Adventures in Human Being

by Gavin Francis

  Stand-up comedians might suggest that to have your large bowel inspected you should drop your trousers and bend over, but the best way is actually to lie on your side, up on a couch, and draw your knees toward your chest. It’s always surprising how many people apologize or make an embarrassed joke as they get into the position: “I hope you haven’t just had breakfast”; “I’m so sorry that you have to do this,” as if the rectum is so sordid that, as the examiner, I might feel repulsed. It’s an understandable belief: we’re taught from our earliest years that feces are untouchable, and that the rectum and anus are dirty and disgusting.

  For most doctors, disgust at suppurating wounds, prolapsed bowels, or gangrenous limbs is beside the point: they have to be examined, so their aesthetics are irrelevant. But though ugliness has little place in the consulting room, there is still room for beauty, in the dictionary’s sense of “calling forth admiration.” The intricacy and economy of human anatomy, both in health and in sickness, is often beautiful. And if imagining the harmony beneath the skin can be beautiful, medical images such as ultrasound scans are too – think of those grainy, chiaroscuro scans given pride of place on the mantelpiece or on the first page in a baby’s album. X-ray images have a particular ethereal beauty to them, whatever part of the body they represent; contemplating them is not just a reminder of the skeleton and our mortality, but a way of transforming perspective and imagining the body anew. Sometimes they are like portraits, but they can also resemble landscape paintings with contours, horizons and cloudscapes. There are parallels in nomenclature: in emergency departments I’ve often ordered “skyline” views of the knee, or “panoramic” views of the jawbone. That those images have clinical importance, useful in diagnosis and treatment, makes them more, rather than less, beautiful.

  The sculptor Rodin said that there was no ugliness in art if that art offered some insight of truth, and the same could be said for the practice of medicine, and the images that it creates. Medically speaking the body is rarely ugly, and images of it can have an aesthetic that approaches art – even if those images are of … the rectum.

  DOUGLAS DULETTO was a thin, middle-aged man who wore horn-rimmed spectacles and a starched white shirt. He had neat graying hair, parted in the center, and sat primly on the emergency room gurney as if waiting patiently for the second half of a chamber music recital. Over his shirt he was wearing a thin hospital gown, and had neatly rolled up his corduroy trousers and placed them to one side of the gurney.

  I picked up a clipboard from a holder on the cubicle wall and glanced down at the sheet: “Foreign body, rectum,” it said.

  “I’m mortified to be here,” he said, flushing suddenly, “but I can’t get it out.”

  “What’s ‘it’?”

  “A bottle,” he replied. “I’ve been trying to get it out all evening.”

  “A bottle of what?”

  He flushed an even deeper scarlet: a senator snapped at a strip club.

  “Ketchup.”

  I asked him to lie on his left side with his knees drawn up to his chest – “I’ve left my dignity at the door anyway” – then pushed a gloved finger into his rectum. “Just bear down,” I said, “squeeze as if you’re trying to open your bowels.” At the tip of my finger, as far in as I could push, I could feel an edge of hard glass – too deep to get a finger on either side of it. I inserted a clear plastic tube – a proctoscope – and shone in a light. At the clear plastic edges of the instrument I could see healthy pink walls of rectum flecked with yellow sluglets of feces. At the center, just at the limit of my view, there was a glint of glass. “It’s going to be tricky I’m afraid,” I said, “it’s quite far in.”

  He sank forward, head in his hands, and his shoulders began to shake. At the ward’s “sluice” – the area where all the urine and feces are disposed of – I found a toilet, and from the surgical ward some ointment ordinarily used in the treatment of tears in the anal skin. The ointment relaxes the sphincter, which can allow tears to heal, but I wondered if it would also allow the bottle to pass. I applied the ointment, and asked him to sit on the toilet.

  After he’d strained a few times I got him back up on the couch, then tried for the bottle again. This time I thought I had it, when at the last minute it slipped away deeper into the swampy anatomy of the abdomen. I swore under my breath, but he heard me.

