8 Jul, 14 | by BMJ
Drawing Women’s Cancer explores the lived experience of gynaecological illness through a unique interrelation between art and medical science. Based in Cardiff and supported by Cardiff University and Cardiff and Vale University Health Board, the project began in 2012 as a collaboration between myself and Amanda Tristram, gynaecological surgeon. Since then it has produced two major exhibitions and several presentations both national and international.
Drawing Women’s Cancer project builds on the premise that philosophy, medical science and visual art all involve an inclusive, and often passionate form of ‘seeing’, and that they are brought into mutual relation through the equally inclusive concept of language. The concept of inclusivity here emphasises the idea that although language is the root and branch of dialogue, and indeed of narrative, neither of these phenomena are necessarily bound to the word.
As an artist and a writer, my concept of language constitutes far more than simply words, and as such it is the language of practice – and its corollary, process – that most concerns me. Consequently I understand both dialogue and narrative as practices and processes in their own right, both ‘creative’ and both profoundly and intimately immersed in experience, wherein language is evident and influential in all its forms. The Drawing Women’s Cancer project, which constitutes an in-depth exploration of experience, is therefore fundamentally and methodologically driven by a hermeneutic approach that embraces a multidisciplinary concept of language in order to delve deeply into areas of subjectivity that can often be felt impossible to express in verbal form.
Narrative language is a vital part of Drawing Women’s Cancer wherein personal narratives as related to me and transcribed either verbatim or in note form provide the foundation for the research as a whole. These are the bedrock of the experimental approach and, together with written narratives that reflect my own feelings about my encounters with women patients, and my experiences in theatre, they underpin the combination, the conceptual superimposition of word and image, verbal and visual, that is engendered through the creative process – itself unashamedly steeped in subjective experience. The creative process thus reflects and perpetuates the dialogical process that characterises my conversations with patients in a continuing dialogue between myself and drawings as I work on them. At the same time the process also responds to a further dialogue, one that speaks to my experience of the ‘Others’ experience of illness. Narrative here shakes off the strait jacket of monologue. It refuses to be confined to any prescribed spatial and temporal dimension. Narrative here becomes polyvocal and takes primacy as the vehicle by which the project as a whole continues and extends.
When a drawing is complete the story is far from over, indeed it has only just begun, and a drawing’s inherent communicative force lies in its capacity as an autonomous art object to maintain a dialogical character even beyond the relationship with its creator. As a work of art a drawing can simultaneously express and provoke emotional significance in an inter-subjective relation with the viewer, who in turn can creates his or her own narrative on ‘seeing’ in it the voices of those suffering the impact of illness, and this leads, ultimately, to the instantiation of what I want to call the meta-language, a form of communication beyond dialogue, beyond narrative and even beyond itself in terms of the expression of subjectivity. It is on the basis of narrative then, and its dialogical implications, that creative representations of the lived experience of gynaecological cancer can open up a ‘discursive space’ wherein a deeper understanding of the relation between a disease diagnosis and the overall existential impact of illness can potentially stimulate further conversations between patient and physician, between patients and their carers, and within the public arena in terms of awareness and acceptability.
So, in the true spirit of interdisciplinary practice in the Medical Humanities the Drawing Women’s Cancer project offers a direct challenge to the rationale of an uncompromising ‘art-science’ dichotomy by demonstrating that, in practice, neither can be disassociated from our understanding of humanity and the manner in which, as human beings, we engage or disengage with the society in which we are a ‘person’. Art, medical science and philosophy are all inescapably entangled here in a web of our own being and are constituent parts of the same overall human project, but visual art perhaps has the more obvious capacity to ‘bear witness’ to the trials that are often borne in the pursuance of being…in our physical enactment and psychological representation of life. Drawing Women’s Cancer is not only about disease, or medical intervention, or suffering, or the impact of illness; it is about all of these things. It is about, as Radley notes, what it feels like when ‘all sense of normality, and all the expectations of a future that accompany good health, suddenly become less real’. It is about the experience of illness, where that experience overrides all others. It is about creating a language that has the power to speak, not necessarily for the women whose personal stories are taken as the point of departure, but rather because of them, so that they may return.
