It’s About Time

What then is time? If no one asks me, I know what it is. If I wish to explain it to him who asks, I do not know.’ So wrote Saint Augustine, bishop of Hippo in North Africa, more than fifteen hundred years ago. And we’re still confused… Okay, I’m confused.

When considered philosophically, you’d think it would be a relatively simple concept: I exist right now: the Present; I remember what happened to me: the Past; I don’t know what will happen to me: the Future. That is Time. It is divided into separate Magisteria like scenes through the window of a moving train. And yet… and yet the divisions seem so arbitrary. So evanescent. It’s almost as if Time were merely an all-purpose synonym for Change. A generic label.

But things happen in time, our bodies being no exceptions, so it’s difficult to ignore. We have come to prioritize those happenings as constituting Time. The intervals between events have gradually become divested of significance, although whether it is the interval, or the event that is prime could be argued -much as whether the placement of a comma in a sentence contributes almost as much to the meaning to be conveyed as the words themselves. And yet, is it really all contingent…?

Are habits -those things we do almost without thought- or the endless train of happenings the commas? Is it actually in the intervals between things where we live? Do we inhabit the interstices, and merely mark their boundaries by events -rely on things that happen in order to count? Do we live between the nodes or does reality only exist for me when stuff happens, when I am aware of what I am doing? And if so, then what about when I’m not aware? What happens to Time then? Do you see why I am confused?

And, at the risk of sounding too Cartesian, is the reality my body inhabits different from the awareness my mind tells me about? Bodily existence seems to have been issued with different rules because it is far more contingent than my mind. Too needy. Too ad hoc, and less spontaneous. It seems overly pulled by evolution and ontogeny, unable to explore new things. It straddles the intervals like a bridge. It is a scaffolded entity, constantly in a state of repair.

No, Time, for a body at least, was always thought to be continuous. Contiguity of events allows restoration and medicine discovered this. It started on its quest to heal the body, even if the mind was not always in synchrony and did not understand. But it assumed that mind was only a by-product of body. It is… isn’t it…?

At any rate, something that has often puzzled me is the difference in prescription instructions for various medications. Of course some drugs are relatively short-acting, and need to be taken frequently, say, Q6H (every six hours), or perhaps they are more potent and require a smaller, but spaced out administration, say, Q8H. That seems fairly obvious, so instructions as to how much and how frequently to take them would therefore make sense.

But suppose the directions are to take them QID (four times per day) or even TID (three times per day)? By comparison, that seems almost sloppy, doesn’t it? I mean, what is the difference…? And how much variation is permissible between the timing of every eight hours, and three times per day? What impact would, for example, a two hour difference -or even more- have on the medication efficacy? This is not meant as a criticism, but merely an exploration of time in the administration of a treatment.

And yet, even a more precise prescription of the interval does not usually state a specific time for its consumption like, say, 8 PM. Given that our bodies (and hence probably our metabolism) are subject to a circadian rhythm, I’ve often wondered whether that might make a difference in a medication’s effectiveness. An article in Nature that I ran across addresses that very issue: https://www.nature.com/articles/d41586-018-04600-8?utm

‘The circadian clock is a remarkable system. A central timekeeper in the hypothalamus orchestrates a network of peripheral clocks in nearly every organ and tissue of the body, turning on and off a bevy of genes including some that encode the molecular targets for drugs and the enzymes that break drugs down. These clock genes are particularly important in cancer because they govern cell cycles, cell proliferation, cell death and DNA damage repair — all processes that can go haywire in cancer.’

Until recently, technology was unable to determine the genes involved, let alone the timing of their activation, and so chronotherapy remained on the fringe. But, ‘More than four decades of studies describe how accounting for the body’s cycle of daily rhythms — its circadian clock — can influence responses to medications and procedures for everything from asthma to epileptic seizures. Research suggests that the majority of today’s best-selling drugs, including heartburn medications and treatments for erectile dysfunction, work better when taken at specific times of day.’

Steroid levels, for example, ‘naturally cycle with the circadian clock. In the late 1960s, scientists found that the synthetic corticosteroid methylprednisolone is safer for treating arthritis and asthma if taken in the morning rather than at other times of the day. This is because the feedback loop in the hypothalamus, which controls the release of cortisol, is least vulnerable to inhibition in the morning.’ Other factors such as age and gender also seem to be important in circadicity. So is the inconvenience of the times when the appropriate genes might best be manipulated. Not only that, but ‘practical biomarkers are needed to help clinicians identify optimal times for treatment.’

There are many variables to account for, but clearly there is a growing appreciation of Time in understanding the body’s underlying physiology. There is a need to adjust not only the treatment, but also its provision in harmony with individually derived schedules that are often by no means intuitive or convenient. As if, by finding each body’s unique variations on the theme of circadian rhythm, we discover the hidden melody playing deep within.

Maybe Rabindranath Tagore, the Bengali polymath who won the Nobel prize in Literature in 1913, was not so far afield after all: Let your life lightly dance on the edges of Time like dew on the tip of a leaf.

