S ky a stone

‫גרוס‬ ‫סקיי‬
Advances in Medical Sociology
Emerald Book Chapter: A Stone in a Spaghetti Bowl:The Biologicaland
MetaphoricalBrain in Neuro-Oncology
Sky Gross
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To cite this document: Sky Gross, (2011),"A Stone in a Spaghetti Bowl: The Biological and Metaphorical Brain in Neuro -Oncology",
Martyn Pickersgill, Ira Van Keulen, in (ed.) Sociological Reflections on the Neurosciences (Advances in Medical Sociology, Vo lume
13), Emerald Group Publishing Limited, pp. 99 - 119
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A STONE IN A SPAGHETTI BOWL:
THE BIOLOGICAL AND
METAPHORICAL BRAIN IN
NEURO-ONCOLOGY
Sky Gross
ABSTRACT
This chapter presents findings of ethnographic work in a neuro-oncology
clinic in Israel. It is claimed that patients, close-ones and physicians
engage in creating metaphorical visions of the brain and brain tumours
that reaffirm Cartesian dualism. The ‘brain talk’ involved visible and
spatial terms and results in a particular kind of objectification of the
organ of the self. The overbearing presence of visual media (i.e., magnetic
resonance imaging, computed tomography, angiographic studies) further
gave rise to particular forms of interactions with patients and physicians
where the ‘imageable’ (i.e., the image on the screen) became the
‘imaginable’ (i.e., the metaphor). The images mostly referred to a domain
of mundane objects: a meatball in a dish of spaghetti, a topping of olives
over a pizza, the surface of the moon, a stone, an egg, an animal, a dark
cloud. Furthermore, conversations with family members showed that
formal facts and informed compassion were substituted by concrete
representations. For them, and especially for the patient, these
representations redefined an ungraspable situation, where a tumour – an
Sociological Reflections on the Neurosciences
Advances in Medical Sociology, Volume13, 99–119
Copyright r 2011 by Emerald Group Publishing Limited
All rights of reproduction in any form reserved
ISSN: 1057-6290/doi:10.1108/S1057-62 90(2011 )0 0000 1300 9
99

100 SKY GROSSA Stone in a Spaghetti Bowl 100
object – can so easily affect the organ of their subjectivity, into something
comprehensible through the materialistic, often mechanistic actions of
most mundane objects. This, however, also created alienated objects
within the boundaries of their own embodied selves. Patients, on the one
hand, did not reject their own sense of ‘own-ness’,of having a lifeworld
(lebenswelt) as subjective agents, but on the other, did talk about their
own interiors as being an ‘other’: an object visible, observable and
imaginable from a third-person standpoint – a standpoint drawing its
authority from biomedical epistemology and practice.
The brain is a world
consisting of a number of unexplored continents
and great stretches of unknown territoryy.
To know the brain is equivalent to ascertaining
the material course of Thought and Will,
to discovering the intimate history of Life
in its perpetual duel with external forces.
–Santiago Ramon y Cajal (1852–1934), neurologist
Recent studies in the social sciences and humanities have provided us with
endless illustrations of the centrality of the brain and ‘‘the paramount cultural
and material importance of the mind’’ (Webb, 1998, p. 1) in Western culture
and biomedicine. Nowhere is this more apparent than in considerations of
‘brain dead’ humans. Such individuals tend to be viewed as having lost their
personhood, and come to be referred to as ‘‘beating heart cadavers’’ or
‘‘neomorts’’ (Kaufman, 2000; Lock, 2002; Ohnuki-Tierny et al., 1994;
Youngner, 1989). The expulsion from society of brain injured or brain dead
individuals has further been associated with the particular features of the brain
as an organ rich in meanings that are central to Western society (Webb, 1998).
Popper and Eccles’ (1977, p. 177) point to the almost truism according to which
a transplantation of a brain into another’s body would amount to the complete
‘‘transference of the mind, of the self’’ into the latter. This idea, says Vidal
(2009, p .6), amounts to the modern doxa that ‘‘the brain is the only part of the
body we need in order to be ourselves’’. This is further exemplified in the notion
of the ‘‘brain in a vat’’ (Bernal, 1929; Dennett, 1979; Putnam, 1981) – human
but not embodied – and science-fiction themes of brain swapping (Vidal, 2009).
Then, in the Western world, the brain – rather than the body as a whole – seems
to hold supreme in contemporary definitions of selfhood and subjectivity.
Commonsense suggests that, if the brain is so significant to the perception
of our selves, facing a brain tumour diagnosis should demand the most
complex types of (re)conceptualisation of this ‘self’. This chapter, however,
shows a different picture. Most patients with brain tumours tend to see the

