CT Suite: The Work of Diagnosis in the Age of Noninvasive Cutting
CT Suite: The Work of Diagnosis in the Age of Noninvasive Cutting.
by Barry F. Saunders
Duke University Press, Durham, NC, 2008
416 pp., illus. 42 b/w. Trade, $89.95; paper, $24.95
ISBN: 0-8223-4104-2; 0-8223-4123-9.
Reviewed by Hannah Drayson
C.T. Suite is based on Barry Saunders’ anthropological work in a university hospital in 1996 and 1997. In it Saunders provides a rich ethnography of the quotidian activities and discourses he observes in the part of the hospital known as the ‘CT Suite’, “a series of rooms; scanner room, waiting room, reading room, file room. And closets.” (p.1) which are home to the technological apparatus of Computed Tomographic Scanning.
C.T. Scanning is a form of imaging technology which creates multiple parallel X-ray images. These can be interpreted as three-dimensional information about the inside of objects; in medical use, the inside of part, or the whole, of the human body. In a series of vignettes, Saunders introduces us to the activities which take place in the C.T. Suite. He describes its ‘diagnostic rituals’ - a highly encultured process, reading, writing, interpreting - by which the medical professionals using C.T. Scanning technology are able to make visual documents come to represent diseases and cases. As we move from reading room to scanner room, and beyond, C.T. Suite describes the apparatus of generation, management, storage, and interpretation of C.T. scans, as well as their use as pedagogical materials and their place in museum and exhibition spaces.
Saunders' tactic of making central to his ethnography the suite, the space in which C.T. Scanning is undertaken, rather than the device itself, allows his discussion to incorporate the entire dispositif of C.T. Technology; placing the scanner within the broader context of its culture and construction. At the same time, the field of interest is clearly defined by its hospital setting and medical uses of C.T.
The space of the C.T. Suite itself is disconnected from the day-to-day activities of patient care, constituting a technologically specialised area of the hospital. In this, C.T. Suite joins a general departure in some contemporary Medical Anthropology and Sociology from a tendency to address the marginalisation of the patient’s voice within mainstream accounts of medical treatment and in medicine itself. While Saunders points out to us that ‘patient subjectivity’ and ‘illness experience’ cannot be excluded from accounts of hospital practices and technologies, they are peripheral to his study. The book's ethnographic content tends toward another tradition in the Sociologies of Science and Medicine, concerned with laboratory and medical cultures, offering an analysis of the discourse between the staff who work within the C.T. Suite, through their transactions with one another and their ‘clients’, (other medical staff from the hospital who order scans).
Saunders’ work develops this analysis to address further philosophical problems which arise in the nexus between socio-cultural concerns and medical technologies. One concern is uncovering how practices are ‘consolidated’ in “machines, protocols and bodies” (p.9). For Saunders “an abiding impulse is to consider how aspects of practices can be elided, or reified, congealed in their products – and thus the products fetishized: as, for instance, the true reading, the unequivocal evidence, the unimpeachable expert” (p.10). This interest in the production and ontological maintenance of medical entities by technological practices shows the continuing influence of social constructionist ideas: giving rise to particular research problems. Scholars are still negotiating the ground between hard social constructionism and realist interpretations of technologies; relations between knowledge, machines, bodies, meaning and culture remain in a 'posthuman' flux.
As a response to this flux, ethnography offers a grounded focus upon technical practicalities, but maintains an interpretative flexibility which allows researchers to factor in social and discursive aspects of technological activities. Scholars like Bruno Latour and Anne Marie Mol have used ethnography in Science and Technology Studies and Medical Anthropology to great effect, and the approach still appears to be offering fresh philosophical insights. Both have observed that for philosophers interested in technology, anthropological methodologies have certain advantages, for example a methodological commitment to avoid distinctions between cultural and technical actions, rejecting modern dichotomies like the nature-culture divide, which has, in the last few decades, contributed to a more nuanced approach in many studies of medical technologies.
Academic literature about technology, particularly the History and Philosophy of Science until the 1980's, has mostly drawn on western philosophical traditions. When reinterpreted by sociologists and others in disciplines less taken with the notion of science as, in Margaret Lock's words "an objective and value free body of knowledge" (Lock, 1998) – a method for generating objective truth – this has tended to generate critiques of ‘allopathic’ or ‘western medicine’ which act as scientific assistants in the fortification of the ‘biomedical worldview —’; a worldview critiqued for its dehumanising, objectifying, and mechanistic representation of human beings. Because of their alternative approach to this issue, it is a shame that book length ethnographic works which focus strongly on particular diagnostic technologies are not more common. They can provide excellent accounts of medical technologies as situated practices, giving equal weight to mixture of technological and social forces which shape medicine.
