t have to take her to the operating room. But the process of diagnosis and decision was not instantaneous. Although the little boy, Timmy, was clearly frightened, his face stayed neutral. And yet it seemed as if he was peeking through hole in a fence, and I could see his eyes carefully following my every move. One of the nurses volunteered to sit with him in the waiting room while I examined his mother, but I was the last one he stared at before leaving; I was the thing he didn’t understand.

I decided to let Edie rest on the stretcher for a while before discharge, and I thought I’d reassure Timmy before I left. He was sitting on the too-big chair as quietly and unmoving as an adult and when I approached, he stared at me like a deer hiding in a forest.

“Your mom’s going to be okay, Timmy,” I said with a big smile.

But he still seemed just as frightened, and stayed silent for a moment. “There was blood on her pants,” he mumbled, perhaps making sure I’d noticed. He allowed his eyes to venture out further into the open and he examined me again. “And she was hurting…”

What do you tell a little boy about his mother’s suffering? I knelt down on one knee in front of him so our eyes were on the same level and put a hand on his knee. I couldn’t  think of anything else to do. “She’s not hurting now, Timmy,” I said and smiled again.

He looked at my hand and then he finally smiled. “Can she go home now?” When I nodded, he reached out and carefully touched one of my fingers, and then when I didn’t pull away, he patted my hand.

I never saw little Timmy again, but a few weeks later, Edie came to my office for a follow-up visit and to thank me for seeing her in the hospital in the middle of the night. “Timmy was really impressed,” she said and smiled. She ruffled through her purse and brought out a rumpled piece of paper she’d nonetheless folded carefully. “He drew this for you, doctor,” she said proudly, and handed it to me.

When I opened it up, it was a drawing of a hand in red crayon.

“He said it was to thank you…” She seemed embarrassed, and hesitated before continuing. “I asked him why he drew it in red…” she said.

She still seemed embarrassed, so I stayed silent until she felt ready to continue.

Edie studied me for a moment with her big brown eyes, still uncertain. Then her face relaxed and a big smile appeared. “He said maybe you were one of us, now…”

I could have cried.

The Unexpected

What I like about the unexpected is that you never expect it. It’s a surprise. A gift. And the world is filled with this stuff. Each day at work –I’m a gynaecologist- there are little treasures hidden within appointments, presents in names. Especially the unpronounceable Persian names that unravel when I try to work at them one syllable at a time to call some nervous woman from the waiting room. But she inevitably understands my bumbled attempt, smiles, and when she sees my embarrassment, immediately forgives.

And there are cross cultural surprises that don’t anymore. Surprise, that is. There are some people for whom a question has to be asked with a lot of forethought. It cannot merely trip off of the tongue; it must be planned well in advance. A simple query in taking her history such as “You’re not married, are you?” might elicit ‘yes’ –meaning either ‘Yes I am married,’ or ‘yes, you are correct in saying I am not married.’ I love it.

Or consider the argumentative patient who doesn’t want to tell you why she is there. Her name provides no advance warning, nor does the note from the referring doctor. The first clue is usually the defiant, silent stare, and the arms tightly enfolded across her chest as if to prove that coming to see me was definitely not her idea. I suspect the behaviour is a punishment, although for whom I’ve yet to determine. And what do I usually do? I ignore the theatre and simply ask her why her doctor sent her. If that doesn’t work, I sit back in my chair and smile at her, hoping the time will allow her to acclimatize. Relax. Sooner or later, of course, she realizes she has to do something  or pay for extra parking, so she will sigh, undo her arms, unlock her eyes and either apologize or leave. I never know which way it will go.

But sometimes I am caught off guard. Something unexpected happens that even I did not anticipate. That something happened only a few months ago in fact: a movie star. Well, sort of…

It was just before lunch, and my stomach was rumbling. I had only one patient to see before I could escape for the morning, so I quickly glanced at the referral note. ‘Pain’ was all it said. Damn! I suppose the family doctor was in a hurry, but even an adjective, a descriptive, might have pointed the word in a more helpful direction. I shrugged mentally and then let it go –after all I was the detective, not him.

