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Table of Contents

TABLE OF CONTENTS ........................................................................................................................... 1 PART I: INTRODUCING THE WORK ................................................................................................. 5

THE STUDY OF THE HUMAN ANIMAL ................................................................................... 5 THE THREE PAPERS .......................................................................................................... 8

Surgeons of the Mind ............................................................................................. 8 Experts and 'Knowledge that Counts' .................................................................. 10 The World of Brain Surgery .................................................................................. 11

PART II: THE ARGUMENT AND ITS THEORETICAL COMPLEX ............................................... 13 THE MIND-BODY PROBLEM AND CARTESIAN DUALISM ......................................................... 13

Descartes and After .............................................................................................. 13 The Cartesian Fallacy ........................................................................................... 15

INTRODUCING THE GNOSTIC SPLIT .................................................................................... 17 Phenognosis and Ontognosis ............................................................................... 17 The Body and Embodiment: Closing the Great Divide ......................................... 18 Social Studies of Medicine and the Body ............................................................. 20 The Discourses of Truth: Foucault and Beyond .................................................... 22

INTRODUCING REPLICATED BOUNDARIES ........................................................................... 25 The Gnostic Split and Replicated Boundaries ....................................................... 25 Replicated Boundaries: The Professional Grounds .............................................. 26

PART III: SURGEONS OF THE MIND .............................................................................................. 30 INTRODUCTION ............................................................................................................. 30 LOBOTOMY IN MIND: METHODOLOGY .............................................................................. 31

A Historical Approach to the Study of Replicated Boundaries ............................. 31 Reading Psychosurgery ........................................................................................ 32

ON PSYCHOSURGERY ..................................................................................................... 34 CREATING ONTOGNOSTIC LEGITIMACY .............................................................................. 38

'Prehistorical' Sources .......................................................................................... 38 Replicated Boundaries: The Professional and the Legitimate ............................. 40 Building the Heroic Ethos ..................................................................................... 43 The Founding Tale ................................................................................................ 44 Out of the Laboratory .......................................................................................... 46 Men of Science ..................................................................................................... 48 Locating the Mind ................................................................................................ 50 Medicalising the Mind: Symbolic Correlates of Ontognosis ................................ 53

LOSING GROUNDS: AWAY FROM ONTOGNOSIS ................................................................... 57 The Traps of Rhetorics: Facing the Debate .......................................................... 57 The Traps of Science: Methods and Rationalisations .......................................... 58 The Traps of Symbolics: Freeman and the Ice Pick .............................................. 60

FROM THE MEDICAL INTO THE SOCIAL AND BACK AGAIN ....................................................... 62

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Social Control and the State ................................................................................. 62 Dystopic Prospects: Psychiatry in Charge ............................................................ 64 Back to Society: The Social Cure ........................................................................... 65 Illegitimate Interests: The Costs of Mental Asylums ............................................ 67

THE HOMO VADUM ...................................................................................................... 69 The Homo Vadum's Brain ..................................................................................... 71 Corporeality, Pain and Phenognostic Truth ......................................................... 73 Madness and Ontognosis ..................................................................................... 75 The Homo Vadum and Society ............................................................................. 76

CONCLUDING WORDS .................................................................................................... 78 PART IVA: EXPERTS AND ‘KNOWLEDGE THAT COUNTS’(BACKGROUND) ....................... 81

THE NEURO-ONCOLOGY CLINIC ........................................................................................ 81 The Clinic: Spatial Characteristics ........................................................................ 81 Schedules and Organisation of Time .................................................................... 84 The Neuro-oncology Meeting .............................................................................. 85 The Patients ......................................................................................................... 86 The Consultation .................................................................................................. 86 Family Members ................................................................................................... 88

SOMETHING ABOUT BRAIN TUMOURS ............................................................................... 88 Types of Tumours ................................................................................................. 88 Location of the Tumour and Functions Threatened ............................................. 89 Treatment ............................................................................................................ 91

PART IVB: EXPERTS AND ‘KNOWLEDGE THAT COUNTS’ ....................................................... 94 INTRODUCTION ............................................................................................................. 94 METHODOLOGY ............................................................................................................ 95 AT THE CLINIC: THE DIAGNOSTIC PROCESS ......................................................................... 96 MEDICOSCIENTIFIC DIAGNOSIS ......................................................................................... 98 THE WEB OF EXPERTISE ................................................................................................ 101 ON THE ONTOGNOSTIC AUTHORITATIVENESS OF REPORTS .................................................. 102

The Sight of the Tumour: Radiology ................................................................... 104 Sorting Things Out: Histopathology ................................................................... 109 Figuring it out: Neuropsychology ....................................................................... 111 Hands-on: The Clinical Report ............................................................................ 112 The Patient ......................................................................................................... 115 General Oncologists: Peripheral Experts ............................................................ 119 The Neurosurgeons and the Tumour Board: Peripheral Experts ....................... 121

MECHANISMS OF INTEGRATION ..................................................................................... 122 Hierarchisation ................................................................................................... 123 Sequencing ......................................................................................................... 124 Negotiation ........................................................................................................ 125 Peripheralising ................................................................................................... 127 Pragmatism ........................................................................................................ 128

CONCLUDING WORDS .................................................................................................. 132 PART V: THE BRAIN EXPOSED ...................................................................................................... 135 ON NEUROSURGERY AND THE NATURE OF OBJECTIFICATION ........................................ 135

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INTRODUCTION ........................................................................................................... 135 METHODOLOGICAL NOTES ............................................................................................ 138 THE SACRED BRAIN: THE MATTER OF THE GNOSTIC SPLIT ................................................... 139 THE STORY ................................................................................................................. 141

'Prelude' ............................................................................................................. 141 The S-day ............................................................................................................ 144 Under the Skin .................................................................................................... 148 The Peak of Surgery ........................................................................................... 149 Closing up: The last stages ................................................................................. 152 Just a Story ......................................................................................................... 153

LIMINALITIES AND REPLICATED BOUNDARIES ..................................................................... 154 The OR as a Space of Multiple Liminalities ........................................................ 154 The Temple of Ontognosis: The OR .................................................................... 156 Keeping Phenognosis Out: Sterility .................................................................... 157 Anaesthesia: Subduing Phenognosis.................................................................. 159 Space and Liminal States ................................................................................... 161 Going Native ...................................................................................................... 162

GNOSTIC SHIFTS AND 'THEORIES OF MIND' ...................................................................... 165 CONCLUSIONS ............................................................................................................ 167

PART VI: CONLUDING WORDS ..................................................................................................... 170 The Bounded Brain ............................................................................................. 170 A Contemporary and Future Look onto the Gnostic Split .................................. 172

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Macbeth: How does your patient, doctor? Doctor. Not so sick, my lord, As she is troubled with thick coming fancies, That keep her from her rest. Macbeth. Cure her of that. Canst thou not minister to a mind diseased, Pluck from the memory a rooted sorrow, Raze out the written troubles of the brain And with some sweet oblivious antidote Cleanse the stuff'd bosom of that perilous stuff Which weighs upon the heart? Doctor. Therein the patient must minister to himself. Macbeth. Throw physic to the dogs; I'll none of it.

Shakespeare, MacBeth Act V scene iii

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Part I: Introducing the Work

The Study of the Human Animal

Sociology and anthropology have forever sought to

understand the ways in which the individual relates to the world,

let it be 'society', 'nature', the 'other', or any category of entities or

concepts. I believe, however, that one element should have been

given a more respectable place in these endeavours: the

understanding of what the human animal is in his own eyes1. That

is, how does he conceive his experience in the world and how does

he conceive his experience of the world. Can he regard himself as a

thing among others, or can he only relate to himself as an

experiencing subject, distinct from a world-out-there, from which

would stem the things which he will perceive?

The question which will follow us throughout this essay is not

the question of how culture defines the 'self' – in that, this work

would hardly be original. Rather the question here is how the self

defines the self: Which can be said to serve as a basis to what is

known in the world-out-there, and in the world of the self? The

'I' (myself), the 'he' (the 'other'), or rather the 'they' ('society')?

Thus, this essay is about epistemology, in it asking how do we

know what we know. In looking at the world and at the self, which

kind of knowledge 'counts'? And if one is considered more

authoritative than another, how much is this hierarchy contingent

upon cultural settings – at both macro-level and micro-level?

These are grand questions indeed, and being able to attend to

them, at any level, is a challenge in and on itself. It is this very

achievement I sought in the years preceding the writing of this

1 The use of masculine pronouns and possessives was chosen arbitrarily – the text refers to both genders

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essay: tackling, in the most plain-spoken way possible, the issue of

human understanding of the world and of himself within this

world.

Before entering the analysis itself, there are two issues that I

would like to address. Both relate to my choice to study the

'Western world'.

Much of anthropological attempts to understand human ways

and culture sought knowledge in social worlds other than the one

from which the discipline itself has sprouted from. This may be a

somewhat curious fact, considering it is itself the source of the

initial interest in – and conceptualisation of - the issue. While

acknowledging the value of these endeavours, I have chosen to

come back 'home', and to try to understand Western culture in its

own context, with its own dynamics, and with its own historical

development (each as defined by its own narratives).

One may oppose the reference to Western culture as if it were

one whole, and I must join these expressions of discontentment.

The Western world is indeed a mosaic of different cultures, whether

defined as based on national aspects, religious beliefs, gender

attributes, social stratification, etc. There is, however, one

important institution, which can be said to hold greater

homogeneity in respect to its epistemological and practical

grounds: Biomedicine. This has been acknowledged by endless

works in the sociology and anthropology of medicine, now well-

accepted subdisciplines, and sources of many theoretical

innovations in the social sciences in general.

The power of biomedicine in the Western world can hardly be

overrated: it may be one of the most dominant, influential, and

highly regarded profession and body of knowledge. Its

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authoritativeness over the individual and the social allows it to be

the source and the culmination of values assigned to Western

culture in the most general meaning of the term. Thus, it seemed

most promising to turn to this field as an empirical arena for the

development of a general theory of knowledge as it applies to

Western society, in its modern and postmodern manifestations.

In my search for the most promising field of study, I defined

another vector of interest: the focal point within which the Western

modern individual defines his identity – mind and body, mind or

body. There, many complexities began to arise: am I a subject,

looking at the world from my own private perspective, defining

Truth as it is sensed, thought of, felt, by me, as an conscious

individual?; Or should I rather adopt a vision of myself as an object

among objects, in a world defined by a general (and scientific)

consensus on which is True, and which is False?

Once having ascertained biomedicine's tendency to reinforce

the second way of defining Truth (adopting a body-centred, or

objectifying epistemology), I shall look at the ways in which it is

resisted by a sense of truth as held by the experiencing subject.

These relations of power stood at the centre of my research in the

last years and will be placed at the centre of this essay as well. My

hope is to be able to convince the reader that these may form a

ground for a theory placing mind-body relations at a focal point in

the understanding of modern and postmodern Western

epistemological cultures.

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The Three Papers

In the course of this essay, I will use three different ways to

substantiate, exemplify, and clarify the claims above. First, I will

propose a historical outlook on the ethical debate regarding

psychosurgery, the use of surgical, material means for treating the

mind; Second, I will bring the analysis of an in-situ work where I

observed the ways in which brain tumour diagnosis is reached,

when based on more or less objective forms of knowledge; And

third, I will lay down an analytical first-person narrative to bear on

processes of objectification associated with brain surgery, as

experienced by the field-worker.

The sequencing will go from the macro, to the micro, to the

reflexive – a representation of the theory itself, by which the mind-

body split infiltrates (as 'replicated boundaries') all layers of

sociocultural phenomena – from broad historical movements, to

micro-interactions, to personal thought. Accordingly, methods will

greatly vary, although remaining within the limits of qualitative

analysis. Although referred to in the coming section more careful

presentation of the methodology will be presented in each of the

three chapters, thereby avoiding redudancies and repetitions, as

well as making the compatibility between the work and the

methods explicitly evident.

Surgeons of the Mind

The first paper will serve as theoretical grounds for the overall

analysis proposed in this work. Thus, although heavily drawing on

philosophical insights, its aim will be to build a framework for a

social study of knowledge. In this, I will suggest a conceptual

framing whereby modern Western biomedical practice and research

sees two forms of knowledge coexist and fight for authoritativeness:

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phenognosis (knowledge based on subjective experience) and

ontognosis (knowledge based on the enquiry of a world-out-there).

Drawing on philosophical and theoretical insights from recent

works on discourse, the body, and social studies of medicine, this

paper will propose an analysis raising cultural aspects of mind-

body dualism in modern and postmodern Western society. This

Cartesian split ('The Gnostic Split') will be pictured through a case-

study of the practice of frontal lobotomy ('psychosurgery'): the use

of brain surgery to transform the mentally-ill, yet fully sentient

individual into a complacent ‘object’, lacking the capacity for

subjective experience. An interpretative reading of the related texts

will show how certain epistemological assumptions led to the

overwhelming acceptance of the technique within modern medicine

of the 1940s-1960s, and how these have increasingly become

depicted as scandalous within a more recent post-modern

bioethical debate. The analysis will then relate this transformation

to the placing of human subjectivity above observable functioning as

more relevant goals of medical and social practices. The study of

the debate over psychosurgery will raise questions as to the ways

in which mind-body epistemologies affect conceptualisations of

humanhood and its association with self-consciousness (being a

subject) and the ability to accept ‘objective truth’ (being ‘sane’).

This historical analysis will allow a bird-eye, macro-level view of

the conceptual issues running throughout this work. It will assert

the social embodiment of the mind-body problem using a broad

perspective settled on the world of biomedicine. This will turn to be

essential to the understanding of the microdynamics associated

with the epistemological forces at hand, i.e. phenognosis and

ontognosis.

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Experts and 'Knowledge that Counts'

Bringing these ideas to the realm of the clinical, this paper

will provide a closer, in situ, look into the life of a neuro-oncology

(brain cancer) clinic of a large hospital in Israel, based on a six-

month participant observation. It will point to the many challenges

involved in the solidification of brain tumour diagnoses by different

experts and forms of knowledge, and present these epistemological

and practical complexities as they are uncovered in daily routine.

