I've first read Gavin Francis's first book, Adventures in Human Being, when I was going through a major crisis. I was on the verge of leaving medicine. One day, I picked up the book I bought years ago on a spontaneous trip to Wellcome Collection after another gruelling day as a busy bumblebee, brushed away the dust and started savouring the first few pages. I never looked back. Now, facing the same crisis, I celebrate my lifelong allegiance with medicine as I leaf through the pages of Shapeshifters, one of the books I highly recommend for everyone who is deeply interested in medicine and, ultimately, the human body (I've actually put it under the section 'Brain Food').
The human body is what has first drawn me to medicine - the intricate biological mechanisms that define our mechanical side. The thoughts that we think, the sensations that we perceive, the decisions we effectuate; all such can be explained in the form of biochemical equations. Such order is learnt through an examination of anatomy and physiology. The disorder lies the essence of medicine - discovering what has gone wrong and making amends to the system. If amends cannot be implemented, then we try our best to make our patients comfortable.
Picture of Cruciform Building in London, next to University College Hospital on Euston Road.
The human body, however, is not constant. Shapeshifters has undoubtedly shedded a light on the matter. Citing Ovid's Metamorphoses, a very long Roman poem (trust me, I truly believe Dr Francis read the entire poem in the original Latin given his profound insights), Dr Francis explored the flux that defines us. On the basic level, we have life as an equilibrium. My mother, a chemist by academic training, used to say that everything in our world was an equilibrium. Balance is what we strive for, although it is barely achieved. This cannot be closer to the truth in medicine. The concept of homeostasis serves as the foundation of human physiology. The crucial state where balance and peace are of central importance, ensuring that mechanical processes are executed in their optimal conditions. When an incoming assault takes charge, knocking the machinery off their ordinary routines, the body adapts and changes. This is our basic level of metamorphosis and the rawest form of evolution. Instead of stubbornly resisting changes in the environment, we survive through such modifications by altering ourselves.
In Shapeshifters, Dr Francis used a variety of examples which integrate humanities with the sciences, proving that medicine is intrinsically different from traditionally 'hard' sciences in that it concerns the human nature. Such changes in the human body can be self-inflicted, such as tattooing (I love the examples on tribal culture and prisoners) and castration, or as part of what we know as human - puberty, pregnancy, gender reassignment and so forth. Such processes cannot be reduced to mere biochemical mechanisms. They do have their respective biological basis but deserve more attention on what they mean to the people who go through such transformations and their social value. For instance, biologically speaking, body modifications such as tattooing might be dangerous and unnecessary. There are various risks incurred during such procedures, particularly when not executed properly (mostly in the context of having them done in beauty parlours by non-medically-licensed individuals), including infections and excessive inflammation (transplants are construed as foreign objects and the human body is the most xenophobic institution I know since they don't tolerate foreigners of any sort). However, to reduce these changes to a mere scientific perspective would have deprived their essence. Body modifications, as with gender reassignment (or as Francis described, gender 'confirmation' - since the alteration of one's genitals is what the surgery does, not the changing of one's gender identity), express the self. They represent who we are. For instance, for a person who has always imagined himself as a Welsh dragon, this self-identity is expressed through such procedures. He is no longer constrained by the confines of the basic human template - a head, four limbs, a tummy and a pelvis. He can have a snout fashioned from his ribs and chest muscles (such as the pectoralis major). He can have his nose removed, so that mere orifices take its place. He can even add a tail and two horns as the crowning jewels of his transformation. It doesn't matter whether he conforms to social norms, or the so-called 'crowd'. He doesn't need to subscribe to modern notions of the 'sheep' mentality. In medicine, he owns his body. It is an artwork, a canvass where he constructs and demolishes, draws and erases; ultimately, dies and is reborn.
Tattooed arms: tattooing can be construed as a form of body modification, since it involves the injection of ink underneath the skin, causing profound changes to one's external appearance.