diseased brain as yet another diseased organ, all the while admitting that it is
probably the site of ‘‘who they are’’ (cf. Pickersgill, Martin, & Cunningham-
Burley, 2011). This, I will show, is based on a particular form of
objectification, where the ‘self’ is split into two elements: one that is indeed
grounded in the brain, and another that is completely separated from the
soma, and which may reflect on neurological pathology as if the brain was
just like any other object, biological or otherwise.
I shall further draw on elements of mind-body philosophy to claim that
processes of visualisation of brains as objects with distinct and sensuous
qualities run along a Cartesian logic of transforming ‘res cognitas’ into ‘res
extensa’. Indeed, if superposed onto ontological dualism, an ethereal idea of
the ‘brain’ could then be assigned properties of ‘matter’ by converting it into
a body spread in space and holding assignable qualities: a res extensa. In
other words, it is the visible and the locutionary that allow for a
materialisation (or ‘objectification’) of the non-material fraction of this
Cartesian self. Patients will thus adopt biomedical conceptualisations –
where spatialisation and sight are key – and apply self-objectification to the
organ of the self, to the organ of their selves.
In the neuro-oncology clinic considered here, Cartesian dualism is
ubiquitous. As shall be elaborated on throughout this chapter, it involves
the use of spatial metaphors and media to portray the cerebral organ in
doctor-patient interactions. On the one hand, creating images in the form of
narratives and metaphors – ‘imagining’ – translates what one patient
referred to as the ‘‘thing in my head’’ into a mundane object, approachable
through non-expert forms of knowing. On the other hand, ‘imaging’ in the
technoscientific sense may render a naturalistic, commonsense form of
knowing into analytic, authoritative objectification, and thus transforming a
non-scientific ‘object’ into one fully approachable to scientific exchange
(Lynch, 1988). Both do not only create the image but also create the object
of the image: the image becomes the object in and of itself. This chapter
considers these exchanges as based either on objectifying metaphors, or
visual and two-dimensional technological apparatus. To this end, I will
bring empirical evidence to bear on the ways conceptualisations of selfhood
and the brain articulate with one another.
METHODOLOGY
In the first half of 2006, I followed the work of members of a neuro-
oncology outpatient clinic situated in a large hospital in Israel. The team

consisted of four neuro-oncologists, a head nurse, a social worker, and a
neuropsychologist. The neuro-oncologists were observed during routine
consultations, in rounds in the inpatient ward, and in the course of three
weekly professional conferences. A lengthy period of negotiation and
clarification with the head of the clinic led to the gradual gaining of the
staff’s confidence. Formal permission from the hospital’s Helsinki ethics
committee allowed me to begin my work. By the end of this process, I was
accorded access to the innermost stages of the clinic.
I spent some 20 hours a week at the clinic, where I gathered extensive field
notes (simultaneously translated and composed in English) along with both
formal interviews and casual exchanges with staff members, patients and
close-ones. Forming a small proportion of the data collected, thirteen
formal interviews – four with neuro-oncologists, two with family members,
and seven with five different patients – were later transcribed verbatim. In
the extracts from these interviews that I draw on for this analysis,
anonymity is ensured by the use of pseudonyms, for both patients and staff.
The field data was analysed so as to identify recurrent themes. I was
especially concerned with the dynamics of the exchange of information
among different team members and patients. In line with ‘grounded theory’
methodological approaches, the analytical scheme was built and refined in
constant conjunction with the empirical data, and the data itself came to be
read with this scheme in mind.
SOMETHING ABOUT BRAIN TUMOURS
A brain tumour presents itself through various neurological signs and
symptoms, which may include epileptic seizures, total or partial paralysis,
speech malformations, visual disturbances, loss of sensation in the limbs, or
personality changes. Reporting diagnostic information such as biopsy and
magnetic resonance imaging (MRI) studies, along with clinical impressions,
allow neuro-oncologists to determine the locality of the tumour, its size, the
types of cells involved, and its degree of malignancy.
This process begins with the first encounter between neuro-oncologist and
patient. It starts with a fairly ritualistic intake of new patients, where the
neuro-oncologist assesses previous findings, gathers clinical history, and
performs a physical examination. Treatment options are deliberated among
a relatively wide array of biomedical professionals, from neurosurgeons to
radiologists to general oncologists. Routine assessments of cases are
typically performed in the course of three weekly conferences: one with