The paper underlines the technological and epistemological

grounds of 'expertise' in the medicoscientific practice of diagnosis,

and their roles in the assertion of expert knowledge's

authoritativeness. When questions of authoritativeness arise,

several mechanisms of resolution are used. These include

Hierarchisation: ranking the relative validity and reliability of the

different sources of information, eventually prioritising reports

from more authoritative expertises (e.g. imaging reports would be

considered more reliable than phenognostic patients’ accounts);

Sequencing: relying upon the temporal dimension, and defining the

discrepancy itself as a diagnostic sign (e.g. the degradation or

amelioration of the disease); Negotiation: adjusting diagnoses via a

preliminary exchange between experts and a consequent 'fine

tuning' of the reports (e.g. radiologists being aware of clinical

evaluations before finalising their reports); Peripheralising: turning

to other expertises to 'explain away' symptoms that do not fit with

a well established initial diagnosis (e.g. asserting that a symptom’s

source was orthopaedic rather than neurological); And pragmatism:

using information only as far as it provides sufficient grounds for

treatment decisions, leaving ambiguities unresolved. These five

mechanisms will here be presented in the context of the daily work

of the clinic, and associated with the theoretical thrust of this

work, i.e., the relation of power between phenognosis and

ontognosis.

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The World of Brain Surgery

In this essay, I will try to show how issues of objectification

can be discussed from the viewpoint of the objectifying party.

Resisting a dichotomy between physician-objectifying and

ethnographer-humanising, I will portray objectification as being of

a fluctuating nature, rather than a necessary by-product of

professional tendencies, epistemological bases, practical

necessities, and processes of socialisation. With this in mind, I will

propose a further look into the settings within which these

discursive dynamics take place and come about through artefacts,

space, symbols, etc. I will first briefly portray my relationship with

Ivan, a brain cancer patient whom I have followed over a period of

eighteen months, and then focus my attention on my observation

of the brain surgery he had to undergo. As it is presented from a

first-person perspective, this account will provide a glance into the

ways in which clinical or clinically-situated exchanges are not only

observed but also experienced.

Considering the breadth of the methodological and empirical

bases for this work, each chapter will be structured as relatively

independent unit, with its own body of literature and

methodological sections. This is, in many ways, the presentation of

three stand alone journal articles, as customarily composed and

structured in the professional academic press. First, references are

used only as far as they are directly relevant to the essays; and

secondly, the textual content is refined and condensed to create a

succinct and to-the-point exploration of the issues at hand.

Nevertheless, the integration of these papers into a unified scheme

allows a broader and more compelling development of the

theoretical framework which will serve the analysis throughout: the

idea of the 'gnostic split' and the suggested concept of 'replicated

boundaries'. I believe that neither of the papers, in and of

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themselves can provide sufficient ground for the conceptual

schemes proposed here.

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Part II: The Argument and its Theoretical Complex

The Mind-Body Problem and Cartesian Dualism222

Descartes and After

"Cogito ergo Sum"

(I think therefore I am)

In these few words, René Descartes (1596-1650) offered his

definition of the mind as an entity outside of the realm of matter.

More specifically, he would define how mind and matter were

distinct: Matter has a spatial extension, i.e., it has a place and a

dimension; Matter has proper characteristics and attributes, such

as colour and shape; Matter is public and accessible to all,

including to scientific observation. The mind, in contrast, will have

no spatial extension, no attributes, and exists in the private world

of the subject (Garber, 1992; Kendler, 2001).

Along the same lines, Descartes will claim that a human

being is not one entity, but rather has different parts: some

mechanical and some non-mechanical. The mind, in belonging to

the latter form, will thus constitute a form of 'ghost in the machine'

(Ryle, 1949; Koestler, 1967). The question of the nature of the

relations (or lack thereof) between 'the ghost' and 'the machine' will

become one of the more important foci of post-Cartesian Western

philosophy (Leibowitz, 1982). The most prominent philosophers

would argue for this or that view of the problem, giving birth to an

immense body of works.

Among the ways in which the problem was tackled, one may

find some that may be viewed as dualist and others as monist.

2 Note: some of the material presented here is borrowed from my own Master's Thesis

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Much like Descartes himself, philosophers adhering to dualist

views conceive of the problem as based on the relations between

two distinct ontological entities (entities that 'are' in the world).

Monists, however, will speak of one dominant substance: this being

either material (materialists) or spiritual (idealists) (Schimmel,

2001).

Dualist explanations, in turn, can be subdivided into

interactionist or non-interactionist ('parallelism'). As Descartes saw

mind and body as interacting entities (more specifically through

the 'pineal gland', an organ located deep within the brain), one

could define him as an interactionalist (Schimmel, 2001). Leibnitz

(1646-1716), in contrast, would see mind and body existing in

parallel, without having one affecting the other (non-causal

dualism, or non-interactionism). This 'identity theory' will have

mind and body as two manifestations of the same phenomenon –

thereby not claiming for a duality of substances but for a duality of

properties. 'Mind will appear when the question is approached from

a subjective angle, and 'matter' when approached objectively.

Trying, like monists and 'substance dualists' do, to ask whether

water is water or H2O, makes no sense to the 'property dualist':

these are not two phenomena, but rather two ways of looking at

one phenomenon (Kendler, 2001).

'Functionalism' will hold a somewhat related concept: the

mind-brain relationship would be comparable to drive-car

relationship, that is, rather than one being a by-product of the

other, there would be between the two a relation of function to

matter (Ben Zeev, 1996). An additional important dualist theory is

referred to as 'epiphenomenalism'. According to this view, mental

phenomena will be but a by-product of material substance, a

Hegelian 'foam on the wave' of brain activity. With the rising power

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of brain research, these views, along with clear-cut materialism,

have become ever more pervasive.

The Cartesian Fallacy

The mind-body conundrum can be defined around the logical

fallacy arguably entailed by Cartesian dualism. Benjamin (1988),

for instance, brings us four prepositions, each considered 'true'

prima facie, yet logically incompatible with the others:

The human body is material.

The mind is spiritual.

Mind and body interact.

Spirit cannot affect matter and matter cannot affect spirit.

In order to have them 'make logical sense', one would have to

relinquish at least one of these assertions. This is, in the broadest

terms, the basis for the different philosophical approaches

described earlier:

The body would not be material (idealism);

The mind would be material (materialism);

Mind and body would not interact (non-causal dualism: e.g.

identity theory, or ephiphenomenalism);

Spirit can affect matter and vice-versa (causal interactionism).

With the development of modern science, idealism has lost

most of its vigour. With the evolution of experimentalism and the

focus on pragmatism in the development of technologies,

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positivism has gained much strength. With it, materialism – in its

less or more extreme version – seemed to have led 20th century's

Western thought. This until recently, when modern physics

(notably quantum theory) raised questions as to the ontological

exclusivity of 'matter'. Along with more general trends of New Age

culture, this seems to have revitalised concepts regarding 'mind' as

a powerful entity, or to the very least, as a consequential actor in

the 'world', were it the world of 'nature' or the world of the 'social'.

This process will stand at the very centre of much of this current

work.

The accumulation of scientific knowledge leaves little doubt:

there is to the very least some correlation between the mental and

the cerebral. The question remains as to the idea of a causal

relationship: is brain activity a result of mental activity or vice-

versa? Science keeps reinforcing the concept of correlation, yet

does not take us closer to resolving the problem of causation

(Midgley, 1996). The answer must thus be found in the realm of

the cultural, of the social, where conceptualisations on the nature

of 'the world' originate and manifest themselves.

With this in mind, I will present some aspects of Western

modern society's marked cultural character, as expressed in one of

its most powerful discourses: biomedicine. I will show it to be

based on movements between two distinct forms of knowledge,

each holding claims to the ultimate Truth: ontological (what IS in

this world, what are its fundamental essences); and

phenomenological (what is it like to BE, how is the world

experienced). For the sake of conciseness, and in order to avoid

ambiguities with related terms, I will term the former ontognosis

(gnosis – Greek for 'knowledge') and the latter, phenognosis. After

proposing an essential definition for each, I will turn to picture the

evolution and manifestations of these two epistemological forms

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within broader contexts, affirming their relevance and

consequentiality in the sphere of the sociocultural.

Introducing the Gnostic Split

Phenognosis and Ontognosis

My analysis will follow a philosophical division of the mind-

body conundrum into two set of predicaments: the easy problem,

and the hard problem. The 'easy' problem involves a view of mind

and body as different kinds of fundamental essences of a 'world

out-there' (there is matter and there is mind, whether experienced

or not). The 'hard' problem emphasises an epistemological gap

between first-hand experience (‘felt’) and public, scientific

knowledge (‘observed’), or between subjective and objective

knowledge (Ornstein, 1972; Young, 1990). This 'hard' problem

rightfully earned its appellation. The subjective/objective split

presupposes a form of consciousness encompassing a set of

'truths' (often referred to as qualia) inaccessible to scientific

inquiry: the sight of the colour red, the sensation of an itching toe,

or a tooth ache whose actuality could never be disputed by a

dentist. Arguably, no progress of science will ever allow being,

feeling, or aching in the place of another, and no map of the brain,

however elaborate, will be able to convey subjective experience

(Damasio, 1994; Edelman, 2000; Searle et al., 1997). As Nagel

(1974), in his famous article "What is it like to be a Bat?"

eloquently notes, true knowledge of 'what it is like' is an

epistemological privilege reserved to the sentient subject, i.e., to the

bat itself: Only a bat would know 'what it feels like' to see with

sounds, and only a particular bat would know what it feels like to

be this particular bat (Jackson, 1982; Heil, 1988; Gertler, 2001).

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Facing an outside world, this first-person standpoint is the

site where one turns acquired knowledge (of the world, of oneself)

into which he/she will define and often declare to constitute the

'Truth'. This, regardless of whether the source is the world-out-

there agreed upon by several individuals or one’s own

hallucinatory world. This first-person’s position is also the focal

point where facts become meanings and where data become

experience, this again, regardless of whether the meaning assigned

to a phenomenon seems ‘objectively’ acceptable or based on some

sort of psychological distortion (Edelman and Tononi, 2001;

Metzinger, 2003). This locus of 'Truth', based on 'I know', 'I think',

'I feel' (phenomenological Truth), will often be challenged and

questioned by a claim for Truth based on 'There is', or 'This is'

(ontological Truth), a claim most often originating from the world of

science and biomedicine.

Thus, in the terms proposed here, I will base ontognosis on a

materialistic approach to the easy problem – portraying the world

as essentially material. With phenognosis, on the other hand, I will

adopt the notion of experience as addressed in the context of the

hard problem, emphasising the irreducibility of the subjective into

material elements.

The Body and Embodiment: Closing the Great Divide

Phenomenology has its basis in philosophy and finds itself at

the centre of much contemporary work in the philosophy of mind,

namely in the field of neurosciences. For instance, one may find

such a view in Bennett and Hacker's famous essay, "Philosophical

Foundations of Neurosciences":

"A human being is a psychophysical unity, an animal

that can perceive, act intentionally, reason, and feel

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emotion, a language-using animal that is not

merely conscious, but also self-conscious – not a

brain embedded in the skull of a body" (Bennett

and Hacker, 2003:3) [my emphasis, S.G.]

The Cartesian mind-body split has ever been the subject of

philosophical attempts to either deny its existence or dissolve its

problematic aspects. One such important – and relatively recent –

attempt can be found in French philosophy and human sciences

(Lanigan, 1991): Maurice Merleau-Ponty (e.g. 1962) sought the

resolution, or rather, the conceptual annihilation of the Cartesian

split. According to him and to many of his existentialist and

phenomenologist predecessors, although the body could be seen as

an mere object, 'experience' or 'mind' cannot. The latter will only

exist as far as it is embodied: the mind is not the 'ghost in the

machine' – it is rather the experiencing, first-person, façade of the

machine. While the body may be without mind, the mind cannot be

without body: both empirically and philosophically, perception,

action, cognition, emotion are all 'embodied phenomena'.

"[The body] is in the world as the heart is in the

organism: it keeps the visible spectacle constantly

alive, it breathes life into it and sustains it inwardly,

and with it forms a system" (Merleau-Ponty, 1945 in

Lanigan, 1995a: 203).

In other words, for phenomenologists such as Merleau-Ponty,

while the body may be regarded as a mere physiological and

natural entity (an 'objective body'), it will, once experienced, turn

into a 'phenomenal body'- unified with (rather than distinct from)

this physiological entity. The phenomenal body, thus, must be

viewed as one with the objective body: experience is experience of

the body, rather than an entity IN the body.

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Social Studies of Medicine and the Body

Scholars, notably in the fields of the social studies of science,

have taken up these leads and engendered considerable research

on the existential and phenomenological groundings of the self and

its relation to 'the body'. This was associated with an ongoing effort

to account for possible gaps between 'sentience' and 'science' at the

level of the self, a self problematised as dual (mind vs. body) by

external expert knowledge (most notably by medical practitioners,

dealing directly with the 'body in pain', or the 'experiencing flesh').

These works generally sought to merge the body’s objective façade

with the less tangible subjective experience of which it serves as

the locus. This would lead to the understanding of culture and

experience "insofar as these can be understood from the

standpoint of bodily being-in-the-world." (Csordas, 1994:143).

Along tangential lines, feminist literature took on the task of

revealing conflicts between sentient knowledge on the one hand,

and biomedically based knowledge on the other, often relating

epistemology to constructions of gender (e.g. Root and Browner,

2001). According to these views (which were generally put under

the umbrella of a 'sociology of the body'), culture, as a system of

thought both external to the individual and concurrently present

within the individual, represents the body in a way that is socially

contingent (Martin, 1994). While agreeing with this basic premise,

scholars of 'embodiment' will claim that the sociology of the body

does not take into account the lived-experience of the body, a fact

that eventually only reinforces ideological and political dualisms. In

relation to the context of gender, these very works will be claimed

to adopt a 'mentalist discourse' (seeing 'mind' as being superior to

'body') by which men are the 'mind', that is, related to public

realm, while women are the 'body' and belong to the private sphere

(Williams and Bendelow, 1996; Webb, 1998).

