Presence in the Flesh: The Body in Medicine - Review

Style, Fall, 1998 by David Herman

Katharine Young. Cambridge: Harvard University Press, 1997. xiii 199. $27.75 cloth.

The opening paragraph of this inventive, stylishly written book outlines the core problem studied by the author:

Medicine inscribes the body into a discourse of objectivity. The body is materialized even as the self is banished, creating that disjunction which is the core of medical phenomenology: the mind/body problem. In the realm of the ordinary, the body is the self, the site of my experiences, the fulcrum of my movements, the source of my perspectives. I experience myself as embodied. In the realm of medicine, the body is rendered an object. It is inspected, palpated, poked into, cut open. From being a locus of self, the body is transformed into an object of scrutiny. (1)

Young borrows analytical tools from phenomenology, anthropology, and folklore to examine medicine's discourses of the body; these tools help ferret out the belief system that medicine "unreflectively inhabits" (1) while constructing the body as something to be investigated and manipulated. More concretely, the book draws on data collected during 1984-1987 at a major university hospital, where Young apprenticed herself to two internists, two gynecologists, four surgeons, three pathologists, two anesthesiologists, several nurses, and a technician. Equipped with a notebook and a tape recorder, the author observed sixty-nine internal examinations, thirty-nine gynecological examinations, nine surgical examinations, nine surgical operations, and three pathological examinations. (Young notes at the outset that because everyone in the morgue tended to whisper and because surgical operations were noisy and chaotic, her pathology and surgery tapes presented significant problems of retrieval.) A linguist, Daniel Lefkowitz, helped Young transcribe the surgery and gynecology tapes. The author includes a note on the transcription devices that she and Lefkowitz used (175-76), techniques of transcription being of course not just a matter of notation (what was said and done?) but also a matter of interpretation (what aspects of verbal and nonverbal behavior are worth trying to capture and with how much detail?). The linguistic and ethnographic dimensions of Young's study raise issues - e.g., the nature of the relationship between 'theory' and 'data' - that need to be faced squarely by all analysts of communicative behavior. These general and basic issues are not always satisfactorily addressed in Presence in the Flesh. Specifically, although Young collected a significant amount of tape-recorded data for her project, at crucial points in the book the author opts for a case-study approach rather than drawing on a more extensive portion of her data-set. In practical terms, this means that Young sometimes formulates very broad claims about the body, the self, and medicine on the basis of communicative behavior observed during a single interaction.

Chapter 1, "Disembodiment: Internal Medicine" (7-45), sketches sociophenomenological aspects of bodily existence, focusing on how physical examinations transform patients from social subjects into medical objects. Borrowing a concept from Erving Goffman, Young discusses how medical examinations require both physicians and patients to manage "evidential boundaries" - i.e., to choreograph the disposition, removal, and replacement of various barriers to apprehension. Such barriers, necessitated by the differential treatment given to symbolically charged parts of the body, are constituted by everything from clothes to walls, postures, gaze directions, arrangements of furniture (11). Indeed, examinations require the management not just of boundaries but also of "frames." Accomplished by forms of address, displays of degrees of deference and dominance, and other metacommunicative signals, framing creates and sustains what Alfred Schutz characterized as alternate realms of experience. The realm-shift by virtue of which the patient's body is made an object of medical examination - the interactionally-achieved shift from the realm of the everyday to the realm of medicine - is not global and uninterrupted but rather partial and intermittent (12). More broadly, Young suggests that realm-shifts in medicine are triggered by the way realms are distributed in space and sequenced in time (12-17). The proper uniforms allow medical personnel to move freely about hospital passageways and rooms, whereas "[f]or outsiders, passage between realms is slowed, obstructed, deflected, or sequentialized partly in order to provide interstices in which to accomplish transformations" (13). Overall this transformation of person into patient, the shift from the body as the lodgment of self to the body as an object of scrutiny, is designed "to protect the sensibilities of the social self from the trespasses of the examination" (32).

As Young emphasizes, however, realm-shifts are never wholesale; there are always enclaves of the ordinary within the medical examination. One key strategy for building such enclaves - more specifically, for reconstituting a sense of embodied self - is narrative. Drawing on her own earlier work on narrative frames, Young remarks that "the storyrealm, the realm of narrative discourse [embedded in a surrounding discourse context], conjures up another realm of events, or taleworld, in which the events the story recounts are understood to transpire" (33). It is in this alternative possible world, the taleworld, that the patient can reconstitute himself or herself as a person. Here, however, is one the places where we face the problem of determining the generalizability of Young's model. During one medical examination, a patient who is a professor of Jewish literature and history tells three stories about his experiences in Auschwitz (34-45). The author suggests that this patient's acts of storytelling "illuminate the nature of narrative, the nature of medicine, and the nature of the self" (34-35). Young skilfully demonstrates how parts of the professor's body (e.g., the bump on his head that resulted from his being beaten repeatedly by a border guard's nightstick) furnish points of access from the realm of medicine to the alternative realm of the taleworld - a narratively constructed enclave in which the professor can insert himself as a fully embodied person. But from this particular case Young makes the following generalization: "Besides creating a separate reality, telling stories during a medical examination creates a continuity between the two realms that converts the ontological conditions of the realm of medicine precisely along the dimension of the body" (42-43). Again, Young writes of this patient's three stories: "The phenomenological cast of the taleworld in which the self is implicated in the body is set against the phenomenological cast of the realm of the medical examination in which the self is extricated from the body" (45). But is it the case that for every taleworld constructed narratively during medical examinations, the storyteller will reattach self to body? Might not patients tell tales of disembodiment as well (e.g., a story about feeling "outside of one's body" during a near-death experience)? And how is Young's analysis affected by her choice to focus on a patient who narrates tales of extraordinary brutality, pain, and humiliation? Because Young does not document, on a wider scale, patterns in the distribution of acts of storytelling during the medical examinations she observed and recorded, it is impossible to know whether or not general explanatory principles can be extrapolated from this one patient's strategies for realm-shifting.