the radiology experts, a second with the neurosurgery team, and a third
inner meeting. Patients attend the clinic up to once a week while under a
radiotherapy regime, and once a month when under chemotherapy. They
are typically referred to imaging tests every few weeks. As most brain cancer
patients remain uncured, diagnosis is literally a lifelong process.
Types of Tumours
Brain tumours can be classified as either primary – that is, forming in the
brain itself-or secondary (‘metastatic’) – originating from a cancerous
process elsewhere in the body. Tumours found in the brain typically do not
involve growth of nerve cells (unlike liver tumours, for instance, which do
involve the growth of liver cells), but rather of cells supporting neural
activity: glial cells. The largest group of primary brain cancers is referred to
as ‘gliomas’. Gliomas involve abnormal growth of glial cells and include
four main categories of tumours, based on the types of the underlying
cellular formation and the location of the tumour: ‘astrocytomas’ (the most
common), ‘ependymomas’, ‘medulloblastomas’, and ‘oligodendrogliomas’.
All tumours are assigned a ‘grade’, that is, a I–IV classification based on the
speed of growth, the presence of necrosis (dead tissue), the number of blood
vessels providing nutrients to the tumour, and the level of differentiation
(pathological deformation) of the cells. Grades I–II tumours are considered
benign, although they may become more aggressive at a later stage of
growth. Grades III–IV tumours are referred to as ‘anaplastic astrocytomas’
or ‘glioblastomas’, respectively. Anaplastic astrocytomas typically progres s
to become glioblastomas (GBM), which are deadly tumours, often giving
the patient a life expectancy of mere weeks.
Treatment
The term ‘treatment’ in neuro-oncology may be misleading. With the
exception of a number of first grade tumours, and although it may take
decades, the progress of the mass is inevitable. Treatment is thus intended to
prolong life or to better the patient’s quality of life, rather than ‘cure’ the
disease. There are three main types of interventions, provided usually in this
order: surgical resection, chemotherapy and radiotherapy. Surgical inter-
vention is seldom able to remove the entirety of the mass’ tissues:
microscopic malignant cells almost always remain to begin the growth

anew. In most cases, the benefit of surgery must be weighted not only
against the risk involved in any serious operation, but against the
neurological deficits that may result from its inevitable assault on the
brain. Another form of treatment involves chemotherapy. The brain keeps
most chemotherapeutic agents out, through what is called the ‘blood brain
barrier’, which protects the brain from noxious intrusions. Temozolomide is
the one agent that is able to reach brain tissue and comes in a form of tablets
self-administered, at home. It does not cause hair loss and has in fact few
side-effects; thus, the patient may at this point be free of the typical ‘cancer-
look’ that affects self-definition and social stigma of cancer-afflicted
individuals. Radiotherapy is typically administered daily for a number of
weeks, in the course of which the patient is to meet the neuro-oncologist
weekly and give blood on a regular basis. Unlike Temozolomide-bas ed
chemotherapy, radiotherapy causes several side-effects (the severity of which
depends on the dosage and areas being targeted), including hair loss,
extreme fatigue, burns on the scalp, oedema, and more. The series of
treatments is usually given once in the entire course of the disease. It does
not have remedial powers but usually does contribute to the shrinking of the
tumour or to a slowing of its growth.
Symptoms relief is another critical aim. Steroids are provided for the
relief of oedema, thereby allowing relief of epileptic seizures and in-
tracranial pressure (a situation that may be merely uncomfortable at first,
but will eventually cause death). Epileptic seizures are also treated with
anti-epileptic drugs, some of which must be continuously accompan ied
with a monitoring of the active agent’s level in the blood. A major sign of
brain cancer is the loss of strength (paresis) or paralysis of one or more
limbs and/or enervated body parts. These symptoms may at times be
somewhat relieved with steroids-agents that are often devastating for
many body systems. Steroids further cause a typical bloated look, making
patients and those who surround them acutely aware of the deteriorat ing
quality of the condition. Palliative and supporting care is offered once the
treatment panoply has been exhausted. Here, neuro-oncologists can only
follow from a distance the care provided to the patient in a hospice or at
home.
There is relatively little pain involved in dying from a brain tumour,
unlike with most other types of tumours. The end may be uncomfortab le,
when more basic functions begin to deteriorate, especially breathing.
However, in general, the process is gradual and loss of consciousness usually
appears before the patient has the chance to enter the more agonising stages
of dying and bodily deterioration.