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21

Thus, sociologies of embodiment (e.g. Shilling, 1993; Crossley,

1995; Turner, 1996; Lupton, 1994; Williams, 1996) have shown

how much 'we are our bodies' and how much of the mind-body

split remains unchallenged by current sociological work (Nettleton,

2006). Thomas Csordas, one of the leading scholars in the field,

explains that the shift from looking into the body to considering the

phenomenon of embodiment:

"…corresponds directly to a shift from viewing the

body as a nongendered, prediscursive phenomenon

that plays a central role in perception, cognition,

action and nature to a way of living or inhabiting

the world through one's acculturated body."

(Csordas, 1994: xiv).

Overall, while ascertaining the presence of epistemological

conflicts in micro-settings where third-person and first-person

views collide (IT vs. I), even these 'embodiment'-oriented

undertakings show little concern for the changing hierarchies

between the two forms of Truth (subjectively experienced vs.

objectively accountable) as broad discursive forces. For instance,

while Turner (1992) brings up the distinction between leib (the

lived body) and korper (the physiological body), he uses it as to

show the preciousness of the leib over the korper as a source and

grounds for culture. Still, the relationship between the two as

'Truths' is never analysed as such.

Throughout this work, I will seek to provide such a

complementary outlook, using Foucault’s (1986) notion of

discursive practices as entailing human desire for 'Truth' about the

world and about the self. In an attempt to do so, I will first propose

a theoretical framing and then attempt to work the theory into the

canvas of the social settings from which individual cases were

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22

drawn from: the history of psychiatry, the clinic, and the surgery

room.

The Discourses of Truth: Foucault and Beyond

Biomedical and scientific discourses generally comply with

ontognostic views whereby Truth would be accessible through the

unravelling of the world of material essences. Medical knowledge is

essentially of a reductionist nature, paying little or no attention to

the subjective aspects of disease. This ontognostic epistemology is,

in turn, associated with the foundation of a powerful ethos, the

establishment of an authoritative system of rhetorics, and the

drawing on highly evocative symbolic elements - all of which

serving to support its discursive supremacy.

Biomedicine has had indeed notable success in achieving this

demarcation as highly respectable, trustworthy, and distinctive

from other social spheres, such as religion, politics, and economics

(Gieryn, 1983, 1999; Mizrachi et al., 2005). This distinction

persists within a particular power structure where a hegemonic

regime of truth is established, defining the forms of knowledge

considered admissible while dismissing competing claims for Truth

(Foucault, 1972, 1980, 1986; Armstrong, 1983). This will ipso-facto

place non-scientifically based knowledge – including phenognosis -

in a subordinate position (Foucault, 1982). Phenognosis, however,

should not be seen as comprising mere 'leftovers' of this biomedical

ontognosis. When considering the development of post-modernism,

the linking of subjectivity with power relations will reveal that it

may indeed constitute a rising discursive force.

In the 1979 Stanford Lectures, Foucault stated that what

troubled him since his first book was:

"In what way are those fundamental experiences of

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23

madness, suffering, death, crime, individuality

connected, even if we are not aware of it, with

knowledge and with power? I am sure I'll never get

the answer; but that does not mean that we don't

have to get the question".

Foucault's analyses distinguish between discursive events

and prediscursive events – i.e., 'things' that are not based on

discourse, and that have not been produced by the social. These

include pain, madness, and experience of self. I shall claim here

that Foucault may have had the question misspelled: what if these

experiences were not prediscursive, but rather discursive? After all,

following his claim that 'Man' is but a discursive event, a "new

wrinkle in our knowledge" (Foucault, 1972; Goldstein, 1994), why

not consider 'Man' as a discursive event based on the phenognostic

authoritativeness of human experience?

Thus, although, according to Szakolczai (2000), Foucault’s

own lifework can be defined as revolving around this issue of

discursive subordination, both his writing and more recent

literature has, by and large, omitted the option of a symmetrical

opposite, by which phenognosis itself would serve as grounds for

legitimacy and, therefore, for power. When at all acknowledging

subjective forms of knowledge, these works rather deal with them

in oppositum to the hegemonic power/knowledge, that is, through

the challenges it may present to the material-ontological bases of

biomedicine, science, and modern Western social order (e.g.

Eisenberg, 1977; Rosenberg and Golden, 1992; Rosenberg, 1999;

Mizrachi et al., 2005).

Traditionally then, phenognosis, as a consequent discursive

formation in and on itself, rarely seems to be deserving particular

interest, again making the relationships of power between

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24

phenomenological and ontological forms of knowledge critically

understudied. This lack of attention remains somewhat enigmatic

considering recent historical developments.

The second half of the 20th century witnessed a gnostic shift in

the form of hierarchical changes in the statuses of the two forms of

knowledge. This shift had both roots and repercussions within

what social sciences have traditionally referred to as the rise of the

postmodern (Lyotard, 1984; Harvey, 1989). This postmodern era

would see critiques of science joining existential,

phenomenological, and relativist influences in the social sciences

(and in general culture, most particularly in art and literature), to

pave the way toward a destabilisation of the grounds upon which

ontognosis drew its force. Grand ontological and metaphysical

accounts lost grace to local, negotiated, and provisional forms of

knowledge, thereby allowing experience to ascend as a legitimate

source of Truth.

Still, although overwhelmingly rooted in phenomenological

thought, more radical postmodernism will reject the whole idea of

Truth, including – if ever considered- phenognosis (Bourdieu, 1992;

Dickens and Fontana, 1994). Thus, while postmodernist thought

may have notable affinities with ideas associated with the concept

of phenognosis, one cannot stress enough the distinctiveness of the

two worlds of notions, whereby stands the value of the proposed

reconceptualisation. This issue shall be clarified as this analysis

develops.

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25

Introducing Replicated Boundaries

The reconceptualisation of the mind-body conundrum will

serve to assert the sociocultural correlates of the philosophical

problem, both at the macro-level and at the micro-level, both

synchronically and diachronically. This work has led to the

formulation of a theoretical framework for the understanding of

such processes: the definition of replicated boundaries.

The Gnostic Split and Replicated Boundaries

If indeed the mind-body problem does stand at the basis of

social phenomena, how can one discern, detect, or recognise its

manifestations? How are phenognosis\ontognosis reflected in the

institutional, symbolic, interactional, spatial, professional,

epistemological spheres?

The systems of classification we hold ordinate the creation of

boundaries at many layers of cultural phenomena (Abbott, 1995),

thus forming 'replicated boundaries'. In broad terms, replicated

boundaries refer to the presence of epistemological groundings –

here, as a relation between two forms of knowledge- which will

replicate themselves in several spheres concurrently, and still keep

structural similarities. These spheres may include both lay and

professional epistemologies and practices, and may encompass

beliefs, classifications, actions, symbols, etc. If, for instance, one

finds a process of subordination of one form of knowledge to

another, this will come about in the subordination of one

professional sphere to another (e.g. one group of professionals

losing their status), in changes in the ways in which space is

distributed (e.g. forming a panoptical advantage in spaces where

the more powerful form of knowledge is exercised), and so on.

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26

The cases at hand will be used to illustrate this concept, and

assert that ontognosis' failure to conquer and subordinate

phenognosis led to a rejection of the latter from the territories of

the former; and that this was followed by the creation of robust

limits to forestall any 'leaking' of the phenognosis into ontognosis'

terrains. I shall further claim that these bounding limits will not

remain within the layer of the abstract, and will have powerful

manifestations at several layers simultaneously: the splitting of

brain and mind in the professional layer (e.g. neurology vs.

psychiatry), in the layer of the spatial organisation of biomedical

areas (e.g. where the operation room becomes a well-bounded

ontognostic shrine), in the symbolic layer (e.g. the apparatus used

to keep each form of knowledge distinct in social settings), the

conceptual layer (e.g. in the case of brain tumours - the conceiving

of oneself as either body or mind) and in the more general

discursive layer, where definitions of authoritativeness remain

crucial (e.g. hierarchies of sources of information in the forming of

diagnosis).

The phenomenon of replicated boundaries will accompany us

throughout the analysis, in which I hope to be able to establish it

as a valuable theoretical concept.

Replicated Boundaries: The Professional Grounds

Professions constitute social fields where particular

organisations of knowledge are often manifested in a most palpable

way. In the course of this study, I have thus chosen to lay special

attention to the professional developments of the fields where the

mind\body split would come about most noticeably, that is,

biomedicine, and most particularly, neurology ('the profession of

the brain') and psychiatry ('the profession of the mind').

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27

The rise of the professions is related to the processes of

secularisation in Western society around the late eighteenth and

nineteenth centuries (Parsons, 1971; Goldstein, 1994). Parsons

(1971:145) sees the professionalisation as a "criteria of cultural

legitimacy", and sees it as the "single most important component in

the structure of modern societies". Foucault (1982) joins him in

pointing to the importance of the professions in Western modern

societies. Associated with the interest in professions and the

attempts to define the phenomenon has always been the study of

knowledge and of epistemological subordination. As claimed by

McDonald (1995: 160), “professions are knowledge-based

occupations and therefore the nature of their knowledge and the

occupations strategies in handling their knowledge base are of

central importance”. For Foucault, for instance, the unbreakable

link between abstract knowledge and the profession would be

based on the idea of the 'gaze', most often present in discourses

related to the practice and epistemological grounds of medicine

(Goldstein, 1994).

Medicine holds several ''core generating traits" (Larson, 1977)

that enable it to be referred to as a profession, rather than a mere

occupation. First, it holds a body of abstract knowledge which

must be mastered by its members; Second, it holds a degree of

exclusivity in the relevant field of practice and knowledge; Third, it

is autonomous in the definition of its practice; And finally, it holds

a 'service ideal', that is a disinterested practice that is based on

altruistic rather than self-centred objectives (Wilensky, 1964;

Goldstein, 2001).

The need for professions to isolate themselves from other

forms of culture and to gain power through knowledge involves

processes of 'boundary-work'. There are several ways in which

biomedicine, as an ideal type of profession may 'do' boundary-work

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28

(Gieryn, 1983, 1999; Mizrachi et al., 2005): First by expanding its

authority or expertise into domains claimed by other professions or

occupations; Secondly, by creating a clearer contrast between itself

and its rivals; Thirdly, by monopolisation of professional authority

and resources; Finally, by labelling rivals as pseudo or amateurish

and exclude them from its turf.

Along related lines, Halpern (1992)has claimed that the

resolution of jurisdictional (and knowledge-related) conflicts

between professions may entail three possible forms: the control of

one profession over a field of jurisdiction; split jurisdiction; and

subordination. These relations find themselves replicated on

several layers, hence my proposed definition of replicated

boundaries. This involves symbolic, rhetorical and professional

modes of boundary formation around and in parallel to these forms

of knowledge.

From a more recent perspective, Gieryn (1999) defined

'science' –the basis for biomedicine's authoritativeness - as placed

on 'a map of culture', bounded off from other territories such as

common sense, politics, or mysticism. In my view, these 'non-

science' territories can all be seen as belonging to the subjective

realm, as the interest of science is to remain the home of

objectivity, reason, and truth. In this case, drawing a map of

science is but replicating a map of a gnostic split.

This essay presents particular cases of professional

boundary-work, in which notions of scientific truth were

challenged and redefined. Through the understanding of the

enactment and then challenging of boundaries, I will try to propose

that Cartesian boundaries are involved in the demarcation of two

forms of 'truths' – the phenognostic and the ontognostic. I will

show how specific demarcation principles of the scientific versus

Sky E. Gross

29

the non-scientific are related to a battle on the hierarchy of these

two kinds of truths.

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30

Part III: Surgeons of the Mind

Frontal Lobotomy and the Mind-Body Problem

The first section of this work, the story of psychosurgery, will

serve as a case-study where the key concepts of 'ontognosis' and

'phenognosis' are taken to their extreme. The boundaries between

the two forms of knowledge will come about at the level of temporal

developments as well as at the level of professional dynamics. Its

value as a basis for analysis is manifold: First, the case reflects a

daring attempt to bridge Cartesian dualism –acting upon matter to

alter the realm of the mind-- making this chasm remarkably

explicit. Furthermore, it relates to the cultural significance of the

brain in biomedical thought. Finally, one cannot overrate what is

at stake here: i.e., notions of humanhood, experience, existence,

and consciousness (Kleinman, 1997). This may account, at least

partially, for the fact that, while over the years many medical

procedures were eagerly embraced only to be consequently

rejected, few arose as lively debates and as much moral outrage as

psychosurgery's.

Introduction

"It is better […] to have a simplified intellect capable

of elementary acts than an intellect where there

reigns disorder of subtle synthesis. Society can

accommodate itself to the most humble laborer, but

it justifiably distrusts the mad thinker". Walter

Freeman, psychosurgeon, 1942 (cited in Kucharski,

1984:766)

I will suggest here an integrative analysis of the cultural and

philosophical aspects of mind-body dualism in modern and

postmodern Western society. I will picture this chasm, now broadly

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31

referred to as Cartesian, through the study of the practice of

frontal lobotomy3 (‘psychosurgery’): a modern endeavour using

brain surgery to transform the mentally-ill -- yet fully sentient--

individual into a self-content ‘object’ only partially able to sense

subjective experiences. I will demonstrate, with the aid of an

interpretative reading of texts related to the debate, how

epistemological assumptions associated with the Gnostic Split have

led to the overwhelming acceptance of the technique within modern

medicine of the 1940s-1960s, and how these have increasingly

become depicted as 'outrageous' within a more recent post-modern

bioethical debate. More specifically, I will relate this transformation

to the placing of human subjectivity above observable functioning as

the ultimate goals of medical and social practices.

Lobotomy in Mind: Methodology

A Historical Approach to the Study of Replicated Boundaries

"Sociological explanation is necessarily historical.

Historical sociology is thus not some kind of

sociology; rather it is the essence of the discipline"

(Abrams, 1982:2).

Historical analysis is often most resourceful when tackling

central interests of sociology (Abrams, 1982). It enables a drawing

of infinite changes and shifts in the relations of the subject matter

with other contexts. Boundaries can be understood as a belonging

to a process through time: their locations are drawn and redrawn,

at times strengthened, at others weakened. This and more, the two

sides of the borders are ever changing, both defining and being

defined by the boundary, or the relationship with the 'other'. This

is why a proper study of boundaries should involve a temporal

3 Lobotomy is but one psychosurgical technique – yet, as it is of common usage to refer to the latter by the former, and as it was the most practiced form of psychosurgery, I will use both terms alternately.