  “What’s wrong?” he asked nervously.

  “Nothing,” I told him. “But we’re going to have to get an X-ray.”

  At that time X-rays were still produced on large acetate films. Once Mr. Duletto was back in the cubicle I took the envelope containing the film back to the doctor’s room, and put it up on a light box. It gathered quite a crowd.

  The bowl of the pelvis stood in the foreground, shaped like the two flanks of a valley, beneath vague, gaseous bowel shadows – a Turner-like sky. Rising up through the middle was an incongruous form: a skyscraper dropped into a pastoral scene. It was the crisp, instantly recognizable outline of a branded bottle of ketchup. It lay along part of the rectum and into the sigmoid colon, with the shoulders of the bottle and its metal lid tapered like an arrowhead pointing deeper into the guts.

  “I’m sorry,” I said when I got back to the cubicle, “I’m going to have to refer you to the surgeons. There’s no way I’m going to be able to get that thing out on my own.”

  ACCORDING TO THE PSYCHOLOGY of aesthetics, art is appreciated not just through the perception of something as beautiful, but because it can elicit a wide variety of emotions: confusion, surprise, disgust and even embarrassment. Looking at the X-ray, it undoubtedly had an aesthetic value: the grainy forms of bone and bowel against the molded artistry of glass and metal. There was pop-art appeal to the juxtaposition of a mass-produced bottle against the organic shape of Mr. Duletto’s pelvis. This X-ray is a work of art, I thought to myself: it could be submitted to a gallery, or projected at night onto the hospital building. I pictured it for a moment hung in MoMA or the Tate Modern, protected by glass and cordoned by rope.

  I dictated a letter for the surgeons, and a porter came down to take Mr. Duletto up to their ward. “Surgical?” the porter asked, and I pointed to the cubicle. He pulled the gurney out into the corridor, and Mr. Duletto lifted a hand to wave as he headed toward the door. “Any X-rays?” the porter called out.

  “Oh yes,” I said, turning to the light box, but there was no X-ray there. It had been stolen: someone else must have appreciated it for a priceless work of art.

  PELVIS

  14

  GENITALIA: OF MAKING BABIES

  I wish either my father or my mother, or indeed both of

  them, as they were in duty both equally bound to it, had

  minded what they were about when they begot me.

  Laurence Sterne, Tristram Shandy

  TO CONTEMPLATE THE OBSTACLES to conception is to dig into the deepest ideas of what it means to be human. Did our lives begin when the ball of cells, of which we were once composed, first bounced against the wall of our mother’s womb? For many women, fertilized eggs won’t implant to the womb lining. Did it begin further back, when the fastest, strongest sperm from our father fused to an egg from our mother? Some men have sperm too sluggish or disorientated to find an egg. Was our life decided three months earlier, in the genetic dance called meiosis, when the successful sperm that created us was created deep inside one of our father’s testes? In some men meiosis doesn’t work properly; they are azoospermic – have no sperm in their semen. Or perhaps our individual selves were generated just two weeks earlier, when the egg that went into creating us won the privilege of being primed for ovulation. Disordered menstrual cycles, and failed ovulation, are a frequent cause of infertility. In a sense our lives began decades before our parents even came together – the eggs in our mother’s ovaries were created when she herself was in the womb.

  Then there are the physical obstacles to the egg reaching the womb: the fallopian tubes have tiny projections on their open ends that gathe
r eggs the way fingers might gather jewels. When each of us was fertilized, our primordial, cellular selves began to divide high in the fallopian tube: one cell became two, two became four, four became eight, and so on. Like a city crowd around a royal pageant, cells within the wall of the fallopian tube pushed the dividing mass of cells toward the womb. By the time it arrived, the fertilized egg had become a ball of cells numbering sixty or more.