THE BIOMEDICALISED AND THE VISUALISED
Mind–body dualism have been accompanying Western society for centuries.
The development of modern science has further added to the conundrum by
assigning the body an ambiguous epistemological and ontological status:
while considered to be one object among others, it nevertheless holds onto
its singular position as the locus of subjective consciousness (Lanigan,
1995a, 1995b; Merleau-Ponty, 1962; Sartre, 1956). Social scientists have
repeatedly shown how biomedicine tends to refer to the body in terms of
matter, whilst overlooking subjective experience (Cartwright, 1995; Lock,
1997; Martin, 1994). Scholars have further associated biomedici n e ’s
practices and epistemological bases with stances of depersonalisation and
objectification of the patient (Scambler & Higgs, 1998; Scheper-Hughes &
Lock, 1987; Thornquist, 1997). This problematic is perhaps best exemplified
in Foucault’s writings:
The presence of disease in the body, with its tensions and its burnings, the silent world of
the entrails, the whole dark underside of the body lined with endless unseeing dreams,
are challenged as to their objectivity by the reductive discourse of the doctor, as well as
established as multiple objects meeting his positive gaze [y] thus the articulation of
medical language and its object will appear as a single figure. (Foucault, 1975, p. xi)
Arguably, this tendency toward objectification has seen biomedicine
centre its attention upon the body as a material entity (Dew, 2001;
Eisenberg, 1977; Mishler et al., 1981), where it is treated as a machine and
deemed observable through expanding scientific technologies and knowledge
(Arney & Bergen, 1984; Synott, 1992; Walters, 2004). This scientific reality
need not be in accordance with ‘everyday thought’: its objectivity is achieved
and not merely ‘‘experienced’’ (Bachelard, 1984 [1934]). It is the product of
the categories of thought, techniques and methodologies through which it is
asserted and by which it creates ‘‘objects of objectivity’’ (Boumans &
Beaulieu, 2004).
Yet, different actors (e.g., physicians from different specialities, or even
patients) within a given field may enact different ‘styles of reasoning’
regarding the same object, including varieties of deduction, experimenta -
tion, observation, and helpful analogies. Thus, by ‘looking’ at the same
‘thing’, a field may create quite distinct objects, or ‘kinds of entities’ – each
with its own boundaries, attributes, and relations with other objects
(Hacking, 1982, 1992). Such kinds of entities become truths once articulated
through the techniques of medical testing and evaluation.

One important way to do this ‘objectivity work’ involves visualisation,
which will stand at the centre of this chapter. Visualisation involves high
technology processes, including radiological practices, as well as use of
metaphors and analogies. Thus different ‘images’ – one in the sense of
‘imaging’, the other in the sense of ‘imagining’ – are key components in the
conceptualisation of brain, self, and pathological processes: all revealing the
‘‘dark underside of the body’’ (Foucault, 1975, p. ix).
Through several technological developments, namely in the ﬁeld of
neuroscience, the last decades produced media through which the brain can
be visualised, creating seemingly ‘ready-to-read’ maps of the mind. Indeed,
brain scans seem to increasingly be replacing other explanatory representa-
tions of mental phenomena in most professional journals, and in the clinic
(Racine, Bar-Ilan, & Illes, 2005). This power is grounded by several broad
cultural stances, including the medicoscientiﬁc tendency to regard sight as
evidence, with ‘‘seeing’’ being almost inseparable from ‘‘knowing’’ (Lynch &
Woolgar, 1990; see also Draper, 2002; Dumit, 2004; Jenks, 1995; Joyce,
2006).Vision is then understood to be an unmediated perceptual source of
knowledge: images themselves purportedly reveal a map, detailing routes
that lead to non-interventional access to the truth (Foucault, 1963; see also
Cartwright, 1995; Daston & Galison, 1992; Knorr-Cetina & Amann, 1990).
Thus, although the MRI is necessarily a mediated view of the patient,
technicians and radiologists seek to eliminate this very mediation by
creating an object: the ‘thing’ that they look upon becomes the ontologically
asserted ‘real thing’ and make its subject transparent (Boumans, 2004;
Duden, 1993; Rohrer, 2007). As the visual is alleged to provide the most
authoritative access to the object of disease, radiology represents the
epitome of diagnostic science (Burri, 2008; Gross, 2009; Gunderman, 2005;
Joyce, 2008). In fact, some may claim that radiology makes things ‘‘more
real than real’’ or ‘‘hyperreal’’ (Baudrillard, 1988; Frank, 1992); that is,
more accurate than any direct assessment – including subjective assessments
by the patient (whom one may even consider as the object itself). Removing
the personal particularities of the patient enables a more clear-cut alignment
with existing nosological categories, thereby clearing what we might refer to
as the ‘fuzziness of reality’ and gaining a halo of pure science (Foucault,
1963; see also Bourdieu, 1977; Rosenberg, 1999; Thompson, 1995).
Supposedly ruling out interferences and interpretations not intended by
the reader (Ala, 2004; Bastide, 1990), MRI creates the artefact that will
replace the original ‘something’ and be present within the space in which the
clinical exchange occurs. Imaging techniques provide a language and a set
of artefacts (i.e., the black and white pictures so characteristic of the