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32

vector, as well as a study of the set of changing relationships

between two entities, were it professional, sociocultural, or

epistemological entities.

Still, this analysis will remain sociological in its nature: I will

seek the theoretical drawing on a historical case, and not a detailed

description, or critical reconstruction of an event. Psychosurgery is

brought here as a "historical individual" in Weber's sense, that is,

as a form of historical ideal type of the phenomenon at hand, or:

"…a complex of elements associated in historical

reality which we unite into a conceptual whole from

the standpoint of their cultural significance".

(Weber, [1930] 2001:47).

And it is the cultural significance associated with the dealing

with the mind/body split which I wish to put at the centre of this

analysis.

Reading Psychosurgery

The insights presented here find support in an empirical

groundwork study of texts pertaining to the portrayal of

psychosurgery and to the debate it generated. The focus on

professional publications –mainly medical, but also from the social

sciences-- provided a relatively continuous frame of analysis, that

was, as a rule, devoid of dramatisation tendencies often present in

lay reports. Primary sources included books and journal articles

published since the 1930's, the selection criterion being their

referring to terms related to psychosurgery or to its main

practitioners. I have included both French and English sources

collected in two central libraries in Paris, and four in Israel. This

revealed 384 articles and 14 major book publications. I interpreted

the texts along a chronological thread, as well as through several

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33

overarching themes: the criteria for the evaluation of the

procedure; the rhetorical devices employed; positive/negative

stances; and finally, the drawing on symbolic aspects of medical

practice. I then defined the debate as rotating around a number of

issues.

First was the inadequateness of theoretical and empirical

bases- using a method of trial and error on groups of patients

diagnosed with etiologically, nosologically, and symptomatically

diverse mental pathologies.

Second were the procedure's mutilating aspects and the

irreversibility of its effects as it inflicted great damage to both

affective, cognitive, and physical functioning by the severance of

brain tissue not targeted by the procedure.

Third were issues of obtaining informed consent from mental

patients, some going as far as claiming the latter to be infeasible in

the case of such extreme mental transformation: in terms of

personality, the patient giving his consent may not be the same

person going through the postoperative phase.

A fourth matter included questions of human

experimentation, with practitioners having limited tools to predict

the outcomes and calculate the risks of such an intervention.

Another issue was the immense power accorded to the

psychosurgeon in social and political spheres: Critics, in fact, often

associated the procedure with contemporary Hitlerian concepts of

euthanasia and eugenics.

And finally was the theme of abuses and aberrations observed

through the implementation of the different procedures, including

interventions on children as young as four year old (Valenstein,

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34

1980a, 1980b; Kucharski, 1984; Bouckoms, 1988; Huynh-Dornier,

1992; Snaith, 1994; Berrios, 1997; Sabbatini, 1997).

Browsing through the literature, one typically finds depictions

of the debate assuming an evolving movement from an inferior to a

superior moral and ethical world (accepting and then rejecting the

technique), from inferior to superior technology (the use of better

instruments), and scientific understanding (knowing more about

the brain). This will eventually represent psychosurgery as a mere

by-product of a darker era in medicine and psychiatry. Here, I will

seek to portray psychosurgery as neither justifiable nor

condemnable, and will insist that the procedure’s ascribed

legitimacy is in line with other sociocultural developments, namely

specific epistemological shifts. I will propose a more contextualised,

less presentist view, which will describe not just past-proponents’

but also contemporary critics’ arguments as equally contingent

upon the particular Zeitgeist within which they took form. The

focus will be thus on transitions in the depiction –rather than

usage-- of the procedure, and on broad epistemological --rather

than mere technological-- aspects of these developments. Indeed,

while historical accounts of the technological and scientific

contingence of the abandonment of psychosurgery (e.g. reference to

the introduction of drug therapy) may account for the decline in

the use of the technique, they offer little to the understanding in

the shift in the debate itself and the values it brings forth. True,

lobotomy may have lost its place to psychoactive drugs, yet debates

over its legitimacy – morally, ethically, epistemologically – carry on,

a fact which cannot be explained away by the pointing to scientific

advances. I suggest the story must be told otherwise.

On Psychosurgery

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35

In 1936, Egas Moniz, a Portuguese neurologist, reported

preliminary success in the severance of brain tissue for the

treatment of mental illness (Moniz, 1936b). Soon, and once

experimented on a small group of patients, the most prominent

neurologists and psychiatrists embraced the procedure. These

included Adolf Meyer (past President of the American Psychiatric

Association and the American Neurological Association, and co-

founder of the American Board of Psychiatry and Neurology),

Edward Strecker (vice-president of the American Neurological

Association and president of the American Psychiatric Association),

and Harold Solomon (president of the Association of Nervous and

Mental Disease). Some promised a full recovery to a significant

share of patients. In 1949, Moniz was granted the most prestigious

scientific acknowledgement: the Nobel Prize (Berrios, 1997; Ligon,

1998). Three years later, the Pope himself accorded psychosurgery

his blessing (Rouvroy, 1954). In the words of one of the

practitioners:

“[Prefrontal lobotomy is] the realization of a new

stage in neurosurgery […]. The introduction of

surgery in the treatment of affective disorders is a

momentous event.” (Wertheimer, 1948:497)

or,

"Psychiatrists, neurologists, and neurological

surgeons may well look back upon the period before

the discoveries of Egas Moniz as equivalent to the

Dark Ages." (Freeman, 1956:771).

It is evident that, at the time, the practice was considered as

one of medicine's greatest promises: In the US of the 1940s, many

would consider it unethical not to propose lobotomy to some

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36

patients. In fact, both asylum psychiatrists and neurosurgeons

viewed it as no less than a breakthrough in the scientific

understanding of the mind. By 1960, tens of thousands of

psychosurgical interventions were conducted worldwide, most

particularly in the US, but also in Continental Europe, the UK, and

Japan (Hirose, 1972; Donnelly, 1978; Kucharski, 1984). Between

1942 and 1954, 10,365 were counted in the UK. Until mid 1941,

more than 18,600 operations were performed in the US (Swayze,

1995). Globally, according to Silverman (2001), since 1945 the

number of lobotomies doubled each year: from 240 in 1945, to

more than 5,000 in 1949.

A meta-study of 10,000 lobotomies performed in the UK

between 1942 and 1954 shows that 41% were fully cured or greatly

improved, 28% had little improvement, 25% seemed not to be

affected by the operation, 2% saw their symptoms aggravated and

4% would die as a result of the procedure. Indeed, a great part of

the studied literature shows a distribution of approximately a third

of 'favourable' results (where symptoms disappeared altogether or

at least greatly improved), a third of 'medium' results (where some

improvement can be observed) and a third of failures (no change,

or the patient's condition has worsen). Still, and although already

in the 1930s most professional widely and openly acknowledged

the ill effects of the operation, both physicians and family members

tended to consider the postoperative patient as better off, or even

cured.

Essentially, psychosurgery offered a source of hope for the

deliverance of the mentally ill from the misery of their existence.

This enthusiastic embrace, however, soon waned. By 1960,

psychosurgery did not only lose grace, but also acquired a

gruesome image as one of medicine's darkest episodes. Fewer and

fewer neurologists showed interest in the technique, research grew

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37

scarce, and its uses were to be confined to the darker rooms of

mental asylums. From a symbol of scientific progress,

psychosurgery came to be regarded as the craft of mad scientists

with ill-defined intentions of mind-control at best, and of pure

sadism at worse.

In the popular press, changes in the attitude towards

psychosurgery were evident (Diefenbach et al., 1999). The first

publications, initiated in 1936, were brief medical reports,

becoming increasingly detailed by 1941. The tone was largely

positive, the descriptions overstating the practice’s miraculous

effects. Between 1945 and 1954, the press became progressively

more critical, with a rising number of negative reports. It is only in

the late fifties that a strong polarisation occurred, with a typical

depiction of the practice as a form of “menticide” or “mental

euthanasia” (e.g. Baruk, 1953, 1956; Umbach, 1976; Chorover,

1974, 1979). With the rise of anti-institutional and anti-

governmental movements in the late sixties and early seventies,

many texts, mainly in the lay press, began to associate

psychosurgery with other forms of governmental excesses of power,

including malicious brain-control techniques. 'Brain-washing' was

so entrenched in the public imagination, that psychosurgery

immediately joined the list of techniques thought to be in the

arsenal of the opponent, whether in the form of agents of secret

services, or as radical communists seeking control over the

American mind.

Today, the concept of frontal lobotomy has some grim

connotations. Although by now, with the introduction of anti-

psychotics, the use of the technique has become extremely rare

(and much more advanced in both target, technology, diagnosis

etc.), an aversion towards the very concept of psychosurgery,

invariably seen as destructive and abusive, is still clearly present

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in a wide range of texts. When considered, ideas of brain control

and psychiatric abuses of power are woven into a fearsome tale of

the terrible consequences an unrestrained science may have. The

practice has become particularly notorious for its effects on

personality, and is said to produce individuals with no subjectivity

or 'sense of self', transforming disturbed patients into jolly, self-

content beings. Here I shall refer to these "soulless" or "empty"

patients (Valenstein, 1980b; Sachdev and Sachdev, 1997) as Homi

Vadum, Latin for flat, or empty, human beings, products of an

ontognostic invasion of the 'mind'. I will suggest that, in

contingence with the gnostic shift, these Homi-Vadum were

alternately seen as cured or simply damaged.

Creating Ontognostic Legitimacy

In line with the scheme of this work, I will argue that the

embrace of the practice was based upon one critical component:

the implicit and explicit use of rhetorical, symbolic, and

institutional measures in the creation and maintenance of a

scientific façade. This, I shall claim, will place psychosurgery

within the unquestioned ontognostic truth-basis of medical and

scientific work, thus forming a solid ground of legitimacy.

'Prehistorical' Sources

Although often ignored in historical accounts of the

development of the practice, the roots of psychosurgery can be said

to go as early as 1890 with the experiments of the Dutch scientist

Friedriech Golz. Golz reported the effect of the ablation of the brain

cortex in laboratory dogs, and suggested that this operation had a

calming effect on the subjects.

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39

This report led to the more ambitious (and controversial)

experiments of Gottlieb Burckhardt, the head of a large Swiss

mental asylum. He put forward the idea that the creation of a

barrier -in the form of a surgical cutting through nervous tissue -

between the cortex (conceived as responsible for the reception and

processing of sensory information) and the lower areas of the brain

(the 'motor areas') will relieve some of the pathological behaviour of

mental patients: and most particularly, behaviour that involved the

patients’ lack of control over themselves (Stone, 2001).

The first patient, Frau B., was considered to be "the most

dangerous and difficult" patient of the asylum. This 51 year old

woman, diagnosed with schizophrenia, was impulsive and violent.

She has been hospitalised for the last 16 years, mainly in isolation.

She once almost strangled to death one of the nurses, and did not

seem to be responsive to any kind of treatment known at the time.

Suffering from chronic diarrhoea and of a lack of proper hygienic

manners, she had to be assigned with two nurses around the

clock. She was particularly difficult to maintain under control as

she spent many of her days screaming in the halls of the asylum.

Burckhardt (1890, in Stone, 2001:83) then began to wonder

whether it would make any sense to:

"…extract this impulsive emotional element from her

brain mechanism, transforming her from an excited

patient to a calmer dement schizophrenic”.

Four surgical operations were conducted on Frau B. in the

course of the next fourteen months. Almost 15 grams of her brain

tissue were removed. Each operation seemed to have had a calming

effect on the patient. As Burckhardt himself put it:

“Though her intelligence seems to have been lost,

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40

she is now calmer and less dangerous”. (Burckhardt

1890, in Stone, 2001:83)

Of the other patients to go under Burckhardt’s scalpel, one

will not survive the operation, and another will commit suicide

shortly after. The positive effects on the subjects' hallucinations

and agitated behaviour did not, however, convince the psychiatric

community of the beneficial potential of this avant-garde

procedure. Burckhardt suffered from harsh criticism and was

forced to bring his experiments to an end, although claiming:

“I will not let myself be discouraged and I hope

neither will my colleagues, but rather, they will use

my experiences and go the way of cortical

extirpations and achieve continued better and

improved results”. (in Stone, 2001: 85)

Burckhardt died convinced of the potential hiding behind this

new technique, stating he could have turned asylum’s chronic

population into calm and satisfied mental patients.

It was not until the 1930’s that psychosurgery began to

resurge. Yet, its origins in Burckhardt's work were, perhaps most

conveniently, forgotten. Considered as utterly unscientific, none of

the more modern psychosurgeons wished to have their practice

associated with it.

Replicated Boundaries: The Professional and the Legitimate

I shall claim here that the boundaries created between

neurology and psychiatry represent replicates of layers of broader

sociocultural boundaries in Western thought: the boundaries

between objective and subjective. They reassert an ethos, a way of

thinking the world. Thus pure reason becomes pure objectivity,

Sky E. Gross

41

pure science: neurology as a mainstream biomedical and scientific

endeavour on the one end; and the fuzzy, the emotional, the soiled,

the subjective psychiatry on the other. Inside the category of pure

reason reigns order and inner classification, and outside: chaos.

Neurology of the mid-1930s was among the most prestigious

and fast-growing academic fields (Abbott, 1988; Pressman, 1988).

Comprising a rather small group of physicians, neurology sought

an alliance with psychiatry, a more commonly practiced, albeit less

prestigious, form of medicine (Abbott, 1988; Gelfand, 2000). By the

1920s, a unification of the fields was undertaken, to the benefit of

both professions. As knowledge on the anatomy and structure of

the brain began to accumulate, 'neuropsychiatry' of the early 20th

century became dominant in research on the cerebral basis for

mental illness (Marti-Ibanez et al., 1954; Lishman, 1992). However,

while 'pure' neurology pursued the incorporation of functional (or

'mental') diseases into the medical field, psychiatry remained

associated with psychological – i.e. non-medical— disciplines, such

as psychoanalysis (Fadda, 1988; Eisenberg, 1995; Shorter, 1997).

