sinn-haft nr 10
für. wahr. nehmung.

CHRISTINA LAMMER

Bodies Boundaries Diagnoses
Opaque Surfaces and Transparent Objects of Knowledge

Durchscheinende Körper und inszenierte Organe: Christina Lammer verarbeitet in diesem Artikel Beobachtungen, die sie während ihres einmonatigen Forschungsaufenthalts an der Universitätsklinik für Radiodiagnostik am Allgemeinen Krankenhaus (AKH) in Wien vergangenen März gemacht hat. Sie analysiert im Rahmen eines dreijährigen Forschungsprojekts kulturelle Praktiken in diesem medizinischen Feld, besonders die Prozesse der Visualisierung des Körperinnern. Dabei fokussiert sie bildgebende Verfahren der Radiodiagnostik und deren sozialen Kontext. Die Körper der PatientInnen werden dabei zugerichtet, in Szene gesetzt und letztendlich transformiert.

Transformed Bodies

The following text will focus the division of surgical disciplines in Vienna`s Allgemeines Krankenhaus (AKH) to show the spatial order of this particular field of media supported examination. The patients treated are either awaiting a surgery or have just had one: In a reception area personal data is noticed, then the patients enter the line of waiting persons - a kind of sterile zone. Depending on the particular examination, patients are sent to different rooms, which are marked with numbers, capital letters and different colors.
When the right room is finally found, the waiting persons can sit down on fixed plastic chairs. The environment is typical of a clinic: the rooms and floors are plunged in a certain clean and artificial coziness that is hard to describe to anyone who has never been in a hospital. The atmosphere is quite alienating, partly caused by air conditioning that produces a rather unusual humid cllimate. In addition the faces of others waiting and patients in their hospital beds call up fears and anxieties. In this zone the persons waiting have no contact with doctors and radiological personnel. This particular spatial order has obvious resonance with the modern "panoptism" which Michel Foucault has analyzed in Surveiller et punir (1975), although the control function of the gaze has changed fundamentally through new optical devices. In the clinical settings of space and time the relationships between patients and radiological personnel are organized: waiting zones surround diagnostic laboratories, where patients get in touch with radiologists and technical devices. The development of different types of pictures and the production of findings build the core of diagnostic space (in the AKH), from which the subjects of observation - the patients' bodies - are excluded.

Whenever the door in front of the line of chairs opens and a patient leaves the dressing room a technical assistant or a nurse appears to ask the next person to unclothe in this rather small room between the diagnostic lab and the waiting zone. Let me use the gastro intestinal examinations of the digestion system as an example: in the dressing room the patient gets a transparent paper shirt, which he or she has to pull on. The body is almost naked, wrapped into this garment, open on the backside, which is discarded immediately following the investigation. During or after disrobing the assistant or nurse informs the patient about concrete proceedings - sometimes everything is already clear, but many people are quite uninformed. Being frightened can be one reason for this sort of ignorance; or perhaps the treating doctor has missed the occasion to inform his or her patient about this particular diagnostic technique and possible results.
The bodies are radically transformed before the radiological diagnosis can take place. People are instructed not to eat a day before the examination and to evacuate the bowels through an enema. Only if the bowels are completely empty can the contrast media be inferred later. In his or her new out fit - without clothes, naked to the bone - the patient's body is prepared and meets the radiologist and the optical apparatus, the X-ray tube, which is connected with a video camera.

Staged Cases

The physician enters the investigation room through a door opposite that used by the patient, who will be observed from in-side out in a short while. Technical assistants are already present, preparing the diagnostic devices for the examinations. Because of the danger of X-rays they wear lead aprons which protect them. Clothed in a white "uniform" the radiologist interviews the patient - questions why he or she is there and tries to find out more about significant discomforts. The patient's personal story is compared with that in the referral from the treating colleague, a more standardized narrative. During all these highly narrative procedures of treatment the subject position is taken over by the objectifying significance of the case.