I walked down the corridor to the waiting room rehearsing her name. “Jojo?” I said with a little uptick at the end to indicate that I wasn’t entirely sure I’d got the name right, or whether it was a name only her closest friends used.

An unsmiling woman with short hair stood up and walked over to me. She shook my hand, but I could tell she didn’t really want to touch me. She wouldn’t make eye contact either. That made me a little nervous, but I assumed that she was just shy and understandably anxious. But I have to confess that apart from that, my initial impression of her was, well… absent. Nothing about her cried out for attention. She was average height, average build, with a pleasant but decidedly unstriking appearance –we are all beautiful in our own ways, but sometimes it is easier to notice, I suppose. I dislike the adjective ‘plain’ when applied to people, but occasionally it’s difficult to find another word without seeming patronizing. Let us just say she was neither attractive, nor unattractive but somewhere on that hazy continuum verging on, well, average.

She sat rather primly on the chair opposite my desk, eyes fixated on something on the wall to the left of my head. I fought the temptation to turn and see what she was looking at and distracted myself by asking her why she’d come to see me.

“Pain,” she said simply, without moving her eyes.

I waited what I thought was a polite interval for her to continue, but when she didn’t  I fidgeted with a pen on my desk -a signal, I hoped.

She glanced briefly at her hands and then her eyes flew back to their accustomed branch on the wall. “It’s been interfering with work lately,” she said, as if she had unlocked a door.

I felt I was getting somewhere. “In what way?” I asked, smiling to reassure her that I would understand.

She stared even harder at the wall and said, without a hint of embarrassment, “I get terrible pain when he…” I could actually see her adjusting words in her head. “When he enters…” She seemed pleased with the word she’d chosen and smiled for the first time –at the wall, mind you, but I figured it was a rapport starter. Suddenly she appeared to reconsider. “No, not ‘enters’ exactly… when he’s, uhmm…” -this seemed to be a real challenge for her- “…you know, in there and looking around.” I could tell she wasn’t exactly happy with her description, but she didn’t offer any more metaphors and resumed the neutral expression she had worn coming into the office.

I assumed I had simply misinterpreted the temporal juxtaposition of  her personal life and work, so I let it pass without further comment, although I did make a few mistakes typing it into the computer. The rest of the history was easier for her and even the subsequent physical examination, despite the pain, didn’t appear to bother her unduly. After she had come back into the office from the examination room, she seemed more relaxed than I’d seen her. “You found it, eh?” she said after sitting down and making more comfortable eye contact with the now familiar space on the wall behind me. “The part he hits,” she added to make sure I knew what she meant.

I smiled and nodded in agreement.

“So, what do you think?”

I’d felt a rather large and tender ovarian cyst in her pelvis -probably from endometriosis, judging from the rest of her history. “Well…” I tried to frame my response in a non-frightening fashion, but it was difficult. Ovarian cysts are always frightening. Threatening. “The area that was the most tender was around your left ovary. It seems larger than it should be –a cyst, maybe…” I thought the ‘maybe’ might diffuse the fright I could see in the eyes that now sought mine. “I’d like to get an ultrasound first, though, before we decide what to do.”

“You mean, like it might be… cancer?” I could tell it was difficult for her even to fashion the word in her mouth.

I smiled disarmingly. “No, more probably endometriosis.” I was about to elaborate on the word when her face turned sour and her eyes fled to the wall again.

“So, if it is a cyst, what are you going to have to do about it?” She sounded angry, but her face grew expressionless.

“Well, if it is a cyst, we’ll have to remove it.”

Her eyes immediately saucered and focussed on the front of my shirt. “You mean surgery?” I could almost see the italics. “Sorry, I don’t do surgery, doctor!” Her face changed; it was no longer unreadable.