For the rest of this post I would like to offer one of my own written narratives, an account of a recent opportunity to witness a gynae-oncological operation. I have attended various operations during the course of the project and all of the women who have allowed me to witness this part of their experience do so with the conviction that it will help me understand more profoundly what they are going through. Having, to borrow a term from legal channels, an ‘appropriate adult’ seems also to help sometimes as they try to deal with the natural anxieties that such an experience brings on.
The image accompanying this post is a painting rather than a drawing. It is an ‘autoethnographic’ image that represents a similar operation to the one that the narrative below refers to. It serves, I hope, to demonstrate how visual language, even where there is no attempt to necessarily create an objective representation of the scene, can nevertheless communicate autonomous and coherent expressions of profound experience.
The painting is called Body in Flux. The narrative is called, simply, The Op.
Twenty minutes ago I was talking with her while she waited to be called down to theatre. She had smiled at me but it was a weak, anxious smile and there was fear in her eyes. We had a brief conversation – she seemed to appreciate the company. Hers is a difficult history, when she began to notice something was wrong she had tried to ignore the symptoms, ‘for the children’. She convinced herself it was just something minor, no need for a doctor, but she got tired of pretending she was OK and in the end she did go for help. As she lives in West Wales, she went to the local hospital and to her relief they told her there that it was nothing serious after all – ‘just abnormal cells’, nothing too much to worry about. They did however organise an appointment for here at the clinic here in Cardiff, for a biopsy. This was unusual, and even though they said not to worry, she did anyway. She worried about being in the city, she worried about her two small children at home, she worried she might die.
It is cervical cancer, quite advanced. She is to undergo a radical hysterectomy. The whole of her uterus and the surrounding tissue, the cervix and the upper part of her vagina are to be removed. The ovaries too, probably.
Reality hit hard a few weeks after the biopsy. It came suddenly, in a phone call. It was the shock! The word ‘cancer’ still makes her cry. She has no partner. She said she wasn’t ‘active in that way’ – not for ages – so she hadn’t been for Pap test for years. She had thought there was no need. She said she felt ‘stupid’ now. She is a primary school teacher; they had called her on her mobile as she was walking the kids to the classroom. They had the results of the biopsy. They told her that she had a tumour, that she had cancer. Now, here, waiting to go down to theatre, her eyes well up as she whispers the word. ‘It was the shock’, she says.
She is asleep now under the lights in the theatre. The lights are not harsh, just very strong. The huge circular structures from which they descend are acutely and disturbingly present, not just here in the room, but even more powerfully in my memory. The monstrous size of them and the pitiless, piercing illumination they provide still haunts me, despite my efforts to exorcise the horror of my own experience in the weeks that followed in paint on canvas.
I am anxious then, for her, for me, for us both. This operation is one that remains very close to the surface of my own consciousness and my presence here has psychological connotations that I cannot ignore or supplant with more rational thought, so deeply are they rooted. This is a test then to the personal limit of my focus on subjective experience. Amanda, the surgeon, knows this. She asked me when we arranged this visit, “Are you going to be OK with this one?” I felt the same way I did when she asked the very first question, the one that kick-started the whole Drawing Women’s Cancer project; she had said “Can you draw what it feels like to have gynaecological cancer rather than just what it looks like?” I knew then that I wanted to try.
Jonathon, the surgeon working with Amanda, reaches up to angle the bulbs. They are covered in their own protective ‘gloves’ so that he doesn’t burn his hands. His hands are so very important. I stand behind Amanda who is pushing paper wadding into the vagina – ‘packing’ it so that it doesn’t ‘move’ during the operation. There is so much paper left over on the floor between her feet. It is to ‘protect the excess’. The pushing, packing, continues and she says, “I pushed too hard once. I was in training and I was so scared of the consultant… we noticed that there was a lot of blood just dripping out onto the floor!”