Once the physical lesion of a disease was understood, it was

passed over from psychiatry’s managing know-how, to neurology as

an expertise founded on complex and abstract knowledge

(Alexander and Selesnick, 1997; Seli and Shapiro, 1997).

Psychiatry was to rely on subjective, introspective accounts, or

symptoms. Neurology, on the other hand, could attain diagnoses

through quantifiable, communicable, and scientifically reliable

signs (Audisio, 1968; Price et al., 2000). The disciplinary separation

of what will become the fields of psychiatry and neurology is

strongly correlated with the distinction made between physical and

mental pathology. As more and more once believed to be mental

disease, have found their physical basis in brain pathology,

neurology has grown to encompass an enlarging group of brain

Black Butterflies

42

(and central nervous system) pathology. Indeed, over the years,

diseases such as aphasia and epilepsy have been relocated from

the blurry field of psychiatry to the more medical-like field of

neurology. The physical nature of disease will be attributed to any

brain-related pathology which physical basis can be understood

and clearly tagged. The psychic nature of disease will be attributed

to any mental syndrome for which no apparent 'physical' cause

could be found. The former group of diseases will belong to

neurology as a medical expertise, while the latter will be left in the

hands of psychiatrists, then conceived as mental asylum

practitioners, mainly directing day-to-day life conditions for mental

patients (more 'technicians' than 'experts'). Medical treatment for

actual 'psyche-related' disease will be inconceivable, since the

basic definition of such a disease is related to the absence of

known brain-pathology.

In other words, the separation between mental – and therefore

non-medical – disease, and physical – and therefore treatable

within medicine – disease, shaped the separation of psychiatry

from neurology, turning psychiatry into a mere nursing

specialisation. This process is not a simple labour separation

process, as the epistemological bases of both of the fields were

deeply affected by this psychophysic separation. One of the effects

is the large group of psychiatrists leaning towards new

psychoanalytical stances, growing apart from the medical model

that has excluded them and marginalised their practice. Early 20th

century saw two groups of psychiatrists beginning to emerge: while

the more psychoanalytically-oriented would insist on a

'psychogenetic' (originating from psychological processes)

explanation of mental illness, another substantial group will

persist in its search for the organic and neurological bases of

mental illness. While the former abandoned any aspirations

regarding the integration into the more mainstream medical model,

Sky E. Gross

43

the latter will strengthen its efforts to differentiate itself from the

'philosophical therapy' to resemble a more scientific model of

medicine. This quest will be the main drive of psychiatric research

into organic-based cures to mental illness, cures that were believed

to be able to form a bridge over the ever growing gulf between

psychiatry and neurology.

Thus, the areas of professional jurisdictions gradually aligned

themselves around a distinct, though implicit, principle: the

gnostic split. While neurology adhered to purely scientific

ontognosis, psychiatry remained in an awkward position: treating

psyche-related illness, yet holding on to an organic epistemology.

Psychiatry suffered from a lack of clarity as to its basis of

legitimacy, hanging in the midst between ontognostic and

phenognostic grounds, leading to a severe identity crisis present to

this day (Armor and Klerman, 1968; Torrey, 1975; Light, 1980;

Merino, 2000). At the time, however, relentless efforts were made to

medicalise (and thus 'truthicise' or 'make true') psychiatry.

Psychosurgery stood at the very centre of this task.

Building the Heroic Ethos

"Doctors are different in nature. One kind adheres to

the old principle: first do not harm; The other one

says: it is better to do something than nothing. I

certainly belong to the second category". (Gottlieb

Burckhardt, lobotomy pioneer)

This statement raises one of the central points contrasting the

Hippocratic notion of medical ethics with the kind of ethic

proclaimed by psychosurgeons. The 'primum non nocere' principle

cannot hold in the face of horrifying mental suffering, and

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44

Burckhardt, Moniz, and others felt they 'had to do something'. This

'something' took form in what was to become the psychosurgical

intervention.

While one can place some of science’s legitimacy within the

ethos of a pure and disinterested search for Truth, the mere

practicability and applicability of a scientific development may be

of no lesser significance (Gieryn, 1983, 1999). In practice, early

20th century's psychiatry held a meagre therapeutic arsenal:

asylum psychiatrists had to content with watching over the

mentally ill and nursing them in their daily routine (McGovern,

1985; Witz, 1992; Shorter, 1997; Abbott and Meerabeau, 1998).

Was psychosurgery to be proven beneficial, it would allow the

discipline to become medicine-like, thus becoming a cure rather

than a care specialisation (Sargant, 1976; Gieryn, 1983, 1999;

Swayze, 1995). This demarcation would then allow the

practitioners to draw upon the legitimacy placed in core medical

practice: the holding of measures that were both heroic and

therapeutic.

The Founding Tale

"For the physical therapy of mental disorders they

[the neuropsychiatrists] had the malaria treatment

of neurosyphilis and prolonged sleep.

Electroencephalography was in its infancy, shock

therapy by insulin and metrazol almost coincided

with leucotomy, radioactive isotopes were unknown,

and control of the autonomic system by

pharmacological means was just beginning. The

introduction by Moniz of cerebral angiography in

1927, and of psychosurgery in 1936 brought about a

revolution in diagnosis and treatment, the eventual

Sky E. Gross

45

extension of which is not yet in sight". Freeman

(1956:771).

An examination of the founding texts reveals that

psychosurgery's quest for scientific legitimacy involved a rhetorical

portrayal of the practice's birth as a momentous breakthrough.

Throughout the years, the tale of its burgeoning was reiterated in

the work of Walter Freeman, one of its most powerful and diligent

proponents. Within several important publications, Freeman

persistently re-established the ethos of psychosurgery's 'discovery',

by Egas Moniz:

"[At the Neurological Congress of 1935, in London,

during their presentation, Jacobsen and Fulton]

noted a profound alteration in response to

frustration in the chimpanzee with both frontal

poles excised. Before the operation, if the animal

made a few mistakes, it would scream with rage,

urinate and defecate in the cage, roll in the feces,

shake the bars and refuse to continue in the

experiments. After the operation [the excision of the

frontal lobes], the same animal would continue in

the experimental situation long beyond the patience

of the examiner, making mistake after mistake,

without the least indication of being upset

emotionally." (Freeman and Watts, 1947:417)

Freeman, among others in the field, depicted Moniz as having

stood up in admiration of Jacobsen and Fulton's presentation. He

is said to have inquired as to whether the reproduction of such

attempts on human would be conceivable. The murmurs of

disbelief in the crowd did not discourage Moniz. In fact, he is

Black Butterflies

46

claimed to have returned to Portugal, his home country, and to

have soon begun his experiments.

This founding tale is present in numerous reports, while,

according to Pressman (1988), having little grounds on reality. The

drawing of the events seems to serve as a constitutive myth, much

less than as a historical account. In a way, the portrayal of Moniz'

deductive mind offered the endeavour a halo of insightful scientific

thought.

Out of the Laboratory

Psychosurgery's initial association with neurology, rather

than psychiatry, would (and eventually did) provide a powerful

stamp of legitimacy. Thus, not incidentally did Freeman observe

that Moniz' 'Eureka' was sounded in the course of a prized

academic neuro-anatomical presentation, and in response to

empirical data advanced by two of the world's most prominent

neurologists: John Fulton and Carlyle Jacobsen. Walter Freeman

and his associate, James Watts (1947:417) begin their presentation

of ten years retrospective on psychosurgeries by presenting the

founding tale again, stressing psychosurgery’s basis on a logical

derivation from the respectable scientific laboratory work on

animal anatomy:

"Moniz presented many of his angiograms at the

Second International Neurological Congress in

London in 1935. It was at this Congress that the

symposium on the frontal lobes brought forth a

great deal of discussion concerning the disturbing

effects upon personality that followed wounds and

tumours in this region. […]". (Freeman, 1956:769)

Sky E. Gross

47

The presentation of psychosurgery as evolving as part of an

existing line of work in the scientific community did seem to have

had an effect on its endorsement, if only by asserting its position

within an ontognostic 'normal science' (Kuhn, 1970). For instance,

linking the practice to the body of accumulated knowledge on brain

localisation, Marchand and his colleagues reported that frontal

lobotomy would allow to "enrich our anatomo-physiological

knowledge of the human brain." (Marchand et al., 1949:515). Moniz

himself sought to advance psychosurgery's position within his

contemporary’s work on the localisation of cerebral functions,

thoroughly underlining his leaning on "anatomical, physiological,

and clinical facts" (Moniz, 1936a:55).

"In the brain there are regions that are particularly

related to mental activity. If we wish to drift away

from this organic orientation, we will enter domains

that seem to us entirely unacceptable". (Moniz,

1936a:40)

"Psychic life is exteriorized in a different manner,

but completely comparable to other functions of the

organism". (Moniz, 1936a:41)

Indeed, the texts of the period defined the benefits of the

practice not only in terms of the relief it could allow the mentally

ill, but also in terms of the potential accumulation of knowledge on

the brain and its functions. There, by being able to spatially define

the mind, science could replace explanation by classification.

Moniz will then take part in the quest for the Holy Grail of science:

the mind. This presented psychosurgery as a symbol of a genuine

scientific quest for 'Truth' through objective observation and

Black Butterflies

48

methods of trial and error, as a bold empirically-oriented

endeavour:

"[if our experiments prove to be successful] we

would have put in relation, and in a definitive

manner, the mental functions, and the parts of the

brain that take part in their production. It would be

a great progress as a primordial fact in the study of

the organic bases of the mental functions". (Moniz,

1936a:55)

In sum, the underlining of this empirical basis served to

reinforce the founding myth, and to support the rhetoric placing

the procedure on an ontognostic-based legitimacy, as out of the

laboratory, the 'factory of Truth'.

Men of Science

Freeman (1956:770) speaks of the basis of the resistance to

the 'discovery' by the medico-psychological society in Paris, 1937.

He explains:

"Here was a brilliant discovery belittled through

political antagonism and possible professional

jealousy, but more likely through philosophical

tenets that blinded Sobral Cid to the extraordinary

alterations that occurred in psychotic subjects at the

moment of prefrontal leucotomy".

Thus, the antagonism was based on three purely "subjective"

grounds: political antagonism, professional jealousy, and

Sky E. Gross

49

"philosophical tenets". Moniz himself is presented as being

"extraordinarily modest":

"He was never flamboyant in his speech; rather he

lectured or presided with courtesy and dignity, and

gave expression to his thought in measured terms.

His was an inner life of thought rather than an outer

one of action" (Freeman, 1956:771)

or,

"…He was also able to present to the scientific world

the results of his meditations and experiments, often

in the face of considerable opposition, including

attempted piracy and murderous assault. The

intellectual vigor of the man, hampered by physical

handicaps, indicates true genius". (Freeman,

1956:771)

Freeman tells us that Moniz is a 'true scientist' in his refusal

to allow non-scientific groups interfere with him getting the

message through to the 'real' scientific world. Interestingly enough,

in 1956, the year this article was published, Freeman himself will

be facing powerful antagonism. Reifying his own status as a 'true'

man of science, Freeman's portrayal of his work (through Moniz')

used the image of a modern day martyr of science: a man so

dedicated to a purely scientific endeavour as to be willing to endure

opposition, however harsh. Freeman, like Moniz, was but a

misunderstood genius.

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50

Locating the Mind

Moniz, in his book (1936a:40) states over and over again that

the central nervous system (which includes the brain) is the seat of

mental manifestations. The physical is the ontological basis of the

explicit phenomena of the mind:

"In the brain there are regions that are particularly

related to mental activity. If we wish to drift away

from this organic orientation, we will enter other

domains that seem to us entirely unacceptable".

"Psychic life is exteriorized in a different manner,

but completely comparable to other functions of the

organism". (Moniz, 1936a:42)

These claims did not grow in a vacuum. The ontognostic

foundations of biological psychiatry (or 'neuropsychiatry') can be

traced back to Franz Joseph Gall’s phrenological theory, which, at

the beginning of the 19th century, linked brain and skull structure

to personality traits (Barker, 1995). Indeed, not unlike phrenology,

the reason for the success of this popular (albeit later declared only

'pseudo' scientific) predecessor in the study of brain localisation:

"The reason for this [success] was the astounding

nature of its claim: that it solved at one stroke the

problem of the mind; that it gave a complete and

accurate picture of the nature of the mind and at the

same time defined and fixed its functions" (Grant,

1968)

Gall (1808:5) himself will claim to seek to:

"…grasp the material conditions of the immaterial

Sky E. Gross

51

principle, which manifests itself through its action,

and seems to undermine our research".

Later studies of brain localisation, such as Broca’s and

Wernicke’s in 1861 and 1874 respectively, persuaded many central

figures -such as Meynert, Liepmann, Charcot, Kraeplin, Freud and

Alzheimer - that the brain was indeed the seat of both mental

functions and mental pathology (Young, 1970; Barker, 1995;

MacMillan, 1996; Kolb and Whishaw, 2003). Freud's work,

although developed along different lanes, was itself based on a view

of the brain as the physical seat of psychic activity. In fact, in his

well known "Beyond the Pleasure Principle" (Freud, 1955[1920]), he

is unambiguous: one needs to apply strict empiricism, reject

speculated metaphysical explanations, and keep in line with

scientific methods. By progressing from observation to theory, one

would find the key to understand the workings of the brain. This is

precisely how psychosurgery's early proponents sought to portray

their undertakings.

World War I further produced clinical evidence on the various

effects of head traumas, thus contributing to already the dominant

trend of cerebral localisation. Studies used more and more

elaborate methods, including electrical stimulation, post-mortem

investigations, experiments on animals, and later, different imaging

techniques. All would suggest some important correlations between

function and location.

Although the understanding of 'higher' brain functions (such

as thought, imagination, emotion) still lingered, even in the context

of mental disease, localisation was still able to replace a nebulous

notion of the mind as a vague spiritual essence, and assert its

fundamental form as purely material. This provided psychiatry a

clear epistemological primacy over claims based on phenognosis,

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52

thus justifying a denigration of subjectivity, reducing it to mere

products of brain function.