“Why don’t we just wait to see what the ultrasound finds and then decide what we…”

But she was already putting on her coat. “You don’t understand, doctor.” She was having trouble fitting the two sides of the zipper together, so it gave me time to ask why she seemed so upset. She sighed, left the zipper for a moment and actually looked at me. Me -not the wall, not my shirt, not her hands- me. “It’s my work… I can’t have any scars for my work.” She stood up and walked to the door, still unzipped.

“The scars from a laparoscope are really quite small, Jojo. I…”

But she stopped at the door and turned to face me as she interrupted irritably. “Any scars. I can’t have any scars! That’s what they told me…”

“Who told you?”

“My producers.” I couldn’t keep the concern off of my face, so she continued. “No scars –that’s what they said.”

My face relaxed. “Producers? So you’re an actor? In the movies?” I must have looked impressed because she nodded modestly and leaned seductively on the door frame. “But… they’d be tiny little scars. And most of them would be lower down on your abdomen. Even the skimpiest little bathing suit would hide them.”

She cocked her head and allowed herself a tiny smile before she left. “I never get to wear one for very long,” she said as she disappeared down the hallway.

The Crown Jewel

 

Ahh, those were the days! The days when naivete reigned. The once-upon-a-times when my practice was young and everyone around me seemed old. They spoke a language I had not anticipated in my training; they seem to have subscribed to different dictionaries, or the words were smudged so they did their best with what they could make out. I began to wonder if my background in the prairies had hidden me from modern descriptive English. Cloaked me in innocence. After all, it was the place where I was assured by a teacher in grade three that Winnipeg was the only place in the world where we did not speak with an accent.

Of course, since then I have lived in many places, and my vocabulary has expanded accordingly -but it is the jargon of common things by and large: words we might use with a person in the office, or a friend at a coffee shop. Every day things… Doctors generally do not unwrap their esoteria in public, and their user-unfriendly descriptives for particular bodily parts or conditions go largely untranslated. Unappreciated in the main. And anyway, most people have their own names for the stuff.

But when you’re first starting and building a practice, the world is freshly scrubbed and terminology an adventure. I quickly discovered that patients are wont to try new doctors in a never ending quest for clarity –someone whose explanations they can understand. Someone who doesn’t have to resort to pointing at the area in question. We are all under somebody’s microscope.

*

It was only my second month in practice, and I wasn’t very busy.

“Doctor, I hope you can help me,” the olive-skinned woman said as soon as she sat down. Her long black hair was carefully pinned on her head, but as she gestured, little strands would escape and cross her eyes like windshield wiper blades. Far from annoying her, she hurried the transit in a trained fluid sweep of her head as if it was an integral part of her everyday speech.

She was a heavy woman, but dressed in a stunning green blouse and black jeans, she wore her weight, like her height, as a gift. The most striking feature about her, though, was her eyes. Intense and brown, they prowled the room in search of prey, then fastened upon me like a cat, and once engaged, stapled me to my chair.

I struggled to disengage and tried to focus on her chart for a moment. Usually there is an explanatory referral letter, but there were only three words scrawled in pencil –hurriedly, I think, because they were almost undecipherable.

My face must have fallen, because she unlatched her eyes, scanned the upside-down letters, and said, “Dr. Edwards is a man of few words, eh?”

I looked up, embarrassed at my inability to decipher the letters, and turned the page so she could read it. “Any idea what it says?”

She studied my face to see if I was kidding. “He was kind of puzzled by my stuff, so he told me to explain it to you… Anyway, it says ‘something quadrant pain’ –whatever that means.” A mischievous look snuck onto her face and her body shivered ever so slightly, the movement slowly descending like a wave. “I’ve got pain in my parts… My private parts,” she added quickly, concerned that fancy might draw me to more public venues.

“And when do you get pain… there?” I asked, hoping for more clarity.

She thought about it for a moment. “Well, mostly during my monthlies I suppose, but occasionally during his act.” I must have looked blank, because her eyes dropped briefly as she searched for a more apt description. “You know,when he… walks through the door,” she said, and sat back in her chair convinced she had simplified the term.

She struggled through her history with a litany of words I had never heard before. Things like ‘tweenie-legs’ and ‘bloaty-stuff’ surfaced briefly, then sank just as quickly after I’d made a stab at translating them into something I could dictate to her doctor.