  While still within reach of the ovary the egg can be fertilized too early and drift off into the wrong part of the abdomen. This is one of the surprises of our anatomy – men have no equivalent connection between the inner and outer worlds as women have, to conduct sperm from the vagina to the inner abdomen. If a fertilized embryo implants deep in the abdominal lining, it may even grow for a while, but is doomed to miscarry because the lining can’t provide enough blood for a developing baby. If it miscarries internally in this way, the woman may not even know she was pregnant; over time, the embryo’s tissues are replaced by brittle, bone-white calcium salts. Surgeons sometimes find these fetoliths, or “stone babies,” inside the abdomens of elderly ladies, carried unknown for forty or fifty years.

  Occasionally the developing embryo embeds itself part way along the fallopian tube: the commoner type of “ectopic” pregnancy – meaning pregnancy in the wrong place. As the growing baby takes up space the tube is unable to expand; the embryo is doomed and the stretching begins to cause terrible pain. If the pregnancy is allowed to go on, the tube itself will split and the mother may bleed to death – a poisonous gift from new life to old.

  UNTIL THE LATE EIGHTEENTH CENTURY, in Europe it was believed that for conception to occur it was as important for women to reach orgasm as it was for men. A textbook of midwifery in use in the seventeenth century declared that without a clitoris women “would have no desire, nor delight, nor would they ever conceive.” Judges presiding over cases of rape would decide that if conception occurred, intercourse must have been consensual. As late as 1795, the Marquis de Sade – who was greatly preoccupied with methods of avoiding pregnancy – was able to write that fluid “discharged” by women during climax was a prerequisite for the creation of new life: “Of the commingling of these liquors is born the germ which produces now boys, now girls.”

  Though many societies had realized that this can’t be true (female circumcision, for example, virtually precludes it), these ideas about the body had been around for thousands of years: new life was generated through a convulsion that necessarily had to be experienced by both sexes for it to work. Orgasm in women was assumed necessary for ovulation, but simultaneous orgasm was even more likely to result in a pregnancy. In the Hippocratic treatise The Seed the author describes how heat is created within the pelvis of both men and women during sex, leading to a paroxysmal climax that would be experienced more intensely by women if occurring at the moment when semen also made contact with the cervix (“like a flame flaring when wine is sprinkled on it”). Galen wrote that backache and limb-ache was common among widows who no longer had sex because of a build-up of female generative fluids within; the cure was to encourage discharge of this fluid, preferably through sex but, if necessary, through manual stimulation. In the sixteenth century the Dutch physician Forestus advised women to engage a midwife to carry out this task “so that she can massage the genitalia with one finger inside … and in this way the afflicted woman can be aroused to the paroxysm.” This perspective on female sexuality went on in attenuated form until the early twentieth century: vibrators were invented for the treatment of women suffering from “hysteria,” and their use recommended right up until the diagnosis itself was struck out of the psychiatry textbooks in the 1950s. (Some of these devices had fittings so that they could be driven by the home sewing machine.)

  ROB AND HELEN came to my clinic eighteen months after throwing away Helen’s contraceptive pills. They were awkward with embarrassment as they took their seats. “We’ve been trying for a baby for ages,” Rob began, then hesitated, but Helen finished the sentence: “We’re starting to think there’s something wrong.” He was a chef: tall and slightly overweight, with silvering hair and anxious eyes. She was an assistant at a day care: slim with bobbed red hair and doll-like, porcelain-white cheeks. “I don’t know if we need IVF?” asked Helen, spinning her wedding ring with the fingers of her right hand, “but at thirty-seven I’m told we should hurry up.”

  I asked about family history. Helen was one of three children, didn’t know of any problems that ran in her family, and both her brother and her sister already had children of their own. Rob was also one of three: though his brother had a daughter, she’d been conceived with the help of IVF.