Descriptions, narratives and conversations about 'cases' are, as I have suggested, aspects of everyday medical work. ... The cases are produced by the case-talk itself. That does not mean, of course, that diseases and treatments are magically conjured up out of thin air by physicians' incantations.
Rather, the case-like quality of all that is reported, seen and done is shaped by linguistic exchange between physicians. The descriptions and other accounts are given their shape and consequence by the many and various spoken actions that are taken for granted in modern medical settings. (Atkinson, 93)

The narratives and stories Paul Atkinson refers to are mostly produced linguistically. The daily exchange between radiologists and patients, the spatial order of the clinical environment, and the staging of bodies and their interior are the main preconditions for displacing the patient's subjectivity through the objectified case. Entering the clinic as a person who is not part of the clinic staff puts one - as a result of the institutional setting - automatically in a depersonalized position.

Cultural Staging

The metaphors present themselves repeatedly - dramaturgical and liturgical. There is always an element of the theatrical about modern medicine, and cases always present something of the spectacular. (93)

Cases are culturally staged in the clinical setting. I am interested in how this particular staging functions, how the contact between physicians and patients is organized and how diagnostic devices transcend individual boundaries in daily practice.
The room where the examination takes place is darkened when the patient enters. After the interview with the doctor, the diagnostic procedures start with laying down the observed person's body with the assistance of the technical assistant. The radiologist gives commands to put the patient in the right position. Then a flexible pipe is inserted into the rectum. Through this, contrast media as well as air can be applied automatically on the push of a button. Behind a wall of windows doctors and technicians conduct the investigation. The X-ray tube and the table with the exposed body are moved from a control desk in front of the physicians. By moving a button, air or the contrast media is introduced to mark pathological lesions and to signify polyps and tumors in the bowel. The contracted and the released motility of the gut are rendered visible via video illuminations.
The success of the diagnosis and the picture quality are mainly dependent upon prefabricating and staging the body's interior and on the patient's discipline before and during the processes of examination. The aforementioned bodily metamorphoses are partly painful and affect individual feelings; they can disturb the personal integrity - literally and metaphorically, get under the skin. The abdomen is screened and radiologists control every single movement and response of the body's inside on several monitors.

Screened Bodies and Experienced Boundaries

In the clinical context of radio diagnosis the skin is constructed - first as a screened boundary, and second still as a living sensual organ which according to Horst Ruthrof implies bodily experiences and a non-verbal language (Ruthrof: 2000). This second meaning of the skin includes the sense of touch, to have body contact in whatever form with the diagnosing persons who direct the procedures of examination.
The skin functions as a mediator of non-verbal expressions, which are staged in the diagnostic practice. Although imaging techniques like video cinematography include verbal contact between the examining doctors and treated patients, bodies are mainly touched through technical devices. Visual traces of the normal or pathological sort are recorded and displayed on monitors. Not even the clinical gaze rests on the patient's body (Foucault: 1973). The doctor's eyes investigate the representations on the (computer) screen to find signs for anatomical lesions. Diagnostic findings are spoken in a voice recorder either immediately after the examination is finished or later. Another person types the results into the computer. The patient is left in his or her anxieties a number of days, until he or she gets in touch with the treating physician again.

Cinematic Space

The diagnostic machinery is a highly complex one as it includes different narrative and visual levels. To describe the settings and to compare imaging methods in radio diagnosis, one has to think in cinematic terms. Optical dissections generate moving pictures of "life", as Lisa Cartwright points out in her book Screening the Body (1995). Video supported X-ray devices are also applied for studying the swallow act. For this, the patient's sip constitutes the beginning of the investigation, which is conducted through the physician's hands on the control desk and his or her eyes on the monitor. The patient's body is positioned on the table in front of the tube and receives verbal commands from the doctor. The processes of staging are comparable with the practice of filmmaking - particularly of documentary filmmaking. Doctors play the roles of movie directors. They stage the entire scenery of examination, take shots, and attempt to control everything on several monitors.
From the patient's mouth the signified sip can be followed to the bottom of the stomach by the eyes of the radiologist, the person under examination and technical personnel on screens. Every movement of swallowing the contrast media is rendered visible in real time and can be sectioned through video tools. One can see through the moving living body, both right after the doctor's command, and when the patient has left the room through the push of a button on the recorder.
The patient's face is displaced by the technical interface. There is no direct eye contact between radiologist and treated person during the X-ray and video recording procedures, though the doctor - wearing a lead apron which protects his or her body against radiation - directs the examination and puts the patient and the X-ray tube in the right position. During these proceedings the radiologist is comparable with a cameraman. All pairs of eyes look at the TV-set, which is mobile, so that everyone is able to watch how the fluid makes its way from mouth to stomach. I experienced these processes of swallowing as highly dramatic and uncanny scenery. Cinematic devices offer illusions of the body's inside, and include manifold narratives.