But when we’d plodded through the symptoms and I’d had a chance to examine her, it seemed likely that she had endometriosis –a painful condition where some of the endometrial cells that normally line the uterus and are expelled during menstruation, are forced back through the Fallopian tubes into the abdominal cavity where they can grow.

The condition is usually diagnosed and treated with a laparoscope –a telescope inserted through the belly button under an anaesthetic. Pretty standard stuff. But this seemed to worry her more than the condition itself. “I’m kinda worried about my crown jewel,” she said, her brown eyes watering.

I smiled and assured her that I would not be taking anything out of her. I had heard the expression ‘crown jewels’ before but always in the plural, and never referring to women. But, summoning up a vague memory of trash talk in the YMCA locker room, I assumed it was a code for ovary and not wanting to become entrapped in another of her semantic vortices, I left it at that.

*

The last thing she said to me in the OR before the anaesthesiologist put her to sleep was “Careful of the crown jewel, eh, doc?” I touched her shoulder reassuringly and watched her close her eyes as the medication took hold.

“What was that about?” the scrub nurse said as she was prepping her adomen.

I shrugged. “I was hoping I was the only one who didn’t understand…”

Belly buttons are interesting areas, I have come to realize. They exist in all sizes and shapes. Their contours run the gamut from vertical alignment to transverse and since the laparoscope has to be inserted through it, the incision has to be similarly tailored so it is inapparent after it heals. Hers was distorted, however, so I found I had to be creative. I ended up cutting a short horizontal line about as long as my little finger nail on its lower edge much to the surprise of the resident doctor who was assisting me.

“I’ve only seen it cut vertically,” she said with some hesitation evident in her voice. It wasn’t exactly a criticism –residents don’t usually criticize their staff- but I could hear the implied judgement in the tone. I smiled beneath my mask, and said something to justify my decision. But it was a bluff; I recognized my heresy all too clearly. If it healed with a ridge, or a scar, there might be complaints. It made me all the more determined to leave her ovaries unharmed.

And then, after dealing with the endometriosis, and dictating the operative report, I promptly forgot about the navel issue. Until, that is, she returned to see me several weeks later.

*

She sat down opposite me as she had that first time, but her eyes were so intense I could barely see her face. “What did you do, doctor?” she said in an accusatory tone before I could even open her chart.

“Do you still have the pain?” I asked carefully –almost shyly, given the spotlight of her eyes. I felt naked in their allegation. Like I had done something wrong.

She turned down the wattage and I could finally see the smile that had been in possession of her face all the while. “No, of course not…”

‘Of course not’? I took a deep breath as the memory of her umbilical incision rose slowly and painfully into my chest; my resident had been right.

“How did you do it?” she said a little too loudly, her eyes firmly grasping my head. “My friends all noticed; everybody’s been commenting.”

“I’m sorry,” I managed to mumble, my cheeks no doubt red with the effort. “I don’t underst…”

“The belly button!” She interrupted and then almost jumped across the desk in her frenzy. As it was, she leaned so far she was almost touching me. Then she relented and retreated slowly into her chair. “You know what I do, don’t you?”

Actually, I didn’t –in those days I rarely noticed if a profession was written on the chart- but I could hear the word ‘lawyer’ humming softly in the background.

“I dance professionally,” she said. “I specialize in the danse du ventre, to use my favorite description.” I think I must have accidently raised an eyebrow, because she rolled her eyes impatiently and added “A belly dance!”

“I still don’t…”

“My crown jewel,” she said, carefully enunciating each word as if speaking to a slow child. “I wear a ruby in my belly button as part of my act.” My face stayed blank. “It always falls out unless I glue it in. Those kittens are heavy, you know. Especially when you’re moving everything around.”

“So..?” I didn’t know where she was going with this, so I tried to stay neutral. Sensitive.

“So whatever you did worked… Sits in there like a baby in a blanket now.”

I allowed myself a smile.

