Afholdte Museion-seminarer december 2005 – juni 2006

Oplæg til eksternt seminar tirsdag d. 17. januar 2006
Jan Eric Olsén: Inscribing medicine in digital culture
OBS! Bemærk, at fodnoter ikke kan gengives på bloggen.
For at få mailet dokumentet med noter, kontakt venligst Jan Eric Olsén på Jan-Eric.Olsen@mm.ku.dk
Dear all
These pages are an attempt to make something out of visual sources. My starting point is the picture of two surgeons wearing monitors, currently displayed on our homepage. I give a somewhat detailed description of the picture and discuss how surgery, performed in this way, can be understood as an expression of digital culture. A field study of 3D-surgery, most certainly would have enrichened my aim and sharpened my conclusions; not least would it have been interesting to see how the optical equipment really is used. However, my project is still in an initial stage. Valuable contacts are being made with hospitals here in Copenhagen and I hope to be able to set out on documentary business soon. Therefore, I can’t provide you with information about the digitization of Danish medicine yet. This will have to wait until later on this spring. Still, I hope that this text can give you an idea of the material and problems that interest me the most. I welcome all kinds of comments, especially, if possible, those related to the museological part of the project. What would be worth collecting from digital surgery? Optical devices? 3D-images? Surgical instruments? Visual and audial recordings? Interviews with the surgical crew? The patients point of view? I look forward to discussing these things with you.
Best regards,
Jan Eric
Inscribing medicine in digital culture
The optics of surgery
The photograph displayed as “Månadens bild” on the homepage of the Medical Museion, shows an operation performed with the aid of stereoscopical vision. Two surgeons, each equiped with a Head Mounted Display, manage the handles of the instruments inserted into a patient undergoing keyhole surgery. Instead of watching the operation on a screen, as is the case in regular keyhole surgery, the surgeons view the interior of the body on the monitors fixed before their eyes. The images presented to them on the monitors stem from a stereoscopic video camera, inserted into the patients body, along with the surgical instruments. A double set of slightly different images is transmitted from the video camera to the monitors, one image for the left eye and one for the right. According to the laws of binocular vision, the different images merge and are perceived as a singular three-dimensional image in the brain. HMDs have been developed for this very reason; the possibility for surgeons to visualize three-dimensionally the navigation of their instruments inside the body.
Although forerunners can be dated back to the early twentieth-century, it was in the 1970’s and 80’s, that keyhole surgery, or minimal invasive surgery as it is also called, first emerged as an alternative method to open surgery. At the same time, techniques for illuminating the interior parts of the body, were developed for diagnostic reasons. Two such similar techniques are endoscopy and laparoscopy, where thin instruments are inserted in the body either through natural openings or by way of surgical incisions. Both of these techniques have been modified to fit surgical purposes as well. An important innovation in the history of minimal invasive surgery, was the computer chip video camera. It appeared in the late 1980’s and brought about a significant change to the way that surgery is performed. This meant that fiber optics in the form of a tiny video camera could be inserted into the body, along with the surgical instruments. The film taken by the video camera could then be transmitted onto a monitor placed somewhere in the operating theatre. Surgeons could thus direct their instruments via the images of the body displayed on the monitor. Since it minimizes the need for surgical incisions, keyhole surgery is considered as a more patient friendly technique than open surgery. From the surgeons point of view though, keyhole surgery is associated with disadvantages such as the loss of dexterity and three-dimensional vision. The coordination of eye and hand, which hitherto had distinguished the skillful surgeon, is in the midst of being readdressed, now that visual access to the three-dimensional body no longer is possible. On the whole, keyhole surgery has posed a set of problems that have yet to be overcome.
Let us return to the surgeons wearing Head Mounted Displays. The stereoscopical monitors enable them to regain the sense of depth perception, inevitably lost when the body is presented as two-dimensional images on a screen. Immersed in three-dimensional space, the surgeons can direct their instruments with far greater precision than by help of a 2-D screen. A further advantage with the HMD is that it can be programmed with significant information about the patients. By means of a voice sensor, the surgeons can consult previously taken X-rays and vital signs such as the patients blood pressure or pulse, which will appear on the monitors before their eyes. The HMD is clearly more than just an optical device for stereoscopical viewing. Connected to a database, it can also supply it’s user with a data bank of figures and graphs. In this respect, optical systems that fuse real-time data with preoperative data, do not simply aid the sense of vision, but enhance the faculty of perception in a very precise manner.