Film Examples

For a short moment I will leave the medical context to bring in the following film examples, produced by the American filmmaker Barbara Hammer: First: SANCTUS (1990) is an experimental movie collage showing X-ray footages from the archives of the George Eastman House Film Department in Rochester, New York (USA). Hammer is also the producer of a documentary on DR. WATSON'S X-RAYS (1990). The films belong together in a unique way: The filmmaker analyzes the symbiosis of the cinematic and the medical gaze - she observes the machinery of "optical dissections", as Lisa Cartwright puts it, without having to cut into the living body. Hammer traces the characteristics of postmodern medical culture of diagnosis in its colorful facets and dramatics. Uncanny cross fades of transparent moving heads and bodies, alienated figures are the main actors of this fantastic play with the audience' imaginations. According to Bill Nichols, who has analyzed the practice of documentary filmmaking: "Documentary offers access to a shared, historical construct." (Nichols, 109) I will compare this with the procedures of image production in radio diagnosis.

Instead of a world, we are offered access to the world. The world is where, at the extreme, issues of life and death are always at hand. History kills. Though our entry to the world is through webs of signification like language, cultural practices, social rituals, political and economic systems, our relation to this world can also be direct and immediate. Here, "strychnine poisoning" [like providing contrast media] is not just a signifier lying innertly on a page in all its polysyllabic density, but a life-threatening experience. (Nichols, 109)

The analysis of the swallow act can be learned with instruction videos. For this kind of video cinematic examination it is important to know how the patient is to position, which picture frames are useful and what sort of contrast media shall be provided to signify possible symptoms. At the Vienna University Clinic a video collection is available for physicians from other hospitals who need to practice this particular method. Individual cases can be studied on a TV monitor to differentiate between normal and pathological functions.

Frames of the Swallow Act

Peter Pokieser has put in a lot of work in studying the dynamics of swallowing and has produced the aforementioned video. He suggests analyzing film scenes in an equally systematic way as X-ray pictures. "The substrate of this analysis is formed by the movement of anatomical structures, which deform … the contrast media" on its continuous way to the stomach (Pokieser, Video Cinematography of the Swallow Act, 2000). The consistency of the signifying media sip varies from watery to viscous. The examined patient has to follow the doctor's commands. The contrast fluid is kept in the mouth for some seconds. Then the patient is asked to swallow. His or her illuminated profile is recorded and particularly framed - one scene after the other. The procedures of staging and recording take around twenty minutes. During this time the patient can observe the progress of his or her own sip through the internal body on a screen (as far the position on the table makes this possible).
Inserting the contrast media (in the mouth) transforms the conditions of visibility of inner bodily structures. The fluid gets a substantial part of the optical apparatus. The highlighted sip, in the form of contrast media, connects the technical eyes with the body's interior. I consider the act of inserting chemical components like barium, which render formerly invisible inner organs and functions transparent, extremely effective for the manipulations and metamorphoses of the body and its boundaries.

Digital Strips

Digitized bodies form new cultural boundaries. They are embedded in a social practice of image diagnosis including the negotiation of verbal as well as non-verbal contact between physicians and patients. The patients' bodies are measured in digital scanners like computerized tomography (CT) or magnetic resonance imaging (MRI) devices. For optimizing the diagnostic results contrast media is injected intravenously automatically through the apparatus. The needle is set before the start of the scanning procedures by the hand of a radiologist. By the way, this is the first and the last bodily contact between patient and doctor during the examination.
The physician questions the person already lying on the table of the machine how he or she is doing. Some words are spoken before the personnel leave the room and the exchange between body and scanner starts - the patient is left alone in the tube of the apparatus.
Technical assistants conduct and observe the proceedings; they "drive" the body and choose optical sequences. The examined patient is loaded up in millimeter thin slices, which the radiological staff can see on several control monitors immediately. The image quality is under permanent control, and in case problems occur, the diagnosed person receives commands such as: "don't breathe" or "don't move" and the failure sequence is "driven" anew.