However, as Francis explores, such transformations do not have to be about the self. One's self-identity has multiple dimensions and the confirmation of one's own belief of oneself is only one key aspect. Self-identity can also include one's personal definition of one's place in society. What does one's job mean to one? What does one's country mean to one? The concept of honour is particularly important in some countries, such as China and India. In 'castration', Francis explores how removing one's genitalia, regardless of geographical designation, is one of the most sacred expressions of honour and allegiance. Francis exemplifies this idea with eunuchs in ancient China, as well as choir boys in the medieval church. China is a fascinating place - I've been there a dozen times, especially during my attachment in Hong Kong. The one feature that strikes me most is the persistent presence of eunuchs throughout its history. As one of the four main civilisations in world history, the Chinese civilisation was the only one that remained intact - it was never conquered and forced into submission by other cultures. Of course, there were times when the country was ruled by racial minorities. However, one idea remained - the cutting of the male genitalia (the entire deal: penis and testicles). Eunuchs were servants to the Crown (although the word 'crown' might be a quintessentially British concept). Many of them had humble origins, sold by their parents to work for the imperial palace (in Chinese culture, the phrase 'royal harem' was used to refer to the family of the Emperor) so that they could support their families and, accordingly, raise their social status. Throughout Chinese history, especially in the Ming Dynasty (13th-16th centuries), eunuchs held extremely powerful positions, to the extent that they controlled the choice of monarch. In the Vatican Church, due to the insistence of the policy of banning female voices from the choir, to hit higher notes, some choir boys opted to have their testicles removed. The removal of influence from testosterone would prevent the elongation of their larynxes, therefore preserving the child-like sing-song quality of their voices. The most astounding aspect of such changes is the value they represent to society, instead of merely the individual. At first glance, removing one's genitalia is degrading. It erases one's only chance to have children and continue the line of succession. Francis also states that such removal constitutes to a relinquishment of one's allegiance to one's family. However, if we look closely, such removal fortifies the idea of honour and pride. On one hand, the genitalia has often been deemed 'dirty'. I have read (sorry to disappoint but I couldn't cite it because I forgot where precisely I read it) that a teenage boy from rural Yunnan, a Chinese province, laboured under the belief that erections were evil and the penis was an organ of rebellion. So distressed one day by erections that he picked up a knife and severed it. As we all know, erections are very normal (but can sometimes be very embarrassing, especially when you're sitting next to your crush. Disclaimer: this has never happened to me, cough cough). They are resultant from an intrinsically involuntary physiological process. However, deemed evil in certain cultural contexts, the removal of such genitalia can be construed as a relief. A form of liberation. On the other hand, such liberation from carnal desires delivers the key message: this person is owned by the institution. The state. The church. There is no burden imposed from his/her family anymore. To them, it is the ultimate honour, just like the warriors who braved no man's land in the two world wars, to sacrifice one's bloodline for one's country and religious institution. Such a major change in the human body, performed by many, turn out to be a significant cohesive force of the fabric of an institution, or even a nation.
Francis also explores the impact of different pathologies on one's body and their meanings in time. There is a super rare illness called porphyria that I originally knew nothing about. It was totally mind-blowing to learn that there are multiple types of porphyria, manifestations of which can give us an inkling of the origins of the 'werewolf'. Aroused by a full moon, where the light rays are stronger than the ordinary sliver, such patients are likely to have photosensitive skin. Such photosensitivity originates from the accumulation of porphyrins (precursors in the haem production pathway, where haem is an integral part of haemoglobin, the oxygen-carrying agent abundant in red blood cells) in the skin, travelling through blood. Such porphyrins vary in property and behaviour, with varying extents of association with reactive oxygen species.
Illustration of a werewolf by Leonardo Da Vinci
Pathologies are often deemed as horrors. Aberrations. Mistakes made by the body. My favourite example is cardiac remodelling, which essentially means the body's response to heart injury. This is common after coronary heart disease without treatment. A substance called angiotensin II is involved. What the body does is producing more and more fibrous tissue as a way of healing. Fibrous tissue thickens the walls of heart chambers, making the heart harder to contract. It thus undertakes a greater difficulty in performing its job properly. A negative feedback response turns out to be a devil rather than a godsend. What about the other way round? What if a pathology positively contributes to a bodily transformation we have never been courageous enough to embark? While Francis talks about prosthetics and bone-setting, I wish to elaborate on cancer. A feared disease, cancer is probably the most well-known pathology in medicine. The thought that a simple genetic mutation can take everything precious in your life away is sobering enough to demand one's full attention (although it has to be said that one simple mutation is certainly not enough to cause a cancer; for instance, a fully-fledging cancer empire in the pancreas often requires the compromise of four genes - SMAD4, KRAS, p53 and CDKN2A). Endometrial cancer might not be, on face, the most welcoming retirement gift to a 60-year old, post-menopausal woman. However, it also leads to a transformation like none other. An alteration in body form and structure has led to profound changes in one's lifestyle and outlook in life. Only during life's hardships does one realise the significance of love and friendship. At those moments, we laugh at the times when we care about what others talk behind our back, or the occasional mellow reflection that we'll never be the person we want ourselves to be. Those times just don't matter anymore. We cling onto life as tenaciously as possible, learning how to live our lives in ways so different that amount to a transformation. In the context of endometrial cancer, regardless of stage, it involves the resection of the uterus (if serious, it warrants a procedure called 'pelvic exenteration', which essentially means removing everything one can find in the pelvis, including all female reproductive structures, as well as the bladder and rectum). This is a change beyond one effected by menopause. In menopause, a woman gains her relief after years of performing her duties assigned by God - conception and labour, bloodline and succession. Her reproductive organs stop working and she can finally regain her freedom. This is also agreed by Francis when he talks about his experience of working at a sexual health clinic in Edinburgh. However, the opportunity proffered by endometrial cancer to remove the entire female reproductive system signifies the ultimate arrival of freedom, not a mere relief. One is no longer a slave to one's natural duties. She is finally free from the constraints imposed on her by society and God. She can finally live in this world as a person, not as a woman.
Endometrial Cancer - FIGO Staging
It is true that our bodies are always in flux. Such changes often have profound meanings to the self or even to one's country. Seemingly cruel afflictions such as cancer can even offer us transformation, a means of liberation. It is the very majesty and uncertainty of medicine that have made me fall in love with it irretrievably.