Amanda goes to a side room to attend to the paperwork and Jonathon is left to make the first cut. Firm and certain. Vertical, from the navel to the pubic bone. He draws the diatherm slowly, painfully, through the skin of the belly and it trembles around the small part of it that is taut and stretched between his fingers. “A cut needs tension”. I am surprised that he uses a diatherm for this initial cut, deep and long as it had to be, so I ask. “Yes”, he replies, “it’s the way we do it now, but some surgeons do still use a scalpel.”
The edges of the cut sizzle and blacken. Smoke and the acrid smell of burnt flesh arise from the wound that becomes bigger, deeper as he works. He cuts down, confidently and deftly through layers of fat. My artist’s eye focuses on how the colours that move through the wound, from the skin, through the fat, to the fleshy muscle, are aesthetically beautiful in harmonious juxtaposition. First the hues of red: crimson, napthol, and the brightest perylene mingle with tiny glimpses of green and blue, the colours of shadows on the flesh, and then on through the spectrum of yellow, from the deepest cadmium to the palest, ‘prettiest’ lemon, the colours of the daffodils that are blooming outside and carry so much significance here in Wales. Cenhinen (kenHINen) means leek in Welsh, while cenhinen pedr means daffodil, or St Peter’s leek. Over the years the two became confused until the daffodil was finally adopted as a second national emblem of Wales. The cenhinen pedr then are blooming today, even as the wound is opened and the fat gives way and melts under the surgeon’s hand.
I think of Chroma, in which Derek Jarman, painter and filmmaker, extends Melville’s view that we ‘learn’ colour whilst not necessarily understanding it. It is understanding that I am seeking here, in subjective form, and in the wound as I watch it open, the red of the initial cut becomes Jarman’s ‘moment in time…quickly spent. An explosion of intensity.’ Further on, as the diatherm moves down through the soft tissuethe red ‘burns itself. Disappears like fiery sparks into the gathering shadow’. Jarman imagined four stages distinguishable in alchemy: the blackening of MELANOSIS, the whitening of LEUCOSIS, the yellowing of XANTHOSIS and the reddening of IOSIS. For me they appear here, but in a different order as I watch the diatherm cut beyond borders, deeper into the body, opening up and invading its private, once autonomous spaces. I feel the sting, but as Jarman says, ‘Painters use red like spice’.
Amanda is back. She brings more even wadding to ‘mop up the excess’. The excess: ‘an amount of something that is more than necessary, than is permitted, or is desirable’. Excess here then, even beyond the metastasising cancer that in itself is excess to the normal cell structure.
I stand on a stool, watching as Jonathon cuts deeper into the muscle. The rectus abdominis yields to the unrelenting diatherm and allows him access to the peritoneum and the abdominal cavity. There it is, the uterus, itself now become ‘excess’. Amanda holds it in her hand. “Look” she says as she gently lifts it towards me, “and here are the ovaries”.
Fat, organs, tissue, all spill over the edges of the now gaping wound. Colours mingle at all levels of the ‘warm’ scale. I am shocked – no, not shocked – more bemused to witness what appears as a mess, a fluid ‘jumble’ of organs that belies the naïve impression that I now realize I have always held that inside we are very orderly and self-contained. Art takes precedence over science here as the boundary between order and disorder becomes confused. Either way the relationship between the two is here emphatically demonstrated through the idea of structure, the structure of the body in this case, which becomes simultaneous with function through the overall concept of process.