technology) that allow both patients and doctors to ‘speak of’ and represent
the disease. It is through processes of ‘‘translation’’ (Callon, 1986; Latour,
2005) that communication is made possible: by the mutual – albeit not
necessarily equal – adoption of a particular language and logic, of ways in
which the object is ‘talked about’. Within the setting discussed here, the
brain is spoken of through both mundane metaphors and concepts of
spatial extension. This, I believe, is also grounded on a long history of
spatialisation.
THE SPATIAL BRAIN
The Origins of the Spatial Brain
The actual scientific study of the brain and its relation with complex
behaviour may be viewed as commencing in the 1870s with Gall’s
phrenological theory, which linked brain structures to personality traits
(Barker, 1995). This theory (soon declared ‘pseudoscientific’) advanced an
idea according to which mental functions (37 overall) had a specific
topographical repartition on the cortex, with the most developed functions
forming a visible protrusion on the exterior of the skull. Thus, by feeling the
skull, the phrenologist will have access not only to the elusive brain but also
to the subject’s psychological realm.
Although short-lived, phrenology saw a golden age where it flourished
throughout Europe and the United States and enticed much attention in
both lay and scientific spheres (Hall, 1977). As well put by Grant (1968,
p. 299), it may well have owed its popularity to its alleged capacity to
‘‘understand and reveal the mind’s secrets at the touch of a hand, thus
solv[ing] at one stroke the problem of the mind’’, and to its proposing ‘‘a
complete and accurate picture of the nature of the mind and at the same
time defin[ing] and fix[ing] its functions’’.
Also in the nineteenth century, and equally interested in revealing the
functions of the mind in relation to the brain, researchers such as Broca,
Fritsch and Hitzig began to identify specific locations in the brain for functions
such as speech and sensomotor activity. Hughlings-Jackson followed with
the notion of the homunculus, where one could identify the somatopic
distribution of body parts along the motor cortex; that is,the representation of
the body over the outer layer of the brain. This reaffirmed a localised view of
brain activity and its possible representation of not only the human body, but
also the human mind – including thought, perception, feelings (Barker, 1995;

Kolb & Whishaw, 2003; Macmillan, 1996). While the phrenological under-
standing of ‘higher’ brain functions (such as creativity, imagination or
personality) still lingered, localisation was able to challenge a nebulous notion
of the mind as a vague spiritual essence, and assert its fundamental form as
purely material. Indeed, for Gall, the ultimate localisationist, one should
forever seek to ‘‘grasp the material conditions of the immaterial principle’’
(Gall, 1808, p. 5).
With a similar goal in mind, modern neuroscience collects data targeted at
describing precise locations correlating with thought, feeling and behaviour.
Indeed, while also incorporating other, non localisationist models, ‘‘the
issue of localisation in the brain is now, more than ever, a topic of
importance’’ (Bjaalie, 2002, p. 322). Such practices continue the phrenolo-
gical mission of reading the internal through the external, thus bringing the
invisible into sight. In its drive to quantify the qualitative and to make the
private public, the localisation of mental phenomena reflects a culture
structured by Cartesian thought.
Spatial Components of Brain Tumours
In the case of brain tumours, the placing of the pathological process within
the space of the body is key: a good clinician will have to ‘‘thin k
anatomically’’ (Good, 1994, p. 73). The clinical gaze requires the turning of
the body into ‘‘a space, whose lines, volumes, surfaces, and routes are laid
down, in accordance with a now familiar geometry, by the anatomical atlas’’
(Foucault, 1975, p. 8). ‘Textbook’ information very much reflects this
localisation tendency.
At the most basic level, the brain can be divided into six primary regions ,
each controlling specific functions. The brain stem is the pathway between
the brain and the spinal cord, where sensory and motor nerves descend and
ascend from and to the rest of the body to controls visceral functions (heart
rate, digestion) and basic alertness. However, since so many nerves go
through the brainstem, pathologies associated with this area can cause
almost any form of symptoms. Above the brain stem is the cerebellum which
is associated with balance, posture, and eye movement. The frontal lobes are
responsible for organising thoughts, planning, problem solving, self-control
and moral judgment. The posterior parts of the frontal lobes also hous e
nerve cells that produce movement. Patients suffering from tumours in or
near the frontal lobes may exhibit motor deficiencies, but may also suffer
from extreme personality changes. Presence of pathology in the occipital