“The girls in the troupe are all impressed,” she said, positively beaming. “I told them to pretend they had pain in their parts so they could get to see you.”

Well, I guess it’s a start, eh?

 

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…

 

 

 

 

 

 

 

 

 

Reflections on the Bell Curve

We -many of us in the Western world at any rate- live our lives on a Bell Curve, thinking -hoping- we occupy a place near an out-lying position: the 5% area that presumes we are not just normal,  but rather, exceptional… And given the population numbers, there is time spent worrying that we are inadvertently drifting towards the center -the average- and hoping that we are somehow firmly anchored on an edge where interesting things happen. We seem to aspire to live in interesting times, despite the doom that these times apprehend in the apocryphal Chinese curse.

It is a mild conceit, perhaps, but one that is not without ramifications: to discover that one is, in fact, quite average is inevitable as one travels through an otherwise eventful life, but to realize it too soon, may be to hold an imperfect mirror up to what had hitherto been seen as important and to distort an otherwise perceptible, measurable -believable- reality. It may denigrate the path, impute the incentives that had determined the choice.  Purpose maligned is purpose denied. We are, to an extent, our choices and we choose what we hope -or expect… 

Or do we? My interest was stirred by an otherwise banal finding in a study reported in the Huffington Post: that ‘dreading pain may be more unpleasant than the pain itself’.( http://www.huffingtonpost.com/2013/11/24/dreading-pain_n_4318114.html ) Uhmm, okay… I mean, how new is this? Let me quote from a 16th century poem (Sir Philip Sidney) that already recognized that: Fear is more pain than is the pain it fears. Plus ca change, eh? But it made me think that how we perceive things is highly conditioned by our expectations of them. Or dread of them.

Think of an impending biopsy, for example, where the result -not volition- may determine the direction of the road ahead. It is when the Bell Curve becomes an albatross, and not a presumption. Although pain and the anticipation thereof was what was examined, it seems to me not a large step to posit that the study would also suggest that we often see ourselves on the wrong end of the 5% -the wrong side of the curve- and the pain varies according to how anxious we are about the result of the test. Even though the likelihood is one of benignity and we have been reassured to that effect, that is not how we feel it beforehand.

Or consider childbirth, with all its attendant myths and worries -pain not being the least of these, of course. That it is a process which has been enacted countless times without incident, or that -hopefully- it will be supervised with expertise and thoughtful care seems of little import until it has happened.  One’s Bell Curve position, in other words, is only of value in retrospect and seems not at all meaningful until it is history.  As a result, we may enact the expected pain or imagined problems over and over in our heads until it clouds our judgement,  or engenders choices that might otherwise have lain fallow.  I’m thinking here of the woman opting for an elective primary caesarian section for the delivery of her first baby, for example -chosen largely through fear of the unknown, fear of the unexperienced, fear generated by the uncontextualized tales of friends. Or even the decision to forego an attempt at a trial of labour after a previous caesarian section because of an anticipated repeat of similar circumstances.

And yet, is this telling us anything new? Well, probably not, except that much of our anticipated discomfort may be misplaced, or at least magnified more than necessary. Of course some of it stems from nescience -a rather obtuse, but kinder term for ignorance -a state that a doctor, say, might hope to ameliorate through patient explanation and reassurance and an exploration of the person’s reason for the anxiety. Spending time with them, in other words…

But sometimes -often, in fact- the anodyne seems to be in getting on with whatever needs to be done -and sooner rather than later, according to the study. Of course this is not always possible -and not even usually possible in obstetrics- but the concept, where feasible, still seems both appropriate and preferable: scheduling the surgery or other treatment at the earliest opportunity, putting the person on a cancellation list to expedite the procedure if there is not a more proximate possibility, triaging operative timing to take into account other factors than merely when they were first examined in the office. Even to be seen to be trying to take her worries into consideration may be anxiolytic… Although I am not overly hopeful; we are who we are: There was never yet philosopher that could endure the toothache patiently -an observation from an earlier but likely more widely read study: Shakespeare’s Much Ado About Nothing...