‘Making Sense of Medicine’: Book Review

Max Perry reviews Making Sense of Medicine: Material Culture and the Reproduction of Medical Knowledge, edited by John Nott and Anna Harris (Intellect, 2022).

An image of a single-crewed sail boat on a calm sea with a man leaning out of the boat with his hands on the tiller extension
A sailor uses a tiller extension. “Sitting out” of the vessel allows the sailor to balance the keel. Source: pixabay, https://bit.ly/46ZRszV

My grandpa worked as a sailing instructor. Originally trained as a welder, he had a particularly tactile and skilful approach to teaching. One evening on the lake, he told me to “put the tiller arm away”. The tiller is a fixed lever attached to the rudder of a vessel, the ‘arm’ — in this instance — was the extension that levered off of the main tiller to allow greater mobility around the vessel and that increases leverage (torque) on the rudder. In folding the arm away my grandpa knew that I would start to feel the rudder more clearly as it cut through the surface of the water, shrinking the distance between myself and a vital technology of the boat. Moving the rudder from this position is harder: you have lost leverage, but you gain a sort of epistemic leverage; you feel more acutely how the rudder works. You feel how the hull of the vessel cuts through the water, how the rudder shapes the wake left behind, and how — through resistance — the rudder re-directs the bow of the boat. I find it hard to explain, in words, how a tiller and rudder work, but I know how they work. I know this because my Grandpa told me to “put the tiller arm away”.

Reading the essays collected in Making Sense of Medicine — coordinated and edited by historian John Nott and anthropologist Anna Harris — I thought, often, of my Grandpa’s instruction. I thought about what I mean, when I say that I know how a rudder works, and of what it was that my Grandpa had taught me when he told me to move my hand.

Nott and Harris’ collection asks its readers to consider how medical knowledge is made and transmitted, and whether transmission is not itself an act of creation. The essays focus on the materialities of knowledge production, each taking a practice or particular material to consider the ways that knowledge is embodied and transmitted in the world. These are all essays that concern themselves with doing; their interest is in knowing the things that are hard to say, hard to convey and hard to name. Readers familiar with Science and Technology Studies (STS), will recognise this material first approach. What is novel in the collection is its invention and ingenuity in trying to reach new audiences outside of STS. Doctors, artists and educators all feature as authors and participants in the essays, and often essays find experimental ways to explore the terrains of medical education. Uniting these various interlocutors is the consideration of how materials shape knowing. Such preoccupations are what made me think of my grandpa and that rudder.

These essays approach knowing as an embodied practice, rooted in the real physical objects of the world. My knowing of rudders thus, is perhaps best understood through a consideration of the tiller extension, the rudder itself and of how a loss of leverage provokes a new sense of how it cuts through the wake. By attending to these materialities we can begin to investigate, more thoroughly, processes of knowing as they are experienced in the world. After all, my grandpa’s tactile teaching was embodied in the materiality of the vessel, not in the signification of his spoken words.

Book Cover of Making Sense of Medicine
Source: Intellect Books, https://bit.ly/3DpNYJB

The volume itself pursues medical knowledge through a pleasingly diverse array of materials, from balloons filled with water (that act as teaching aids to demonstrate how ascite fluids shift inside the body [Harder & Harris pp. 48-55]), to laser pointers that link images to speech (Winter pp. 344-360), to Stethoscopes that may not just ‘reveal evidence of dangerous biological processes’ but also, to the keen ethnographer, ‘provide evidence of dangerous social processes’ (Wendland, p. 393). Another essay, early in the collection, investigates the strange persistence of the chalkboard in medical pedagogy. The author Rachel Vader Allison — drawing parallels with the work of Michael Barany & Donald MacKenzie who described the performative utility of chalkboards in rendering abstract mathematical problems intelligible (Barany& Mackenzie, 2014) — attends to the unique qualities of the chalkboard to explicate its persistence. A chalkboard in conjunction with chalk can, Allison argues, be used to depict, to overlay, to rub out, to shade, to make lines firmer or softer through the control of pressure, to use colour to differentiate substances and concepts, and is inexpensive and manoeuvrable. These realities make it well suited to the classroom, but it is what Allison terms the ‘ephemerality’ (p. 78) of the chalkboard that elevates its pedagogical utility. The impermanence of the depiction — their ephemerality — demands the frequent and repeated demonstration of an instructor’s skill, for it is only a skilled hand that can produce such detailed clinical figures. These acts of doing seek to render the body intelligible and reinforce the skill of the artists, not just to draw, but to know the objects they draw. Thus, it is impermanence of chalk, its flexibility as a medium, and its availability and cheapness that make it such a vital tool in medical education.