Instruction Devices

Patient and apparatus build a particular unity. Automatic Patient-Instruction Devices are received through the loudspeaker of the CT scanner. Alexander Bankier, radiologist at the University Clinic Vienna, investigated the impact of automatic and non-automatic patient-instruction devices on image quality. He points out:

A patient's conception of the radiologist's concern is intensely associated with spoken language, and the patient-radiologist interaction is primarily determined by means of oral communication. With API [automatic patient-instruction] devices, this communication, although oral, is inevitably one-sided, is delivered in a monotone voice, and allows no possibility for staff members to react appropriately to a patient's needs during the examination. Without API devices, despite the spatial separation of patient and technologist and the use of microphones, a sufficient amount of interaction is achievable by a staff controlled and staff-monitored examination. To our knowledge, API devices are widely used in the performance of thin-section CT of the thorax because they are convenient and potentially timesaving for radiology technologists. (Bankier, 841)

The authors of the study (1995) cannot "recommend the use of API devices for thin-section CT of the thorax". They suggest the "use of direct voice communication" because this "humanizes the diagnostic environment and avoids the 'high-tech', anonymous atmosphere that increase patient anxiety" (844).
I asked Alexander Bankier about the practical results of this investigation, and whether at least a discussion among radiologists took place. He could not notice any practical changes, although he did get positive reactions from colleagues. In the context of this study the contact between patients and radiological staff is defined as a mainly verbal one. I would like to emphasize the non-verbal characteristics of treating and observing individuals - shining forth in the completely transformed exchange between subjective experiences and radically objectified and digitized body material.

Opaque Body Objects

The omnipresence of technical apparatuses like CT and MRI proceedings, during an examination negates the personal body and the status of subjectivity. Bodies become parts of the optical devices, have to fit into the tubes, to produce reliable diagnoses.
Or as Catherine Waldby states:

Das Gestell [used in Martin Heidegger's sense] also has connotations of visuality and of the telematic operations of technology that are peculiarly suggestive when considering the ordering of medical imaging technologies. As I have already pointed out, if the work of technics is a revelation which is also a venturing forth or unsecuring, it suggests forms of visuality which are also practices of dis-placement, rather than a simple and stable unveiling of what is already in place. (Waldby, 30)

In her analysis of The Visible Human Project (VHP) Cathy Waldby addresses "the problem of opacity" (24). Procedures of framing the human body go hand in hand with diagnostic practices of digital particularization of the former invisible interior on the computer. In these proceedings the skin as the mirror of individual feelings and identities is literally stripped away - subjectivity is displaced by digitized body objects. On the CT interface one can 'stage' organs and bodily structures. Radiologists produce a 'brain-', a 'lever-' or a 'lung-staging', bones and tissue can be enhanced visually or rendered invisible on the push of a button on the computer keyboard. The finding rooms are plunged in darkness; physicians sit in front of their electronic workstations analyzing and discussing cases. In comparison with CT, MRI devices are much more elaborate: All kinds of anatomical tissue can be differentiated and enhanced from every angle and perspective.

Conclusion

I consider cinematically and virtually produced diagnostic pictures of the inner body as cultural processes of transcending and dissecting subjective boundaries. The contemporary clinical practice of radio diagnosis is a highly telematic one, generating new relationships between radiological staff and patients. The body's interior is made to appear in its digital omnipresence - displacing the patient's presence. Medical diagnoses include electronically generated frames which are "staged" with the help of programmed devices of cut and paste. The opaque Gestell is increasingly made transparent. This technically-created virtual, pure illumination frames the radically objectified other side of the same subject. The omnipresence of the digital apparatus overtakes patients' bodies and generates imaginative boundaries of significance.

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