Lets take a final look at the picture. Besides the two surgeons, faces hidden behind the stereoscopical monitors, there are three more people in the operating theatre, the patient not included. In the front to the far left we see a surgical assistant; face covered but free vision. Behind her, barely visible, someone seems to be tending to the monitor, on which images of the ongoing operation are displayed. Finally, a fifth person is placed just behind the surgeons, engaged in an activity which doesn’t require standing upright. A computer, set at stand-by, is placed in the far right end of the room. Except for the part of the body in which the surgical instruments and the camera are inserted, the patient is all covered with green clothing. The differences between open surgery and keyhole surgery are striking. The direct sight of the incised body and pulsating organs are absent in a keyhole surgery operation. A range of new optical equipment has gradually transformed the appearance and design of the operating theatre. Surgery is more and more seldom performed in gross anatomy scale. Instead, the patient’s body is being mediated through miniature cameras, television screens, computers and visual aid such as the stereoscopical monitors used by our two surgeons. Consider the gazes of the surgical crew. No one is actually looking at the body on which the operation is being performed. Rather, their attention is drawn to the representations of the body, mediated through various optical apparatus. If the crew performing open surgery, was primarily focused on the body per se, optical technology has gradually drawn the attention of surgeons and nurses away from the very same body to live images displayed on video monitors, computer screens and 3D- devices. Through electro-optical networks, operations are even being distributed outside the operating theatre, giving the term panopticon a new meaning.
The role of visual respresentation in medicine goes a long way back. From renaissance anatomical lessons, through the graphical boom of nineteenth-century laboratories, to twentieth-century technologies such as X-rays, ultrasound and PET-cameras. With the rapid development of digital technology, yet new modes of investigating and representing the body are taking form. Whether digital technology will generate new conceptions of the body or merely reproduce existing ones is hard to tell. There can be no doubt however, that the digitization of Western culture is altering the ways in which doctors and nurses work. Digital networks are setting the standards of hospitals and clinics in very obvious ways, allowing bodily data to be converted into information and spread freely across time and space.
The logistics of perception
The term telepresence has lately been used to describe the shrinking of temporal and spatial distances between doctors, patients and hospital units inscribed in global information networks. Nik Brown and Andrew Webster, for example, argue that electronic circuits are destabilizing the actual locus of the body. Once converted into electronic format, patient data tend to be “everywhere and nowhere at once”. Likewise, powerful optical systems are creating complex gaps between the corporeal existence of the body and its visual representations. These technologies of visualization have given rise to what Brown and Webster name suveillance medicine, the term designating, among other things, the adjustment of hospital space to video cameras. Surveillance medicine implies both a proliferation of real-life images of the body as well as a general tendency towards a telepresent state in which spatial and temporal distances no longer pose an obstacle to action and communication. According to the French philosopher Paul Virilio, the digitization of Western society has brought about a dramatic change as to how we interact with our physical environment. Architecture used to imply the question of how physical space best can be arranged, in order to fit our bodily activities. Today, it is only concerned with how electronic online technology can be used to control our environment. “People are not so much in the architecture…”, says Virilio, “…it is more the architecture of the electronic system which invades them”. For Virilio, digital technology constitutes the peak of a scientific-technological development which has promoted the invention of ever faster modes of transportation and communication. Paradoxically, this fierce upgrading of vehicles culminates not in bodily motion and action but in inertia, a domestic inertia which obliterates all differences between action and remote action, presence and tele-presence. Virilios notion of a domestic inertia, symbolized by the remote control and the joystick, also includes what is refered to as the logistics of perception. Historically, the logistics of perception runs parallel with the speeding up of life. Since the days of the photopioneers Nièpce and Talbot, visual perception has undergone a thorough mechanization in Western society. Faster exposure times and powerful optical machines have eventually rendered the viewing subject dispensable. Electronic optics and digital systems have paved way for what Virilio calls “the production of sightless vision”. Whereas light and darkness are the organizing principles of human vision, the sightless vision of electronic optics, is characterized by its intensification of light and automatic registration of everything that comes within its visual field. The old slogan of Kodak, “Just press the button and we’ll do the rest”, has gained a wider significance.