Jonathon and Amanda push the organs around with their hands, bullying them into compliance as they try to force them into the chest and pelvic cavities in order to isolate the uterus. But the organs keep spilling back out as if defending, even nurturing the one that is the object of attention. Yet more wadding is pushed in to hold back the tide, up into to the chest and down into the pelvis. Finally, with his arm up to the elbow inside the passive form Jonathon, like Canute, pushes and shoves with a physical force that promises a painful recovery. I am stunned by the seeming violence of it all, the brutality, the deeply and bloodily visceral reality of scene. The edges of the wound are pulled wider open with clamps that grasp the bloodied flesh and become bloodied in their turn. Now, the diatherm, held lightly first in Jonathon’s hand, then in Amanda’s probes and cuts on respective sides of the pelvic cavity, now an empty space devoid of organs and ‘excess’, save the hapless uterus, the one, which is soon to become the other. It sits isolated, bounded by smooth, ‘slippery’ walls that shine and appear translucent and yet opaque at the same time. It looks so small, so vulnerable under the threat of the diatherm, and the ovaries, white and tiny, are hiding, sheltering, in the darkness of the void.
The violence of the procedure is salutary in terms of my understanding. The pushing, the shoving, the manipulation of the bodily structures and organs, bloodied tools that are first discarded, then retrieved, then put into service to cut, to staple, to open and to close, all this is played out in front of me in sanguine ritual. The same blood pools in the crevices on the body and on the floor at Amanda’s feet, small bits of the flesh that it once made red are thrown up onto the green sheet, or down onto the floor. This is not clean, not clinical; this is raw, visceral, almost primeval. It feels… it feels. This is the unadulterated, non-sugar-coated authenticity of surgery; the cutting, the slicing, the pushing and the pulling, the packing, the mopping up… and it is all the raw bloodiness of real flesh, real wounds; nature rent and protesting. The body, once a closed space of quietude and privacy, now wide open, stretched, clamped and ‘mined’ for the tumours that threaten its very existence as they create of the acting Self (that part of being human which here, in this theatre, is absent) Sontag’s ‘non-self’.
I draw nearer to see as best I can while careful to avoid any contact with the green sheet that protects the human being who has become subject to – or is it object to –this therapeutic violation. Standing beside Amanda, I have a clear view of how she works, now with force, now with gentleness, but always with dominance. The body submits. Once the surface and the underlying defences have been breached there is little to resist the relentless subjugation of its autonomy. The chest is rising and falling gently however, normality and regularity at least in this respect confirmed by the anesthetist who watches the fluctuations of his parallel and multi-coloured digital lines.
Carefully now, the surgeons begin to work more slowly and delicately. Brutality is replaced – in the details – by the sensitivity that must dictate the smallest and most intimate of incisions. They need to explore, to single out the pelvic lymph nodes, the arteries the nerves. They are suspicious. The cancer may not have settled only in the cervix, there may be subsidiaries, so, like Selzer’s ‘predators’ on the prowl they move quietly, deliberately, stalking the prey, the obscure ‘lumps’ of flesh that have become firm to the touch and thus differentiated from the soft masses within which they hide.
And so they delve with life-preserving precision into the depths of the body, first one side then the other, moving slowly, constantly aware of how far they can to go before breaching a physical boundary impossible to cross with any hope of returning. The main tumour will be taken coldly and cleanly with the uterus, an eradication of the very taproot of the cancer’s existence, but its morbid potentiality may lie in the lymph nodes. Carefully then they search, steadily and without pity, isolating, feeling, cutting, debating, and moving on. They take various samples, all of which ‘feel’ benign, and then, there it is. A tiny lump of bloody flesh is dropped into a plastic vial and a phone call is made. This sample they are not so sure of, they need to do a ‘frozen section’. The operation has to be delayed while they await the result of the analysis because, they tell me, if it is positive there’s no point in going on. I feel suddenly cold although it is very warm in the theatre. They switch off the lights.
She is under anaesthetic for eight hours. I have to leave, and Amanda does another operation, the next lady on the list, while her first lies covered with the wound open but packed with the endless wadding paper while the sample is sent to the lab. I receive a text later in the evening. The sample was negative and they completed the hysterectomy. They left one ovary.