  On average, couples who have regular unprotected sex have about a 20 percent chance of conceiving within a month, 70 percent chance of conceiving within six months, and 85 percent chance of conceiving within a year. It’s for that reason that doctors prefer to wait at least a year before initiating infertility tests. The first tests to be carried out are the most straightforward: for Rob, two semen samples sent in at least a month apart after a few days’ abstinence, and for Helen, blood tests at two separate points in her menstrual cycle to assess whether she was ovulating regularly. The semen samples are trickiest to arrange; they have to be delivered to the lab, which is only open at certain hours, within an hour of ejaculation. “What … these?” said Rob when I handed him the specimen tubes. “They don’t give you much … to aim for.” How he went about obtaining the samples we left undiscussed. Helen laughed, dissolving the tension in the room at last. “What are you trying to say about your equipment?” she said, elbowing him.

  Helen needed a blood test on the third or fourth day after her next period began, followed by another one seven days before the following period was due. The first test gives an idea of whether the two hormones that coordinate ovulation – “luteinizing hormone” and “follicle-stimulating hormone” – stand in the right ratios to one another and to levels of estrogen. The second test gives an idea of whether the ovary is creating enough progesterone – the hormone that prepares the womb for pregnancy – to suggest she had ovulated. Helen drew her diary from her bag, where all her periods for the past year had been plotted out on a grid. “This is my menstrual map,” she said grimly, “a map of disappointment.” We picked out the days she’d need blood tests, and fixed the appointments.

  When I met her next she came alone. After giving the blood samples she rolled down her sleeve and paused. “You know the worst of it?” she said. “It’s what it’s done to our sex life … I mean, it’s difficult to feel romantic, or desirable, when all you’re thinking about is ovulation and conception.”

  “Some people don’t conceive until they get their appointment through for the fertility clinic,” I said, “that’s when they stop worrying about it. Don’t make it a trial, or something to get stressed about.”

  “That’s just it,” she said. “Before, I hardly ever had an orgasm with sex. Now, I never do. Do you think that’s a problem?”

  THE NERVE THAT COORDINATES ORGASM, called “pudendal,” has an almost identical course in men and women. Its name comes from the Latin, pudere, to be ashamed, as if we’re still cowering in the Garden of Eden, trembling behind fig leaves. The pudenda might be comic, absurd or even embarrassing, but never shameful: without our parents’ pudendal nerves, after all, few of us would be here. People can be reluctant or embarrassed to discuss aspects of conception, sex and sexuality, but as a doctor it’s unavoidable; you can’t work with human bodies for long without having to talk about them.

  Whether folded in foreskin, or desensitized by circumcision, the pudendal nerve in men branches through the skin of the glans penis, and in women through the clitoris. Those nerves coalesce into bundles that run down the back of each corpus cavernosum – the “cavernous bodies” present in both sexes which stiffen through being engorged with blood, but that were once thought to be inflated by the pneuma, or spirit, of sexual desire. The nerve on each side then drops d
own into the penile or clitoral root and loops under the arch of the symphysis pubis of the pelvic bone – an angled Gothic arch in the male, and a rounder Roman arch in the female (with its smoother accommodations for a baby’s head, and its more dissipated scatter of nerves). It then tunnels deeper into the layers of muscle and sinew that support and give continence to the bladder, taking in out-branches that supply sensitivity to the skin between the thighs. It’s here that it slips under the prostate gland and seminal vesicles in men, which store and bathe the sperm that have migrated up from the testis, and the cervix and womb in women. Then it continues toward the spine, emerging into the pelvis between powerful muscles that cantilever the weight of the body into the legs.

  The sacrum is a triangular bone at the base of the spine, perforated by holes like a priest’s censer. It is so called because it was once believed to be sacred: a reservoir of human essence – medieval Europeans thought that at resurrection their bodies would be reconstituted first from the sacrum, and that energies discharged from the sacrum were essential in the creation of new life. After twisting themselves through the tangle of the sacral plexus, pudendal nerve fibers slip through the sacrum’s perforations, and plug into the spinal cord.