lobes (located in the mid back of the brain) can cause partial blindness or
the inability to recognise shapes, colours, or faces. The parietal lobes are
located behind the frontal lobes, and at the top of the brain. They control
our sense of touch, our feelings and understanding of weight, size and
texture, as well as much of our cognitive comprehension of the world.
Tumours affecting the right parietal lobe can cause a lack of spatial
orientation and may hinder the ability to recognise one’s own body.
Tumours affecting the left parietal lobe can cause difficulty speaking or
difficulty understanding speech. Finally, the temporal lobes, located on the
right and left side of the brain (near ear level), help us distinguish smells and
sounds, and may be involved in the experience of fear. The right lobe is
primarily responsible for visual memory while the left controls verbal
memory.
As noted above in the ‘textbook’ like information, this focus on the body
as a map is derived from the superposition of the conceptual order of
disease, with its assigned logic of symptoms and nosological organisation,
onto the solid, present body: the ‘‘concrete body, that visible whole, that
positive plenitude that faces him – the patient’’ (Foucault, 1975, p. 9). This
order of disease thus advances a rational construct that defines relations
between first-hand experienced symptoms and objectively-reachable somatic
spaces, the flesh, the black and white MRI image. As shall be argued below,
the nature of the neuro-oncological disease makes this process particularl y
powerful.
A Space Defined Disease
Brain cancer is an organ-defined non-systematic disease. Gliomas spread
spatially as ‘chunks’ of cells and are unlikely to colonise, or metastasise
throughout other parts of the body. Also, symptoms tend to correlate with
the surfaces of the brain affected by the disease. As discussed above, when,
for instance, sensomotors systems are affected, symptoms affect specific
body parts that point to the location of the tumour in the brain, to its
spreading, to the rate of its spreading, and to the spatial characteristics of
the spreading.
Case presentations are illuminating in this respect. Professional meetings
reveal two important processes: the first meshes the ‘case’with the ‘patient’
and the second constructs the disease as the object of medical practice
(Anspach, 1988; Good, 1994). Although having long lost its grasp on the
patient, the information is exchanged in a way that is coherent with the
direct clinical encounter, based on concepts of space and visibility. When

speaking of a patient’s pathology, physicians often uses gestures that point
to the area of the brain involved rather than to the location of the
symptomatic revelation of the tumour. For instance, when Dr. Lise left
Simon’s room and discussed his condition with her colleagues, she naturally
placed her hand on the left side of her skull, rather than where the (very
visible) paralysis was (i.e., on the right side of the face). The patient’s
narrative was then transformed into ‘‘disease processes, localized spatially in
disease tissue lesions and disordered physiology’’ (Hardman, 2010, p. 38).
The patient was then represented as the site of this process, and the process
as a site within this site (ibid.).
Cancer and Metaphors
The overbearing presence of cancer in our lives, and the failing of medicine
to fully treat, cure, and control the disease gives it a particular position in
society where metaphorical language thrives (Reisfield & Wilson, 2004).
Looking specifically at medical metaphors, Van Rijn-van Tongeren (1997)
for instance, shows the functions they may be serving: they can both provide
a vocabulary to speak of disease (catachretic metaphors), explain to another
(didactic metaphors), and structure relatively unclear phenomena (theory-
constitutive metaphors). Metaphors alter the concepts, knowledge, beha-
viour and attitudes we have; they work to make graspable and effective that
which is not pre-given as such. This is achieved through the use of several
worlds of meaning, which have also been the interest of research. Thes e
works and others have also analysed the use of metaphors in cancer in
relation to the worlds of meaning they refer to. Source metaphors of the
disease often involve war and battles (against the intruder, the tumour),
concepts of a journey (through the illness trajectory), or detective stories
(where diagnosis is sought) (Hodgkin, 1985; Reisfield & Wilson, 2004;
Sontag, 1978). Although readily seen in the field, these metaphors do not
feature prominently in this analysis. Instead, I focus on how patients and
those close to them regularly drew on metaphors of everyday objects (a
stone, a bubble) to describe cancer and its locus – the brain – thereby
distancing the self from the organ ‘gone wild’.
OBJECTIFICATION IN THE CLINIC
Through practices such as surgery, clinical examination, and history taking,
a lived, subjective, ‘‘presence in the flesh’’can be transformed into a medical

body (Young, 1997). Other components, however, may be central to the
spatialisation and objectification of self and disease.
Turning the Screen
In neuro-oncology, one of the most important methods of tracking the
disease is through the use of MRI and the comparison of tumour growth
and visible characteristics over the disease trajectory. This might explain
why so many consultations observed included a typical script where the
physician would load the MRI picture on the screen, observe it, and then
turn the screen towards the patient. The sharing of the ‘image’ of the disease
may be more than a didactic device. It seems to involve the exercise of what
Bourdieu calls ‘symbolic power’: ‘‘the power of constituting the given
through utterances, of making people see and believe, of confirming or
transforming the vision of the world’’ (Bourdieu, 1992, p. 170; see also
Bos, 2004). It induces a specific form of objectification on the part of the
patient – a ‘brain talk’ that would assert the biomedical object ‘placed on the
table’.
As will be claimed here, ‘brain talk’ was created through the conception of
the brain tumour in visible and spatial terms and resulted in a particular
kind of objectification of the organ of the self. Visual media (i.e., MRI,
computed tomography, angiographic studies) more often than not gave rise
to particular forms of interactions with patients when having exchanges with
me, and by the physicians (mostly during the radiology meetings). Thes e
included metaphors that referred to a domain of mundane objects: a
meatball in a dish of spaghetti, a topping of olives over a pizza, the surface
of the moon, a stone, an egg, an animal, a dark cloud.
Mundane Language and Metaphors
As succinctly put by Lakoff and Johnson (1980, p. 5), ‘‘the essence of
metaphor is understanding and experiencing one kind of thing in terms of
another’’. The translation of the brain tumour as an abstract entity, not
directly observable by the sufferer, into a physical, visible mundane object is
a metaphorical process of creating and sustaining a conceptual – or even
ontological, radical constructivists would assert – world around a less
graspable reality. Metaphors in general involve concepts from the familia r
and concrete world to refer to more abstract and fuzzy realms of notions