This is contrasted in a later chapter by Drew Danielle Belsky in which we follow the crafting of images created by medical illustrators, who are described as in a ‘double bind’ (p. 223). The legitimacy of their images is enhanced by a sense that they are not at all ephemeral; here Belsky borrows from the influential work of Lucy Suchman (2009) to argue that the images are bolstered by the ways in which they circulate as naturalised artefacts of seeing (i.e. as things that appear ready formed). They are not presented as carefully crafted depictions of material realities, but as objects extracted from nature. As such they must masquerade as objects that require no artistic or imaginative skill to produce. The ‘double bind’ that Belsky describes is that the image maker is both required to be hugely creative and skilful (for such images are not natural, they are the product of complex labours) but also entirely invisible. The medical illustrator, who produces the image, must leave no trace or evidence that betrays the reality of it: that it was created through the skill of this single human. Leaving such traces would risk undermining the integrity of the image. The ephemerality of the chalkboard, described astutely by Allison in her essay,  allows instructors to demonstrate their skill; to show students that each image is a rendering of nature to the gaze of science. The naturalisation of images produced by medical illustrators, which we encounter in the essay by Belsky, requires skill, judgement, and experience just as the chalk board images do. This is made ironic because these attributes must be hidden to produce naturalised images, images that hide traces of their ephemerality, and hiding such things requires a huge amount of skill.

Despite Allison’s celebration of chalkboards, and Belsky’s critique of naturalised digital imaging, the collection works hard not to seduce the reader with idealised depictions of past technologies. Anthropologist Andrea Wojcik reminds us — in one of the many ‘thematic essays’ that reflect on the essays collected in the book — that anachronism can be dangerous and captivating (p. 363). Wojcik, noting the persistence of non-digital simulation and its productive capacities, reminds readers that all simulation requires work and simplification and thus, a critical eye. Chalkboards and digital imaging must be subject to critical examination to expose their positive productive capacities, as well as their damaging potential.

Wojcik’s is one of many intermissions throughout the volume. Each of these intermissions discusses a theme that unites essays in the collection. This is an important structural feature, with Nott and Harris playfully ordering the collection alphabetically, rather than through editorial imagination (p. 13). This practice, which mirrors medical textbooks, dictionaries and other clinical taxonomies, assumes a lofty indifference to the subjectivities of lived experience, and allows the editors to feign objectivity. Here, Nott and Harris gently tease such notions, and the intermissions serve as regular reminders of the ways in which the collection could be ordered and arranged otherwise (and thus, of the particular effect of any ordering system, especially of one that assumes indifference).

Other experimentations with scholastic form are to be found throughout: Allison’s essay on chalkboards imitates an educational guide to chalkboards written by Frederick Whitney. Editor Nott provides a chapter that is half transcribed dialogue and half theoretical reflections presented as footnotes, a stylistic choice that echoes Annemarie Mol’s dual commentary in her seminal text The Body Multiple in which the top half of each page is empirical and the bottom half theoretical (2002). Nott’s chapter reads like a stage play, but one in which the audience can choose to investigate the internal monologues of its characters. Elsewhere there are dialogues, reflections on artistic images produced for the book, and a description of simulated sutures applied by an embroiderer to a cigarette paper.

Surgeon Roger Kneebone and artist Fleur Oakes (who earlier featured as an empirical subject, sewing cigarette papers) produce what I see as a kind of thesis statement for the collection. The chapter explores the unorthodox professional relationship between artist (Oakes) and surgeon (Kneebone) that the two have formed inside the operating theatre where Oakes is an artist in residence. They describe how they each inform and transform the work of the other: ‘seen through the eyes of an embroiderer and a surgeon, thread too means different things.’ (p. 402). The convergence of artist and surgeon, allows Kneebone and Oakes to explore how their desires — of healing and of artistic creation — can expose thread as something that shapes, but is also shaped, by these desires. Oakes and Kneebone argue that through re-positioning subjectivities we can gain new knowledge about the materials we use and about the things that we do with them. Kneebone knows better how to be a surgeon because he has seen the materials of his trade subjected to a different set of desires, a different set of provocations, a different set of functions. The reader is left to ask, if thread can be the medium of beauty, what is its essence when performed in the production of healing? If we can ask such questions of thread, then the more complex assemblages of medical technology can and must also be stripped of their essence and subjected to an investigation that accounts for the desires that shape them.

My grandpa taught me that knowing isn’t just about hearing words, about reading, about seeing and reproducing. There is a degree to which to know something one must do that something. To know how to steer a boat, one should get as close to the rudder as possible, should feel more closely the way that the water pushes against the instrument as it carves through its surface. One can’t learn at a distance. In Making Sense of Medicine, this collection suggests that we need to reposition ourselves, move our hand closer to the rudder. I am inclined to agree.

About the Author

Max Perry is a Sociology PhD student at the University of Bristol where he is in the final stages of a thesis on Medical Records.

Twitter: @0404am

References

Barany, Michael J., and MacKenzie, Donald. 2014. Chalk: Materials and Concepts in Mathematics Research in Coopman, Catelline.  et al. (eds), Representation in Scientific Practice Revisited. Cambridge, MA,  MIT Press Scholarship (Online), https://doi.org/10.7551/mitpress/9780262525381.003.0006, accessed 21 June 2023.

Mol, Annemarie. 2002. The Body Multiple: Ontology In Medical Practice Durham: Duke University Press. 

Suchman, Lucy. 2009. Human-Machine Reconfigurations : Plans and Situated Actions 2. Ed., reprint ed. Cambridge: Cambridge Univ. Press.

 

 

 

 

 

 

 

 

 

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