Psychosurgery took on this lane of scientific studies by

asserting, de facto, the spatial grounding of the mind as well as its

material ontology. Porot (1947:126), for instance, describes the

surgical proceedings of Freeman and Watts:

“The surgery is usually conducted with local

anesthesia. After the surgery, X-rays are performed

in order to precisely localize the plan of the section.

The films are put against the trepan holes”.

Thus, by endeavouring a mapping -however primitive and

restricted- of the mental, the technique drew significant attention,

undoubtedly more than any other non-localised attempts to treat

psychopathologies (such as shock therapy from the early 1930s,

and, in the second half of the century, psychoactive drugs). A more

thorough study of the literature supports this assertion. Much of

the work on psychosurgery involved notions of gross anatomy, a

few practitioners going as far as to weight the brain tissue excised

in the course of surgery. According to Puech (1949:117), for

example, 72% of the cases operated on had a "macroscopically

pathological brain". This anatomical knowledge, as general and

imprecise as it may have been, may have well served as a source of

authoritativeness grounded on materialist ontological concepts.

However, once the localisation of mental illness was largely

discredited as a scientific endeavour, the idea of gross intervention

into the brain to alter mental status began to seem unreasonable

(Koupernik, 1977). The cutting of brain tissues, considered then as

the epitome of the scientific ethos, now served as a rebuttal to the

practice. Baruk (1956), for instance, will claim that psychosurgery

Sky E. Gross

53

should be morally forbidden since it would transform a functional

disorder into an irreducible disease. The idea of physical

intervention into the realm of the mental began to lose its

association with a momentum of scientific advances.

Medicalising the Mind: Symbolic Correlates of Ontognosis

This trend soon moved from the field of research to the field of

practice. As noted, ontognosis lies within an overwhelmingly

materialistic episteme where the primal focus of attention is the

body (Eisenberg, 1977; Dew, 2001). This predisposition involves a

form of objectification by which the human body is stripped of its

subjectivity and transformed into a plain object (Babbie, 1970;

Csordas, 1994). An ideal form of these processes occurs in the

operating room.

Surgery, by definition, demands a suppression of the

subjective, and the reduction of the human body from a sentient

whole into a seemingly lifeless object, accessible to dissection and

rearrangement. The creation and maintenance of the operating

room as a well-guarded shrine of ontognostic purity are supported

by a surgical ethos as well as by several symbolic elements (Katz,

1981, 1999; Fox, 1992, 1997). These include, for instance, the

scrubbing rituals preceding the entry into the operating room and

the elaborate draping of the patient which absorbs him/her into a

small, depersonalised, objectified body-part upon which the

surgeon holds complete visibility (Hirschauer, 1991; McNay, 1991).

This 'symbolic theatre' thus creates a demarcated space within

which ontognosis prevails4.

In the case of psychosurgery, a surgical blade was employed,

literally, to excise sentient experience, to subordinate it --by means

4 This point will be further developed at a later chapter.

Black Butterflies

54

of a simple sway of a knife-- to the realm of matter. Again, altering

the spirit through the severing of a physical essence provided clear

evidence to the spatial subsistence of the mind, as well as to its

materiality. Although most biomedical practices do hold implicit

reductionist bases, seldom do they constitute, in and on

themselves, such powerful proclamations on the very nature of

mind-matter relations. Psychosurgery, however, did not only

comply with ontognosis, but also substantiated it by providing it

direct and unequivocal evidence. As practiced, it was not only

reductive, it also reduced: It brought the mind onto the surgical

table based on it being deemed operable, but ipso facto, it also

created and recreated this 'operable mind', this ontognostically-

approachable mind.

This may explain why other measures, such as

psychopharmacology, did not raise nearly as much outrage as

psychosurgery. The introduction of anti-psychotics in the mid-

1950s did have direct effects on the practice of lobotomy, and the

former almost instantly substituted the latter as the treatment of

choice in cases of severe agitation and hallucinations (Snaith,

1994). Clearly, psychopharmacology offered a less costly, safer

alternative, with more readily visible and immediate results, as well

as less serious and permanent side-effects. This brought about

psychosurgery’s transition from a state-of-the-art endeavour to a

second-line treatment at best.

More significantly, however, psychopharmacology proposed

what was, at least in appearance, a more subtle paradigm of mind-

brain activity. Although equally based on ontognostic views and

although equally establishing a domination of brain over mind,

some of its characteristics were more compatible with phenognostic

views than its therapeutic predecessor’s. First were the symbolic

aspects of its administration, involving the body as a whole, rather

Sky E. Gross

55

than a small, spatially defined area where 'the mind' would be

seated. This stood in clear contrast to the protruding intervention

and intrusion of an external, technical, and artificial object: the

lobotomist's knife. Second was the fact that the mechanisms by

which the psychoactive substances actually affect the brain are

still little understood, allowing the 'mind' to retain its mystique as

being too complex for science to grasp. Psychopharmacology’s

superiority over psychosurgery, thus, would be more than just

therapeutic: its characteristics would be more in line with

epistemological assumptions on the nature of the mind. While this

may not be enough to explain the replacement of one treatment by

another, it may well account for the lesser magnitude of the debate

surrounding drug therapy.

Another form of physical therapy for mental illness should

perhaps be mentioned in this context: Electroconvulsive therapy

(ECT), better known as 'shock therapy'. This technique, introduced

in the 1930s and still of widespread use in treatment centres

around the globe, involves the induction of electric stimulation5

causing the patient transient seizures. This would be highly

effective in cases of severe depression, and to a lesser extent, in

some cases where psychotic symptoms became unmanageable

(Braslow, 1997). The mechanisms of ECT's action are still poorly

understood, although two main sets of explanations were brought

forward: psychological and physiological. According to the former,

the shocks would be so unpleasant to the patient to have him

cease his 'bad behaviour'. On a more psychoanalytic note, it would

satisfy an unconscious need to be punished. In contrast, according

to the physiological thesis ECT will have the brain respond to the

electrical charge by altering its own electrical activity and restore it

5 The first attempts to incur states of shock for psychotherapeutic ends involved insulin injections. The technique was relatively short lived.

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56

to its functionally optimal level. Not surprisingly, by now, the

physical explanation is regarded as more sensible.

As with psychosurgery, the usage of the technique will

become less common with the apparition of psychoactive drugs,

but readopted with the disenchantment from psychopharmacology,

from the 1970s onwards (Friedberg, 1977; Weiner, 1984). Since,

the procedure has greatly improved, reducing side effects such as

memory losses, limb fracturing, and general anguish to the patient.

The debates over both psychosurgery and ECT followed psychiatry

throughout its development as a legitimate 'cure' expertise

(Valenstein, 1986). The latter, however, remains in use to this day

and is still given a place of honour in the panoply of psychiatric

treatments (Alexander and Selesnick, 1997).

As with psychopharmacology, there are several symbolic

characteristics which may serve as a complementary explanation

for ECT's more lasting state of legitimacy. First of all, there is no

actual opening of the skull, nor direct contact with the brain, the

'organ of the mind'. Secondly, the effects are believed to be (at least

in the public eyes) less irreversible than psychosurgery.

Furthermore, these effects would not include actual personality

changes, but rather temporary losses of memory or transient states

of sedation or psychocognitive 'numbness'. Another factor may be

the general acceptance of the idea of brain function as based on

electrical exchanges, rather than on gross anatomical processes (as

claimed by proponents of psychosurgery). Finally, as in the case of

psychopharmacology, non-localised, less direct, and less

ontognostically ritualised procedures seem to find a more accepting

attitude in the laps of a publicly scrutinised psychiatry.

Sky E. Gross

57

Losing Grounds: Away from Ontognosis

The Traps of Rhetorics: Facing the Debate

Throughout the first stage of the debate, it was evident that

psychosurgery held a strong ontognostic position of legitimacy.

Science, Babbie (1970:14) tells us, is ideally amoral: its role is to

judge on questions of truth and falsehood, not on questions of

right and wrong (or what would be moral or immoral). Indeed,

initial disapproval of the practice belonged to the realm of science,

and not of ethics: Opponents insisted that the practice of

psychosurgery was justified by poor research methods. More

specifically, it would be claimed that a systematic, empirically-

based assessment of outcomes was unattainable, none the least

because more than twenty different techniques developed over the

years, a similar number of theoretical rationales proposed, and

more than a dozen different sites targeted (Huyn-Dornier, 1992;

Kolb and Whishaw, 1994; Pressman, 1998; Feldman et al., 2001).

While initially, the disapproval of psychosurgery focused on

the delicate process involving the choice of lesion as well as on the

intricate selection of candidates, it became increasingly apparent

that the results of psychosurgical procedures were equally difficult

to assess: First was the lack of precision inherent in the technique

(Andy, 1977; Lopez-Ibor and Lopez-Ibor, 1975; Ballantine, 1980).

Secondly, the patients were typically under several therapeutic

courses, which made the attribution of success or failure less than

certain (Bockoven, 1950; Bockoven et al., 1950). Thirdly, the group

of patients operated on was nosologically heterogeneous: there was

no common pathology that could be given to proper

experimentation (Malizia, 1997; White, 1998).

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58

In these respects, the practice proved to be in discordance

with a valid scientific model by which results could lead to a

falsification of the theory (Popper, 1965). The responses to some of

these claims involved a drawing on the words of psychosurgery's

mythical father, Egas Moniz, who reported his attempts as

representing but a first success, still needing refinement (Moniz,

1936b). This portrayed the procedure as correctable and dynamic,

staying in touch with empirical facts and ongoing observations.

Practitioners, rather than addressing ethical and moral questions,

continued to urge the development of better and more precise

surgical techniques, and for a more effective choice of candidates.

The discussion remained almost entirely restricted to the 'science'

of the practice, keeping relatively insulate from the spheres of

public debate. The procedure indeed grew more precise and less

hazardous, thereby diminishing both frequency and severity of its

side-effects (Fairman, 1950; Greenblatt and Solomon, 1953;

Hitchcock et al., 1972; Gildenberg, 1975).

Although these responses did allow for some justification for

psychosurgery’s shortcomings, the initial questioning of the

practice will result in an abrasion in its status as a pure scientific

endeavour. De facto, psychosurgery surrendered itself to public

scrutiny.

The Traps of Science: Methods and Rationalisations

Moniz conducted the first operations with a methodical

approach, both with the dosage of alcohol he injected into the

brain, and with the choice of medical apparatus. Beginning with

the use of a Berthelemy's syringe, he went on to design a

specialised instrument: the leucotome, a device used as a way to

pit (as one would do an apple) selected sections of the brain (Moniz,

1936a).

Sky E. Gross

59

The procedure was such that a hole would be drilled into the

patient’s skull (depending on the patient, this would be performed

under local or general anaesthesia), and the device would be

inserted into the frontal lobes of the brain. Then, the steel thread

attached to the leucotome would be manipulated to cut through

the white matter (where neuron cells are linked), and dissociate

'pathological' neuronal connections. Based on Moniz’s reports, we

could abridge the rationale behind the procedure as such:

Healthy psychological functions depend on a flexible and

adequate set of neuronal connections within the brain;

Mental disease is due to a malfunctioning of these sets of

connections, the lack of flexibility leading to pathological "idées

fixes";

To alter one’s pathological fixed ideas, it is necessary to

disconnect the underlying nervous ties;

Psychological activity is mainly located in the frontal lobes of

the brain, although we are still unable to precisely locate and

differentiate the different functions;

An ablation of the frontal lobes will not result in irreversible

psychological damage;

Based on those assumptions, Moniz decided to concentrate

his efforts on the frontal lobes of the brain, and cut through

pathological nervous connections, which are, according to him, the

basis of pathological ideation. Rather faulty or not, Moniz

presented an elaborate theoretical basis for his work, a basis which

he would carefully associate with neuroanatomical advances of the

time.

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60

The Traps of Symbolics: Freeman and the Ice Pick

Some years later, psychosurgery's most fervent supporter,

Walter Freeman -himself not qualified as a surgeon- contemplated

on transferring psychosurgery from the sacrosanct operative room

into the mundane world of the asylum. In fact, he went as far as to

suggest psychiatrists employ the procedure within the setting of

their own private practices. This brought Freeman to propose, in

1947, 'Transorbital Lobotomy', a procedure based on the insertion

of an ice pick (on which the name of the ice company was still

engraved) through the eye orbits, and into the frontal lobes of the

brain. The psychosurgeon would then manipulate the instrument

in swift vertical movements and sever groups of nervous

connections. The operation barely lasted a few minutes and

allowed Freeman to perform dozens of lobotomies a day.

Freeman ignored much of the developing models of

neuroanatomical functioning, and suggested but a primitive

rationalisation for his work: The idea behind the operation was to

cut-off the frontal parts of the brain (which were believed to be

associated with self consciousness, as well as rational and

imaginative thought) from the more irrational, affective lower parts

of the brain, and, further in the back of the skull, from 'primitive'

areas. By so doing, a certain measure of affectivity would be lost,

making the pathology less significant for the mentally disturbed

patient. This was, at the time, an explanation that was considered

weak to the very least and improbable at best.

This and more, Freeman's instrument was a mundane, non-

medical object. Transorbital-Lobotomy turned the practice into a

form of 'non-surgical surgery', most particularly with the

introduction of a 'psychiatrist-friendly anaesthesia', based on

electroconvulsive shocks. In fact, unlike Moniz, who conveyed his

Sky E. Gross

61

patients from mental asylums into his well-equipped operative

room, Freeman chose to perform some of the surgeries in his own

consultation office (Bernstein, et al., 1975; Valenstein, 1986).

Neurosurgeons soon objected this trend. James Watts,

Freeman's co-author in major psychosurgery publications, decried

transorbital-lobotomy, claiming it unbearable to witness this:

"….theatrical sideshow, with Freeman administering

electroconvulsive shock for anaesthesia, holding an

ice pick for a surgical instrument, and taking no

time to wear gloves" (quoted in Valenstein,

1986:257).