and ideas. Whilst metaphors do not necessarily reintroduce subjective
meaning to disease, they provide other means of objectifying it in ways that
intuitively ‘make sense’.
The metaphorical transformation of the brain is exemplified in the case of
Lea, a 25-year-old woman, with advanced cancer. Her husband, Albert,
accompanied her along with her mother to the office of Dr Franz, a neuro-
oncologist. Lea sat on a wheelchair, completely lethargic, smiling emptily
when spoken to and dozing when not. Dr. Franz read the file according to
which Lea had just completed a round of radiotherapy. Yet, she appeared to
be in considerably worse health than the last time he saw her. Dr. Franz
looked at the MRI image and without uttering a word, turned the screen
towards Albert: ‘‘Look’’, he said. Albert remained unsure of what he was
supposed to ‘look’ at, but understood that something must be wrong. This is
when Dr. Franz solemnly announced:
The radiotherapy had no effect. In fact, the tumour has grown, and surgery is now
impossible: the tumour takes on half of the brain.
‘‘This’’, Dr. Franz pointed at the screen, now more clearly drawing
around the edges of the tumour, ‘‘explains how she is’’, as if the image
contained knowledge that was easily accessible even to the untrained eye.
In response, Albert asked, ‘‘Couldn’t you vacuum it out, like in a biopsy?’’
Dr. Franz bluntly answered, annoyed by the naıve question: ‘‘This is not a
liquid! You would suck up all the brain out!!’’ Clearly, Albert’s
metaphorically mediated imaginary of the disease based on its image was
not one Dr. Franz expected or endorsed. One must note that Dr. Franz is
not exceptionally blunt when compared to other physicians’ attitudes in
clinical exchanges. This presentation reflects ordinary microsocial events in
this field.
Family members and close ones deal with many challenges. A central
concern is the fragmentary knowledge of their loved one’s experience and of
the medical aspects of the disease. They are often kept out by the patient
her/himself, while the medical staff tend not to be generous in providing
information – especially when asked for an evaluation of the patient’s life
expectancy. Conversations with family members show a trend, by which
formal facts and informed compassion toward their loved one, are
substituted by concrete representations. This process of objectification
provides both a representation and a narrative, a metaphorical story of a
disease (Dennett, 1992; Sontag, 1978). These redefine an ungraspable

situation into something comprehensible through the actions of most
mundane objects:
What I remember about my father’s brain tumour is the surgeon telling me that his
surgery was like trying to remove a small stone from a bowl of spaghetti. (Jane, a student
in her twenties, daughter of Phil who is now at the terminal stage of brain cancer)
My son’s skull is like a closed box. I can just picture it: once the tumour gets big enough,
his head will explode. (Dina, mother of Sean, 25, under chemotherapy)
Brain cancer is thus very much referred to as an ‘it’ – a discrete thing rather
than as a process. The reference to an ‘it’ emphasises several characteristics
assigned to cancer: one can ‘get rid’ of ‘it’, and a removal of the ‘it’ is a sine qua
non to cure. One can thus draw a relatively solid line around the pathological,
and keep the ‘normal’ untouched (Cassells, 1976; Hodgkin, 1985).
The separation between the self and the disease takes form not only in the
use of metaphors, but also in the raising of common anecdotes. One patient,
Sahid, narrated his disease through focussing on his ﬁrst seizure. It
happened while he was casually smoking a cigarette in his tent (Sahid is of
Bedouin origin). What he describes as a complete loss of control could have
easily led to the burning down his and his family’s home – the safety of
which he feels is his responsibility. The ‘thing’ took control by its very
unpredictability. Such a story is typical in that it portrays the disease as ‘‘an
object that has befell upon’’ the patient, rather than as a bodily process that
is enmeshed within his own notion of self. Another patient, Rona, was
playing with the children in her son’s kindergarten (‘‘I don’t know if the kids
thought I was playing a game’’); Shlomi was walking down the stairs at his
mother’s house (‘‘I’ve always hated those stairs’’); Nathan was brushing his
teeth (‘‘I felt my head was going to tear out of my body and fall into the
sink’’): none had any sense or experience of a process going on in their
brains. The seeming whimsicalness, the suddenness, the randomness of the
attack in familiar settings all contribute to the concept of an outside
intruder, completely out of synch with their ‘lifeworlds’.
Throughout the disease journey, the brain and its extension – the body –
take on a life of their own: where the brain is involved, the symptoms are
unpredictable and sporadic. More so, they are to a large extent beyond one’s
control. The brain ‘does what it does’, often at odds with one’s own wants,
expectations and choices. Under these circumstances, ‘self’ will no longer be
readily identiﬁed with this unruly organ, and as a result, the materialist
brain-self equation may be seriously challenged. This may channel patients