I’d like to think we all dance in Time…

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Time Enough

Time, the faceless tyrant that rules our lives like an absentee landlord, is so abstract, so opaque, it is difficult to grasp. It is seeing through a glass, darkly if at all. Enslaving everything within its reach it is an impartial despot. Dispassionate in its all-embracing realm, we are each of us imprisoned and there is nothing outside the bars.

Time is an aloof conqueror with no interest in our supplications, no ear for our protests, and no concern with how we define it, measure it, embrace it. It simply is, whether or not we choose to acknowledge its existence.

And yet the question of its perception has always intrigued me. Is Time truly an owner and we, powerless and abused, its hapless chattel? Or are we merely imprisoned by perspective -glasses half empty? But as we continue to drain the glass, there is an increasingly vexing thought: what is it we have drunk?

*

The patient population that are sent to see me seems to have aged over the years I’ve been in practice -or, more likely, the referring physicians have aged as well, and the phone number of my office surfaces easily in their heads, like habits, traditions -Canon law instituted in a more insecure epoch in their careers. But the accretion of age around me is instructive: I am more aware than ever of the differences in our apprehension of Time. Our repudiation or acceptance of its influence in our lives.

Nora was an interesting example of time-obsession. I say ‘was’, because I saw and treated her a few years ago and she has never returned to see me; I like to think it’s because she had no further need, but I fear the worst. A silver haired woman in her late eighties, she sat solid as a post in the waiting room, absorbed, it seemed at first, with inner thoughts. And yet, as I stood behind the front desk attending to another task, I noticed her eyes darting about the room like bees investigating a busy field –alighting first on a child crawling on the floor then moving on to a bright but enigmatic picture hanging near the door. A woman busily turning pages of a magazine near the window was next, and then the little boy playing noisily and impatiently with a smartphone waiting for his pregnant mother to return from the washroom down the hall –little escaped Nora’s scrutiny, and yet she was a statue. Nothing else about her moved. Her black, floor-length dress might have been painted on, the golden bracelet around one of the wrists that rested in her lap was still and as yet ungleaming. Even her face was a calm mask revealing nothing –the only hint of serenity in the busy room. A place of refuge in the roiling world.

She was no different in the office at first. She sat quietly in the chair across from my desk and unleashed her eyes again to explore the room, the furniture, and then, almost as an after thought, me. “The terracotta lady in the corner…” She turned her whole body to stare at the sculpture as if her head and neck were welded to her shoulders as a unit. “…It has some coins scattered around it.” She turned once again to look at me, this time disapprovingly. “Am I supposed to feed it?”

It was an effigy of a woman with a begging bowl that someone had given me and it was beginning to accumulate coins for some reason. I smiled and shook my head. “I meant it as an ornament for an otherwise boring corner but…” I shrugged to indicate the coins were merely accidents.

“Guilt is something I outgrew years ago, doctor,” she said with obvious concern that the the terracotta lady and her bowl were put there to supplement my income.

I wasn’t sure if I was supposed to reply, but her eyes seemed intent on interrogating my face. “Time smoothes things out, doesn’t it?” It was a trite comment and I’m not sure why I even said it, but her expression changed immediately.

“After all my years, do you think it cares how I feel?” This time I decided to say nothing; she seemed angry about something. “We are its slaves, after all…”

“Slaves?” I thought maybe allowing her to vent would enable me to ask her why she thought she’d been sent to me. I’d read the referral letter, of course, but patients often understand things differently from their doctors.

She stared at me as if I were a little slow. “You wouldn’t understand, doctor. A woman is a slave to many things, and Time is no exception.” Her eyes continued to crawl along my face looking for a reason to continue their search. Finally, they returned to their home and she shrugged, as if the territory they had explored was not a threat. “Think about it,” she started carefully, the words slowly assembling inside her mouth. “Most of our lives we are calendars, ticking the months off from period to period, our hopes and fears captive to whether or not it arrives on time, our lives inextricably entwined with its schedule.”

I have to say, that the obvious is sometimes invisible –or at least disguised and camouflaged in the background. I hadn’t thought of the exigencies of Time on a woman being recorded like that.

“Males,” she continued, “are not subject to the same calendar. Time passes, for sure, but there is usually no need for it to be regimented in little orderly blocks. It is a different animal for you…” Her face softened and her eyes stopped moving. “Still a demon, perhaps, still unkind, but less constantly in your face.” She sighed, but visibly. Audibly. “It is a different Time.”

I wasn’t certain what to make of her idea –wasn’t certain how to turn the conversation towards the reason she had been sent to see me- but I was fascinated all the same. Maybe how we perceive the allotment, the measuring stick, changes something. She had been sent to me for the investigation of vaginal bleeding –abnormal and unexpected bleeding, to be sure, but nonetheless it was a calendar waved in her face once more. Something she had thought was long destroyed, was back to plague her yet again. As Hawthorne said, ‘Time flies over us, but leaves its shadow behind.’

Well, I suppose it does… but I am rather more drawn to the view of Rabindranath Tagore: ‘The butterfly counts not months but moments, and has time enough.’

I hope that Nora did, as well.