The lack of medical caution in the care of the postsurgical

patients was also apparent in many of the reports:

"…In the first hours, one has to watch the patient

very carefully, as he is completely unaware of his

condition and may, as we have recently reported,

tear away his bandages and put his fingers into the

surgical wound, and up through his brain, which can

lead to unfortunate consequences". (Porot,

1947:127)

The drifting away from the rituals involved in surgery, as well

as its detachment from the powerful ethos and symbolic aspects of

medical practice and science, undoubtedly contributed to

psychosurgery's declining legitimacy as an endeavour based on

scientific, ontognostic demarcation. Its introduction into the

asylum and away from the control of specialised neurosurgeons

denuded it of its biomedical aura and demoted it to the mundane

universe of daily-life. Ironically, while supporting psychosurgery

until his very last day, Freeman contributed to the vulgarisation of

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62

the practice and to its consequent decline (Pressman, 1988, 1998).

The role of conquering the realm of the mind could not be left in

the hands of mere 'technicians', and this is precisely what Freeman

portrayed himself to be.

From the Medical into the Social and Back Again

By the 1970's, ethical issues began to surface. A powerful

public scrutinising both created, and reflected upon the loosening

of medicine's epistemological demarcation from the spheres of

political, ideological, and professional interests. Parallel to the

development of the critical debate on psychosurgery, was an

erosion of the autonomy usually attributed to scientific practice,

placing it on pedestal, away from political, ideological, and

professional interests, hence the rise of the larger field of

'bioethics', and its association with issues of science and the social

(Gieryn, 1983).In fact, scholars such as Freidson (1970) made

'autonomy' the definitive component of professionalism as a

cultural authority: the involvement of any governmental regulation

on science would therefore be detrimental for its distinction as a

pure arena where only Truth prevails (Gieryn, 1983). Public

scrutiny will lead to the practice's loss of absolute authority and a

decrease in its scientific autonomy, and thus, power and prestige

(Rudin and Zimmerman, 1978; Goldbeck-Wood, 1996; Snaith,

1997).

Social Control and the State

An important polemic arose in the 1970s following the

publication and wide circulation of Mark and Ervin's monograph:

"Violence and the Brain". In this text, the authors proposed a

surgical intervention that would solve the social problem of

violence: psychosurgery. A suggestion within the same range

Sky E. Gross

63

appeared a year earlier, encompassing a vision of a utopian

'psycho-civilised society', where individuals would be controlled

through electrical brain stimulation (Delgado, 1969; Mark and

Ervin, 1970). The outrage was immense, and reflected the changes

in the assigned power of medicine, and more particularly, of a

medicine of the mind: its intervention into the social, however

effective, constituted now but a malice intrusion into an illegitimate

area (Chorover, 1980). Equally, the very involvement of social

interests in the provision of medical treatment became increasingly

objectionable, in sharp contrast to the formerly accepted vision of a

'psychosocial' medicine (Breggin, 1975; Scheflin and Opton, 1978;

Kaimovitz, 1980).

That being said, the psychosurgical treatment of certain cases

seems to have been more controversial than others, such as in

instances of criminal deviance, and, to a perhaps even larger

extent, where homosexuals and children were chosen to undergo

the operation. This led to a perception of psychiatric treatment as a

means of social normalisation, and further reinforced the view of

an omnipotence of the institutionalised power over the individual.

This would remain an issue of concern to this day, as Howard

Dully, a lobotomy 'survivor', will open his 2008 biography with:

"In 1960, when I was twelve years old, I was given a

transorbital or 'ice pick' lobotomy. My stepmother

arranged it. My father agreed to it. Dr. Walter

Freeman, the father of the American lobotomy, told

me he was going to do some 'tests'. It took ten

minutes and cost two hundred dollars" (Dully and

Fleming, 2008: ix)

Another troubling element was amplified by the air-du-temps

of a post WWII Western world: The association of the technique

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64

with attempts to apply 'Brain Control' over the general population.

The period of World War II, with the eugenic notions of sterilisation

and euthanasia of deviant population, brought a certain sensibility

regarding issues of mind control, and questions of social control

over individual differences. Freeman himself would declare that the

best candidate to undergo lobotomy would be "women, black and

Jews". Those were described as having a lesser degree of initiative,

and therefore as expected to have lesser difficulties in adapting to

their new post-operatory personality (Brisset, 1949). The relation

with localisation, this powerful enterprise of revealing the mind

through a science of the brain, associated psychosurgery with what

was seen as a perhaps equally dangerous trend: control through

omniscience. The ability to see through the mental would create a

dangerous panopticon, at the head of which would stand

neuroscientists accompanied by 'surgeons of the mind'.

Psychosurgery found itself connotating with such

controversial ideas, an association not totally unfounded.

Dystopic Prospects: Psychiatry in Charge

How much could mental patients be seen as responsible for

their own choices? How much control should the psychiatric

institution and caretakers in general have on their decision

making?

Informed consent is a central issue in all questions relating to

therapeutic choice. Yet, it seems to be even more complex in the

context of psychosurgery. The fact is that informed consent is

difficult to assert in the case of mental patients, especially those

locked behind the closed doors of the world of the asylum. A

second problem is based on the assumption that psychosurgery

brings about basic changes in the patient’s self: does it not mean

Sky E. Gross

65

that the patient agreeing to go through the operation is not the

same person coming out of it, in him\her having an – at times

radically- different constructed image of him\herself, his\her

values and preferences. The 'neuropacified' patient has better

chances to be compliant with the advices of his caretakers: this

would hardly mean that his pre-operation person had 'genuinely'

consented to be mentally transformed: this, especially considering

that the effect of 'pacification' and the general agreeableness of

post-operative patients may have been, after all, the very target of

the procedure.

This claim is also likely to be based on the fact that the first

patients to undergo psychosurgery suffered from severe psychiatric

symptoms. Since indeed, the intensity and duration of those

symptoms were the main criteria for selection, we can see a large

heterogeneity in the nosological categories of the different patients.

The diagnosis as such, then, had little to do with the decision as to

whether or not proceed with the operation. Moreover, although

countless studies showed that the main indication was the

presence of anxiety and a diagnosis of obsessive-compulsive

disorders (regardless of the severity of the symptoms), the

aggressiveness and agitation of the institutionalised patients still

formed the main criteria for the decision to operate.

Back to Society: The Social Cure

“…[Interesting is] the case of a 15 year old young

girl, who was going through episodes of violent rage

during which she would rhythmically hit her head

on the ground or on the wall, or would bit her hands

and knees and scream for hours. Her parents were

forced to attach her hands and legs to her bed as

well as her head and chest. After the surgery, this

Black Butterflies

66

girl could be left alone with her toys; she walks

around the apartment, eats on a table. She has

become capable of living in society. Such a result

aids in legitimizing lobotomy…”. (Klein and Tardieu,

1949: 113)

The patient could be back to 'society'. This idea of a

'psychosocial medicine' was evident in the context of

psychosurgery, where the position of medicine vis-à-vis the social

sphere formed a central issue. Practitioners were clearly

unapologetic when stressing the social aspects of the 'cure'. For

instance, according to the concept of post-operative re-education,

lobotomy would allow patients to become candidates for active

'pedagogic intervention'. In one such 'lobotomised school',

established by Joseph Farmer in 1948, therapeutic progress

included three elements:

"Lowering the tone in delirium and hallucinations;

gradual modification of behavior; and progressive

adaptation to exterior circumstances" (Brisset,

1949:491).

This reframed the intervention as a cynical brain erasing and

rewriting, compromising the sense of self-determination of the

psyche and the agency assigned to the individual- all central

elements of a phenognostic discourse. Proponents acknowledged

this loss from the very beginning, but considered it as a relatively

small price to pay in return to the benefit of re-socialisation:

"Whether the effects of frontal lobe deficit will

neutralise or accentuate the disharmony already

present, whether the individual will be able to think

more constructively with less brain at his disposal,

Sky E. Gross

67

whether the relief of the depression and its

conversion into euphoria will permit of adequate

adaptation in society, and whether the individual so

treated stands a better chance of survival in the

highly competitive society of today than he would

with intact frontal lobes and a potentially

recoverable psychosis." (Freeman et al., 1942:214)

Or, according to Porot (1947:130):

"Their [the post-surgery patients’] behaviour is as a

rule impeccable since, even more so than normal

person, they are sensitive to the demands their

education impose on them; they also know with

much precision the sanctions that are involved in the

transgression of moral codes".

Hence the growing (but eventually little effective) demand for

the legal regulation of psychosurgery (the then famous 'Habeas

Cerebrum'). This demand most often referred to the question as to

whether the psychiatric institution has a legitimate right to act

upon the minds of institutionalised individuals, might they be

conceived as mentally ill or as responsible criminals.

Illegitimate Interests: The Costs of Mental Asylums

In the beginnings of the 20th century, a patient entering a

mental asylum had lean chances of ever coming out alive. In

Warren Hospital in Pensylvannia, for instance, 75% of patients

would die in the five years following their first hospitalisation

(Duffy et al., 1997).

The two World Wars brought a growing rate of

institutionalised mental patients, which turned 20th century

Black Butterflies

68

asylums into crowded 'human warehouses', with no efficient

treatment available. In is in that context that Fulton, at the time

optimistic about the treatment, will declare that psychosurgery

should be able to decrease the number of institutionalised patients

by a fourth and save close to a million dollar a day for the tax-

payer. Even patients not be able to be released after a lobotomy will

at least be more manageable, not requiring as much staff and

facility costs as the pre-lobotomised patient (Swayze, 1995). Other

proponents will talk of 40% of mental patients being able to be

released after psychosurgical treatment (Sargant, 1976).

Anti-psychiatry advocates could easily use these types of texts

to establish their claims: psychosurgery, as an important

constituent of psychiatry’s therapeutic arsenal, was but a

conspirative means for social control not only at the state level

where it is embedded within political and ideological interests: This

'surgical strait jacket' also served ill-intended asylum psychiatrists,

seeking to make their patients more manageable, both in the

asylums and in the home – thereby benefiting the patient’s

caretakers as well. For Baruk (1956), for example, these

procedures would only serve to relieve some unmanageable

symptoms, and will have no effect on the patient’s well-being as

such. He himself could base his claim on the very words of

psychosurgeons:

"We are familiar with this lamentable picture of

these children with profound imbecility who are but

a long scream and whose agitation makes life

impossible for their parents or any other persons

who would be willing to take care of them. An

intervention holding but a modest intent to cease

this agitation is received as a deliverance by the

family". (Klein and Tardieu, 1949:116)

Sky E. Gross

69

In effect, Szasz (1977), arguably the most important figure in

this anti-psychiatry movement, was himself not opposed to

psychosurgery per se, but regarded it as yet another instrument at

the hands of a coercive institution seeking to eliminate individual

autonomy of thought, experience, and action: turn individuals into

'Homi Vadum'.

The Homo Vadum

Black butterflies appear on Walter Freeman's 1942 book

'Psychosurgery', and represent the releasing of madness from its

captivity, under the skull, inside the brain. By destructing their

prison of material flesh and bone, these creatures of the mind will

be freed back into their own universe. Black butterflies endanger

the materiality, efficient causality, and orderliness of the physical,

the brain. By doing away with these uncanny creatures, order

could be restored, control re-established. The brain would be but a

bodily organ. Ideas of free will, of an immaterial and unreachable

mind, of the unobservable phenomena of subjective experience will

all be cast out from a medicine of the mind: either tamed or

overthrown, madness will cease to operate its threat on ontognostic

reason. It is only when the price of these 'emptied' brains, i.e., the

loss of a phenognostic compass, became intolerable that this

surgery of the mind became a practice with victims and

perpetrators, rather than patients and healers.

While the outcomes of psychosurgery were of a wide range,

the 'flattening' of human subjectivity is by far the most discussed

in both professional and lay literature. According to these

accounts, the personality of the lobotomised patient hold fairly

consistent traits, including a so-called 'loss in human's superior

mental capacities', such as creativity, reflexivity, and fore vision:

Black Butterflies

70

"The lobotomized patient achieves his

normalization at the price of the vertical component

in his being-in-the world, at the price of a loss of

horizon and perspective […] Neither hopes nor fears,

desires, nor regrets can present themselves in his

greatly reduced temporal horizon…". (Vidor, 1963,

in Freeman, 1965:654).

or,

“The outstanding feature [of the emotional set that

characterizes people who have been operated upon]

is a lack of self-consciousness […]. They cannot be

insulted; no matter what one says to them, they do

not take offense. They laugh easily and flare up in

anger on slight nagging or frustration, but seldom

weep. […] Life is enormously simplified by the

relatively complete obliteration of the need for

introspection.” (Freeman and Watts, 1947:416).

The rationale Freeman (1951) provided for the workings of

prefrontal lobotomy seems to reflect this notion. As discussed

earlier, according to Freeman, the frontal lobes inhabit the

functions of foresight, imagination, and the consciousness of

oneself, while their emotional tonality is provided by the limbic

system located deeper within the brain. A disconnection between

the two areas will pacify the emotional tone, or associated

phenognostic experience, of any higher-level functions.

Hallucinations may still be present, but will not necessarily be

experienced as 'true' to the individual.

Sky E. Gross

71

The Homo Vadum's Brain

According to many contemporary psychosurgeons and

neuroanatomists (e.g. Porteus, 1955; Bouchard, 1968), the effects

of psychosurgery on patients' personalities would be related to the

damage incurred to the frontal lobes, 'the seat of higher functions'.

Moniz (1936a) linked the frontal lobes to the higher human

functions of planning, controlling 'lower' needs of the organism,

such as hunger or sexual drive. The frontal lobes were further

claimed to be related to the ability of learning from experience,

doing purposeful acts, that is, acts that are beyond reflexes and

automatic responses6. This is which places them at the centre of

Moniz' book:

"Two categories of clinical facts can be used in this

study: the different types of lesions of the frontal

lobes and the results of mutilating surgical

operation on these lobes" (Moniz, 1936a:30).

He reports:

"We have noted with those who have injuries of the

frontal lobe disorders of voluntary attention skills

and of mental synthesis. They are in fact incapable

of the most simple of intellectual tasks; they are

unable to group and orient the different elements of

a given problem. […] in sum, the highest

manifestations of psychic life are altered". (Moniz,

1936a:31)

6 These assertions are generally believed to be correct to this day

Black Butterflies

72

"It is […] certain that the frontal lobes tumors

present, above tumors of other lobes, the greatest

frequency of mental disorders". (Moniz, 1936a:31)

Moniz (1936a:35) goes on to report studies according to which

bilateral ablation of the frontal lobes will have two categories of

results: First, intellectual disorders and second, lesser control over

emotional responses. Interestingly, although later research will

refute the presence of the first effect, the image of the frontal lobes

as a form of super-ego, and a centre of 'reason' will remain central

to the description of psychopathologies related to lobotomies.