toward an adoption of a Cartesian notion of the self – a notion already
embedded within the biomedical setting they are forced to interact with.
The Brain Is Silent
Anthropological studies of pain and illness have contributed to our
understanding of the subjective, lived aspects of disease (see, for instance,
Good, 1994; Hardman, 2010; Scary, 1985; Schutz, 1970). These works
consider the ways in which suffering shatters the patient’s commonsense
experience of the world and demands a reconstruction of a meaningful
narrative to replace the objective-biological narrative. A person may
consider their body as taken-for-granted, leaving it outside of the scope of
awareness until disease strikes. It is only once an individual is subjected to
unpleasant sensations that this ‘silent’ and ‘recessive’ inner body can be
made ‘visible’. It is through what Leder (1990) calls ‘dys-appearance’ that
individuals come to experience themselves as embodied subjects (see also
Belling, 2010).
A brain tumour, however, does not cause ‘pain’ at the site of the
pathology: there, in the brain, silence remains. Furthermore, the presenta-
tions of brain pathologies seem often detached from the organ in itself, if
only considering their anatomical dispersion across the body. Indeed, the
popular view of the main and warning symptom of brain cancer is
headaches, when in fact any initial indication of cancer will almos t
invariably come in the form of seizures or sensomotor disturbances –
neither of which obviously point to the brain as the locus of disease.
These non-perceptible things, according to conceptual metaphor theory,
need to be subject to metaphorical structuring (Goschler, 2005), creating
alienated objects within the boundaries of our own selves. Their belonging
to the ‘me’ will then be based on their being physically attached to sentient
parts of the body or to keeping the latter functioning. The brain in this
case becomes ‘asomatognosed’, in a way. Asomatognosia is a disorder
where a person’s limb seems to be an object glued onto one’s body, having
nothing to do with her/his ‘self’ (Greenberg, Aminoff, & Simon, 2002;
Tsementzis, 2000). In these cases, patients may go as far as calling this
limb by a name, such as ‘Joe’ or ‘Mary’ (Feinberg, 2006), where in our
case, the brain and the disease located within it will answer to
metaphorical references.
Thus, on the one hand, patients will not reject their own sense of ‘own -
ness’, of having a lifeworld (lebenswelt) as subjective agents but on the

other, they may talk about their own interiors as being an ‘other’; an
object visible, observable and imaginable from a third-person standpoint –
one which draws its authority from biomedical epistemology and practice.
CONCLUSIONS
As is the case in any modern trade, the exchange demands one settled
currency, one particular language, may it be purely biomedical, materialist,
phenomenological – or some flexible blend. How, then, does this exchange
take place? The neuro-oncological encounter demands that brains and brain
tumours be placed in the space separating the physician and the patient, as
objects with specific properties, sets of metaphors and worlds of meaning.
The brain relates to the body in various ways; some are unpredictable,
others work utterly against intuitive logic. A lesion deep within an opaque
skull – only visible through alienating instruments – will not show its
presence at its original site: it would rather reveal itself through another
body part, and will be experienced by the patient as, say, a loss of feeling in
the toes. The brain, the site of endless nervous connections, is itself not
‘experienced’ by the patient. A toe will ‘hurt’, as will other internal organs –
kidneys will also ‘hurt’, for instance – yet the brain finds itself in a curious
position: being the site of subjectivity, yet not an experienced site. This
becomes evident in the findings of this research: the readiness of patients and
close-ones to adopt an objectified brain. Cartesian dualism will then enter
the picture, splitting brain and subjectivity. The self will cease to be
identified to this ‘unreliable’, ‘unreachable’, ‘unpredictable’ organ. The self
will become an abstract notion.
This chapter shows that doctors, patients and their close-ones all engage
in a form of translation where phenomena out-of-sight and out-of-reach
become communicative objects: objects with spatial coordinates (thus
‘imageable’ through high-tech instruments) and objects that belong to the
worldliest spheres of everyday living (thus ‘imaginable’ through lay
experience). The brain becomes a bowl of spaghetti.
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