The early sections of the book introduce the reader to a multiplicity of exchanges and activities through which C.T. Scans are deciphered. In a sequence of themed vignettes – which include accounts of staff reading; laying out and examining film (completed CT scans), negotiating diagnoses with colleagues, text books, and writing; dictation, note-taking, marking the films with wax pencils – Saunders builds up an account of the daily work and perceptual techniques and concerns of radiologists, students and clients. Referring throughout to dialogue between participants in these activities, he describes both the practical aspects of the reading room activities, and the manner in which hierarchical, social and collaborative aspects of the participants behaviour are manifest in the activity of reading scans.
The two chapters covering 'reading and writing' and 'diagnosing' illustrate diagnostic processes which involve the application of informants ‘trained judgement’ where their readings of scans are negotiated and reified through dialogues between the radiology staff members. Referring to the work of Edgar Allen Poe, (responsible for the first murder mystery novel), Saunders takes as his theme the apparent similarity between the diagnostic puzzle and the crime mystery. As a frame for diagnostic exchanges he records in the reading room of the CT Suite, intrigue offers Saunders a theme from which to explore the assessment and juxtaposition of a variety of diagnostic evidence by the radiologists and their clients (p.10) The importance and particular character of diagnostic puzzles is made explicit by Saunders in his discussion of the way that they are used in teaching conferences and in-hospital seminars. At these events, cases are presented in “confusing specificity of detail”, including scans, patient history, examination data; then discussed by a senior physician who “hazards a diagnosis” (p.133). Citing Carlo Ginzburg’s description of “venatic logic”, the “hunters knowledge” the divinatory knowledge used to read the ‘tracks’, ‘hairs’ feathers’ and ‘excrement’ of animals; he links the presence of intrigue in diagnosis to its “special, intuitive, elite knowing… not simply mental, but embodied practice” (p.130). For Saunders, diagnosis is far less concerned with “utilities or outcomes” - but is actually more “moral and aesthetic”. Therefore intrigue becomes “crucial to teaching modes of thought that escapeescape determination by rules, protocols, metrological structures–especially conjecture and judgment." Earlier in the text Saunders makes a claim; that the particular power of medical images is not what they reveal to the ‘mental’ or ‘analytic’, but in their “primary cultic context: diagnostic work” and his exploration of intrigue in medical teaching serves as a fascinating exploration of this notion. His observation of the importance of, and cultural development of an 'intuitive' approach as vital to the practice of diagnosis and provides an interesting distinction to the perceivedperceived importance of medical rationality implicit in medical training and medical school entrance exams observed by medical anthropologists like Byron J. Good and Daniel Moerman.. In this he provides another, less instrumental depiction of the cognitive capacities underlying the practices of medical diagnosis.
C.T. Suite is a valuable addition to the small literature which deals with medical imaging technologies as sociotechnical networks. The book is notable for its centering on one particular technological apparatus, anchoring a rich account of the practices, activities and rituals that surround it. It provides a compelling and well-illustrated insight into the technological practice of Computed Tomographic Scanning. It is also an engaging read, Saunders’ use of the conversation of the radiological staff throughout the text is not only informative, but conveys the sense of familiarity and humour in the working atmosphere of the C.T. Suite. The at times subtle analysis of this material conveys the experience of a radiology lab field trip.. The author ties together strands from the literature of Science and Technology Studies, History of Science and existing scholarly work in the Visual Cultures of Science and Medicine. Thus diagnostic imaging as it manifests within the hospital is rendered within a wider array of technical, economic, archival and socio-cultural conditions, providing a fascinating exploration of an instrumental culture based around a medical imaging technology.
Ginzburg, C. (1989) Clues, Myths, and the Historical Method, translated by John and Anne C. Tedeschi Baltimore: Johns Hopkins University Press.
Good, B. J. (1994) Medicine, Rationality and Experience: An Anthropological Perspective, Cambridge: Cambridge University Press.
Latour, B. (2007) Reassembling the Social ; An Introduction to Actor-Network-Theory, Oxford: Oxford University Press.
Lock, M, (1998) Biomedicine Examined. London: Springer.
Moerman, D. (2002) Meaning, Medicine and the 'Placebo Effect', Cambridge: Cambridge University Press.
Mol, A. (2002) The Body Multiple: Ontology in Medical Practice, Durham and London: Duke University Press.