Virilios aversion against digital culture is well established. Along with other critics of a scopic regime, such as Guy Debord and Jean Baudrillard, he has condemned capitalist society for reducing the realm of the political subject and depriving the act of perception of its meaning. Despite, or as a consequence of his strong disapproval of contemporary culture, Virilios work, together with Browns and Websters book, provides a well-found analysis that has bearing on the conditions of present-day techno-medicine. Take for instance the two surgeons performing keyhole surgery with stereoscopical devices. Doesn’t the whole operation bring in mind the logistics of perception, so well described by Virilio? The “sightlessness” of the stereoscopical camera inserted into the patients body, the distribution of images via automatic vision machines, the blending of the present body and the tele-present images, the speed with which distances in time and space are interwoven through television and computers, all these components add up to what Virilio calls the vision machine and Brown and Webster, surveillance medicine. Even the sense of three-dimensional space is created with the aid of electro-optical technology.
Most likely, Virilio would take the two surgeons as evidence that ours is a culture in which visual perception is devoid of any significance and experience what so ever. Still, one has to ask exactly how digital technology is effecting the visual experience of doctors and nurses. What is becoming of the experienced surgeon, now that computers have been brought into the operating theatre? What will medical experience signify now that the senses of doctors are gradually being replaced by sensors and simulators of all imaginable kind? The question of how doctors can best acquire experience and skills is widely acknowledged in contemporary medicine. It is a frequent issue in medical journals and has prompted a great deal of conferences and studies. The general view in these discussions is that medical learning has a lot to benefit from the use of simulators and Virtual Reality technology. Not only do computer simulators offer feedback and can be utilized repeatedly . Unlike animal models and human cadavers, they don’t provoke ethical arguments. Throughout the history of medicine, ideals of how to best gain experience of the marvels of the human body have alternated. Physicians have either stressed the importance of postmortem dissections or clinical studies. Instruments such as the stetoscope and the pulsewatch have either been praised or rejected. Today, with the spread of high-performance computers, yet another paradigm of learning and experience has appeared; the paradigm of interactive learning with the aid of computer simulators and Virtual Reality graphics. “Interactivity is the key”, the authors of an introductory book on the role of simulation in medical education state. Apart from an overview of the telemedical information society, the book also provides a detailed account of the latest devices and techniques, presently used in interactive training centres. The list of simulators and Virtual Reality equipment is long and the modes of application endless. Although much of the technology is still under development, the impression one gets by reading about it is that Virtual Reality is taking medical perception to pieces and rebuilding it in a form, suited for computer simulations. In one way or another, surely this will have an impact on medical experience.
Digital culture
The technology which contemporary medicine is bringing into play is closely linked to the mass media of consumer society. This fact is made all the more obvious when medical doctors refer to their own field as cyber medicine or tele medicine and to doctors, nurses and patients as cyber surgeons, tele nurses and virtual patients. Hip terms like these, indicate an awareness among medical professionals of partaking in the making of modern culture. Digital technology does not only provide hospitals and clinics with proper tools, it inscribes medicine in the wider framework of digital culture where the boundaries between entertainment, science and ideology have become difficult to discern. Before computer graphics became a serious option in medicine, producers of computer games like Nintendo, used them to create virtual environments into which players could plunge their avatars and simulate action. Today, computer aided design is used for a number of reasons, but whether it is a question of playing games, educating doctors or training soldiers, the main purpose is to create an illusion of reality. “A successful virtual environment is one that engages the user, encouraging a willing suspension of disbelief and evoking a feeling of presence and the illusion of reality”, Akay and Marsh declare in Information Technologies in Medicin. “Presence” and “illusion” are important features of digital culture. Computer simulations are used precisely for the reason of creating an illusion of being present in a virtual environment. In the case of medicine it is the patients body that doctors have to envision on their computer screens; in the case of the surgeons refered to above, it is the stereoscopical device which creates a 3-D illusion of the tele-presented operation. Now that computer simulations have become widely recognized, one can wonder how these “suspensions of disbelief” will effect the future pedagogics of medicine. If medical training before involved too much reality – blood and fainting, the stink of decomposing corpses, vomiting and nausea – we find today a situation where great efforts are made to enforce an experience of the real thing.