The greater the advance, the more beautiful the snake appears

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From Luke’s Journal 2022 | Technology | Vol.27 No.2

The first ultrasound machine I ever met was a large, ugly, black metal box. It was energised through an electric cord to respond to sound (that had been channelled down another cord) from a hand-held sensor applied to various sides of the skulls of neonates reckoned to be suffering from subdural collections. The sound caused an arrow to move in a dial screwed onto the front.

The sales representative declared deviation of the falx would be revealed by unequal movement of the arrow.  He claimed that such a feat was, surely, an ‘essential’ (though admittedly costly) part of the armamentarium of all modern nurseries.  No unit should be without it!

The problem was that ours was far from a modern unit, even though it served, with bravery, the demands of more than ten thousand in-house (and some external) deliveries from the African population in the middle of (what was then) a beleaguered Rhodesia.

Premature and sick newborns were housed in open wooden ‘fruit box’ cribs, warmed by heat from electric lights positioned below. Subdural collections were very rare, and were both diagnosed and treated by needling the lateral angles of the fontanelles. The black box would have slowly disintegrated in a store room. There was disdain at first sight – so much money for such pretension! I turned my back on ultrasound.

Several years later, I was obliged to return a horrified gaze. One morning, nearing delivery, my wife declared she could no longer feel the baby moving. In a hurry to check other babies in a nearby hospital, I listened with a stethoscope, fulsomely assuring both of us that I could hear normal sounds: there was absolutely nothing to worry about.  

In the middle of the queue of normal babies with the insistent chorus of closing valves, reality finally overwhelmed: I had not heard a baby’s sounds, merely those propagated from the mother’s heart. I had known that all along, but had chosen delusion. I felt sick. An ultrasound was performed and, in the darkness and silence of the room, a motionless heart was confirmed. Brighter, echodense walls of distended ventricles enclosed dark, unmoving blood. It was horror at second sight.

“An ultrasound was performed and, in the darkness and silence of the room, a motionless heart was confirmed. Brighter, echodense walls of distended ventricles enclosed dark, unmoving blood. It was horror at second sight.”

More years passed in subliminal rejection of the technology.  Then, one day, in yet another country, I happened upon a cardiologist examining the heart of a child with then-modern equipment. It was love at third sight. The choreography, the precision, the discipline, the life, the colours, the potential for therapy were hypnotising. I felt I was looking upon the beauty of creation. Sadly, my wonder was tainted by a sense of indignation: “How come this technology had transformed in my absence?” I felt, however, a determination: I must learn this stuff!

A course of re-engineering

Some months later, having embarked on the course of re-engineering myself into a neonatologist, I found opportunities to learn.  The static brain of a newborn was not difficult to master, but the moving three dimensional heart was another matter. It was plain that I had little idea of normal anatomy, and none of the complex. Shown a specimen of a hypoplastic left heart with absent ascending aorta, I amused a pathologist with my ignorance. But with his kindness, I learned of complexities, and with the further kindness of a couple of cardiologists, I learned to recognise the patterns on the screen. Along the way, I was introduced to foetal physiology and imaging. I had never been more intellectually fulfilled.

Ultimately, becoming the Director of a neonatal service distant from a state’s capital, I realised the fundamental value of ultrasound in caring for premature and sick babies: distinguishing cardiac from pulmonary causes of distress, defining congenital syndromes, and recognising the process of dying.

It was, however, obvious that we needed experienced opinion from expert centres in the capital.  As telemedicine emerged, we wondered if it was technologically possible to not merely show videos of ultrasound images, but to actually project the images, live, ‘down the line’.  Therefore, in association with experts far and near, experiments in transmission were performed:

• How many phone lines would be needed to convey the electronic information with such resolution that specialists could discern the structure and mechanics of the hearts and other organs of babies, within the uterus, not long after conception?
• Could such telephonic equipment be installed in the wall beside the incubators of sick babies, so that an ultrasound machine could be ‘plugged in’, to interrogate organs without disturbing the sick baby, resting in an incubator?

In retrospect, it is surprising how quickly the challenges were solved.  In regular foetal sessions, otherwise-unsuspected foetal abnormalities were diagnosed, permitting preparation for surgery soon after birth. Repair of such lesions as gastroschisis became routine, as were (though less common) those with herniation of diaphragms.  Complex heart lesions were able to be diagnosed and transferred to the capital for repair while safely within the womb.

Ultrasound also permitted recognition of patterns of cardiac abnormalities in babies for whom retrieval teams had been dispatched to distant corners of the state. This recognition allowed diversion of the aircraft to the capital, minimising disturbance and delay.

An intellectual Garden of Eden

In all, for me, ultrasound might be likened to a kind of intellectual Garden of Eden: a flourishing of the fruits of research, a panopoly of intellectual delights, enjoyment of the technology – it felt good to turn the thing on and display the images. There was certainly no ‘sweat of the brow’ in it!  Its very spirit seemed to walk with us in the evening.

But, in that original Garden there were complications: A sanction against eating the fruit of a tree, even though it  would appear to provide knowledge of the substance of good and evil and the ability to overcome the latter. Also, there was a snake who urged possession of those God-like facilities.  Therein lies a problem of ultrasound: not in the detection of abnormality but in the judgement of what is good or bad about the findings, and what should be done to overcome apparent shortcomings.

“Therein lies a problem of ultrasound: not in the detection of abnormality but in the judgement of what is good or bad about the findings, and what should be done to overcome apparent shortcomings.”

Early in my training, I had observed a mother being advised that termination would not be inappropriate because of the cleft that had been detected in the lip of her child. The power of the black and white photographs of a gaping face overshadowed the assurance that surgery would leave but a minimal scar. The emotional burden became too great: termination ensued but, tragically, so did the burden. Many days of farewelling set in during which, I am certain, the poor mother barely noticed the cleft in her son’s lip, clothed as he now was with knitted gown and lace edged bonnet against the cold of the refrigerator.

Even back then, at the flick of a probe, the difference between a male and female baby could be discerned and the latter programmed for termination. The ‘progressive’ difference now is that the termination can be undertaken until term.

Pondering a great and wonderful mystery of life

Some of these experiences caused me to ponder a great and wonderful mystery of life: a veritable transformation from darkness to light. Technology is cold and dark – even the gel is cold; and the procedure is performed in darkness, where imagination grows and fears are confirmed by uni-dimensional, lifeless, black and white images.  When the baby is born, however, and its squirming body is embraced in the transforming warmth and light of mother’s love, everything seems transformed. To the four things that wise Solomon could not understand (Proverbs 30:18-19¹), I, as yet another perplexed male, must add a fifth!

The temptation to feel assured of the ability to distinguish what is good or bad for a patient, or to submit to that judgement by others, slithers like the proverbial snake. The temptation to partake, one way or another, in decisions of life and death that are not our prerogative, whispers through much of our otherwise wondrous advances in technology.  We can now deliver ‘perfect’ babies to desiring parents. We can change male children into non-physiological females and females into males. We can provide painless death on demand. And, on an even grander scale, we can blow people to bits with applied chemical and aeronautical science.

What is more, we can do these things with an ‘elevated’ conscience – justified by the utopian application of our new ‘knowledge’ of what is ultimate good or evil. In that sense, the snake is thriving in technology.  You could even conclude: the greater the advance, the more beautiful the snake appears.  The age-old story continues on.

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References:

1. Proverbs 30:18-19 “Three things are too wonderful for me; four I do not understand:the way of an eagle in the sky,  the way of a serpent on a rock, the way of a ship on the high seas, and the way of a man with a virgin.” ESV