The gains of psychosurgery, according to Moniz (1936a:53):

"It would be the solution to a clinical problem of

great value: wipe out the intimate suffering of these

prisoners of anxiety, of hypochondriac, melancholic

and other forms of delirium: occult forces that lead

patients at times to acts of despair".

Frank, 1946:457:

“None of the patients regained full insight in the full

sense of the word, or is able really to appreciate

what the operation was for, or its importance. […]

The specific [personality] change was a poverty, or

entire lack of dreams, and a thinning, or

disappearance of dereistic experience-they cannot

daydream about their wishes, or be abstractly angry

in a sustained fashion. They become, due to this

emotional asymbolia, more plain, matter-of-fact

like”.

Sky E. Gross

73

Let it be noticed that Frank added in the same paper that "no

cases were considered worse". Indeed, some will claim that the

beneficial effects of the procedure derive precisely from those

personality transformations, without which, the patient could not

have reorganised his psychic scheme (Mayer-Gross, 1949).

Yet, the fear of loss of the human, of the turning into a Homo-

Vadum, did seem to intensify over the last decades. With the

gradual rise in the authoritativeness of phenognosis, the position

towards the Homo-Vadum began to change. Normative functioning

could no longer compensate for the damage inflicted upon the

Homo-Vadum's phenognostic sense of truth. Existential ideals of

self-fulfilment became ever more dominant. The

straightforwardness of the surgical act stood in contrast to the

complexity accorded to human experience: the idea that a crude

'razing' of the brain could alter the multi-dimensional phenomenon

of consciousness led to an overt discomfort. As sentience prevailed

as a discursive force, this formerly amoral scientific endeavour

turned immoral.

Corporeality, Pain and Phenognostic Truth

Perhaps not unsurprisingly, over the years, a growing body of

literature referred to the patient's inability not only to reflect upon

his/her own condition and behaviour. Indeed, although the

patients that were to undergo lobotomy seem to have had some

improvement as far as their pathological symptoms (at least those

related to anxiety and agitation), this would often be

counterbalanced by certain personality changes. Reports describe

the post-lobotomy patients (as many as 91% according to one

source) as being apathetic, lacking motivation and spontaneity,

childish, passive and dependant. Some will add the notion of "post-

operatory personality"(or "moria") to describe the combination of

Black Butterflies

74

symptoms observed after psychosurgery has been performed. It

seems that the patient’s initial complaint of having to deal with

overwhelming emotions was substituted by a total loss of the

ability to feel any emotion at all. This was associated with the loss

of a full consciousness of his/her own corporeality and emotional

state:

“[Freeman] points out that the person whose frontal

association areas have been particularly inactivated

by prefrontal lobotomy presents a number of

peculiarities that distinguish him from his pre-

operative self. […] he loses interest in himself, both

as to his body and as to his relationship with his

environment, no longer caring whether his heart

beats or his stomach churns, or whether his remarks

embarrass his associates”. (Porot, 1947:129)

The Homo-Vadum, as termed here, was thus to a certain

extent aware and conscious, yet incapable of sentience, the quality

that translates mere stimuli into full-fledged qualia and by which

experiences feel pleasurable or painful. These patients had a

tendency to be unconcerned by subjective aspects of their being:

while acknowledging drives and feelings, and internalising sensory

information, they reacted as if these cues were external (based on

out-there sources of Truth –ontognostic knowledge), rather than

internal (experience-based Truth – phenognostic knowledge).

“[after a prefrontal lobotomy] pain may be present;

but it no longer arouses a mental picture of future

disability and all that this may mean in terms of

disaster to the person and his family, the experience

can be borne with equanimity” (Freeman and Watts,

1946:445).

Sky E. Gross

75

Or:

“L.S. A 44 year old woman was first seen in

November, 1936, at which time she had spent two

years in bed because of “arthritis”. There was

moderate lipping of the vertebrae, but no other

significant changes. However, the patient

complained so bitterly and was so apprehensive that

it was impossible to make any headway in

treatment”.

After being lobotomised:

“Within three days the patient permitted

manipulation of the limbs. She winced and cried out

when the knees were straightened, and the crepitus

was very considerable, but instead of shrieking with

apprehension and refusing to cooperate, she showed

interest and willingness to help in the efforts that

were made to aid her. […] She fell and sprained her

ankle, but nevertheless kept on walking”. (Freeman

and Watts, 1947:427)

Madness and Ontognosis

The concept of 'madness' is intriguing in this regard. This

phenognostic experience cannot, by definition, comply with an

ontognostic agreed-upon Truth as to a world-out-there, hence its

characterisation as deviant in thought, affect, and/or perception.

"More difficult to influence satisfactorily are those

persons who have drifted away from the world of

reality.[…] [Only when] the individual lapses

completely into a dream world of psychosis with no

Black Butterflies

76

struggle against the manifestations of disease, is he

to be considered too emotionally deteriorated to be

aided by psychosurgery." (Freeman, 1943 in

Fleming, 1944:490).

When intractable, 'madness' remains, in fact, resistant to the

reasoning of ontognosis, and thus expressing an incapacity – or

unwillingness- to recognise what is collectively considered as True.

This will, in turn, justify the use of techniques intended to secure

willing or coerced subordination of what is seen to be a faulty or

muddled phenognostic experience.

As psychosurgery did not seem to have negative effects on

one's intelligence, at least as far as studies of the time could show.

Some proponents went on to claim that the inflicted personality

changes allowed patients' intelligence to actually become more

effective, providing them with the ability to perceive, analyse, and

respond to the world more 'rationally':

"After a prefrontal lobotomy, a person who was

previously trained for the practice of law,

engineering or scientific work, remains capable of

calculation, deduction and accomplish all mental

operations that concern productive activities"

(Wertheimer, 1948:497).

Here, while typical patients' sensitivity to ontognosis grew,

their phenognostic consciousness deteriorated: the patient would

know but not experience.

The Homo Vadum and Society

Still, in line with the idea of the 'social cure', psychosurgeons

who did refer to the personality dimension argued that the creation

Sky E. Gross

77

of the Homo-Vadum was a moral act par excellence, for it enabled

the return of the insane into the laps of a normative society. One

must consider that, based on an ontognostic conception of

humanity, turning a socially incompetent individual into a Homo-

Vadum was a valuable accomplishment. Rather than referring to

the patient’s acquired condition as a regrettable – albeit perhaps

unavoidable - side effect, proponents of the technique used the

descriptions of the Homo-Vadum as a validation of the beneficial

results of psychosurgery. At the peak of its popularity,

practitioners depicted psychosurgery's effects as pointing out to the

success of the procedure.

Questions as to normalisation and the creation of Homi

Vadum are apparent in other areas of culture, notably in fictional

literature. Ken Kesey's influential novel "One Flew over the

Cuckoo's Nest", published in 1973, depicts its protagonist as

resisting the system of the mental asylum only to be eventually

lobotomised. Eager to empower a group of mental patients to trust

in their own phenognostic sense of Truth, in what they believe to

be right, the central character was calling for an alternative source

of power: a Truth that feels true to the individual, a Truth that

cannot be challenged by external authorities, a Truth that does not

have to be subordinate to the gaze of the world-out-there. The

'hero' was finally defeated: lobotomised and turned into a Homo-

Vadum, he was now both literally and symbolically at the hands of

the more authoritative power: Ontognosis. Surgery left him barely

conscious: a mannequin, a 'thing'. As an act of mercy, his friend

would euthanise him.

This classical piece of literature became one of the strongest

manifests for the liberation of individual thinking from the hands

of a normalising society. Its mere popularity demonstrates the

claims presented throughout this analysis, namely, the idea that a

Black Butterflies

78

rise in the discursive power of phenognostic Truth would place free

subjective thought, although deviant, above the ability to accept an

agreed-upon ontognostic Truth. The practice's discordance with

emerging phenognostic conceptualisations of the self placed

psychosurgery in the focus of debates on the significance of

sentient experience. Over the years, the procedure came to

symbolise "the substitution of a soulless robot for the insane

patient" (Mayer-Gross, 1949:320), and the diminution of the full-

fledged subject into a shallow façade of self: "exhibiting a purely

objective mentality" (Golla, 1946:444). Yet, in an era where

questions of value are so often approached with a phenognostic

view in mind, to be reasonable by ceasing to be does not make

sense anymore.

Concluding Words

I have attempted here to present a historical motion involving

two powerful sources of Truth, phenognosis –based on inner

experience- and ontognosis –based on observation of a world-out-

there. I have then used the case of psychosurgery to substantiate a

somewhat provocative claim: this sense of Truth experienced at the

level of the conscious individual— would play a role in the

sociocultural realm, not as a prediscursive form, but rather as a

full fledged discourse; not necessarily as a negative picture of an

objectifying gaze, but as a positive picture in and on itself.

The conceptual scheme proposed here is potentially useful in

the analysis of other phenomena where ontognostic knowledge

finds opposition in the form of phenognostically based claims. This

seems evident in the study of New Age spiritual movements. Both

practices and epistemological bases of such movements typically

involve some extent of disregard of external cues (as conceived in

ontognostic terms) as well as the assigning of high legitimacy to the

Sky E. Gross

79

Truth as experienced by individuals in specific states of

consciousness (claims of re-incarnation for example, or sensing the

presence of spiritual entities, all clearly not supported by empirical

evidence). Indeed, although often contrary to ontognostic evidence,

these subjective experiences will be given high status as True, as

long as they 'feel' authentic, genuine, non-mediated, to the

individual. Another example may involve the understanding of the

credibility associated with states of trance, in the context of healers

and shamanist medicine and the authoritativeness attributed to

those able to experience it. All can benefit from the positioning of

phenognosis against ontognosis on the issues of credibility, faith,

and beliefs.

One may find similar trends in modern psychotherapeutic

discourses, where one’s inner feelings are considered a priori

legitimate. Along a similar line, one is often advised to seek for an

'authentic self' through deep introspection rather than through

external appreciation of 'reality'. The fact that these trends are all

accompanied by oppositions and by countering phenomena may

point to the power ontognosis maintains, and to the complexity of

the proposed forms of analyses. In effect, it is precisely these

exchanges and conflicts, which may profit from an analysis based

on an opposition of phenognosis and ontognosis and on a dynamic

view of the exchanges between these two sources of power. I

suggest here that further understanding and empirical grounding

of the scheme proposed here may be of value in both anthropology

and social studies in general.

In the next section of this work, I will hope to show how the

dynamics of more and less phenognostic sources of knowledge

come about in the routine workings of a clinic. This will be based

on a synchronic, rather than diachronic view of the phenomena,

and on a sustained in-situ observation rather than on a more

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macro outlook as proposed in this paper. As I try to ascertain

throughout this work, the boundaries between phenognostic and

ontognostic knowledge are created, formed and reformed at several

layers of the world of the sociocultural. Here, I shall provide an

analysis along similar lines, albeit with a different field, different

methodologies, different references to bodies of literature, and

different empirical points of focus.

Sky E. Gross

81

Part IVa: Experts and ‘Knowledge that Counts’(background)

The World of Brain Cancer Diagnosis

The Neuro-oncology Clinic

During the first half of 2006, I followed members of a neuro-

oncology outpatient clinic situated in a large hospital in Israel. The

team consisted of four neuro-oncologists (NROs), a head nurse, a

social worker, and a neuropsychologist. The NROs were observed

during routine consultations; in rounds in the inpatient ward; and

in the course of three weekly professional conferences: one internal

conference, one with the radiology experts, and another with the

neurosurgical team. I spent some twenty 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. A total of 103 consultations were observed, and 68

patients were informally interviewed. Although forming but a small

share of the data collected, formal interviews –13 overall, 4 with

NROs, 2 with family members, and 7 with 5 different patients--

were later transcribed verbatim.

The Clinic: Spatial Characteristics

The neuro-oncology clinic is an outpatient unit located in a

general oncology clinic. The secretariat is shared by both groups of

physicians (the latter's forming a more substantial share of the

staff). The clinic includes about ten offices. Each office has, nailed

on the wall next to the door, a metal name-tag-holder that can be

replaced at need, according to the physician who happens to be

using the room on that particular day. Thus, there is no

permanent office for any of the NROs, although on the days in

which the neuro-oncology clinic is active (Mondays, Wednesdays,

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and Thursdays), the working physicians tend to be placed in a

habitual office (used by other physicians -or even nurses - on the

days they do not receive patients). The neuro-oncology clinic has

thus no actual spatial presence: it is a virtual set of specialised

knowledge held by 'visiting' professionals.

Each Sunday is spent around professional conferences. The

conferences take place at different locations, none of which is

actually secured for the NROs. The conference room at the "Moses

Institute" -a building with mostly oncology-related inpatients units;

ambulatory divisions; and out-patients clinics- is used for the

weekly NROs' staff meeting. However, was some other group

needing this room, the NROs will find a temporary office at the

clinic, squeezing in into a room much too small.

The Radiology conference takes place at the radiology (MRI)

unit, in a small office, where the experts usually sit and go through

the MRIs (and reporting, in writing, their impressions and

interpretations of the images they survey). The Neurosurgery

conference (referred to as the 'tumour board', hinting to its more

decision-oriented character) takes place in a conference room at

the radiotherapy unit. At times, when the conference room is used

for other purposes, the whole team will go up to another conference

room, at the neurosurgery inpatient unit, at the hospital main

building.

Professor Lise, the head of the Neuro-oncology team has a

large, luxurious office at the Moses Institute, albeit at some

distance from the actual clinic, or the inpatient unit. Her office is

actually located at the one floor where the services provided are not

targeted toward cancer patients – i.e., where nuclear medicine tests

are conducted. Her office has an interesting standing: it is both the

heart of the clinic, in terms of research mostly and administration

Sky E. Gross

83

at times, but it never serves as a meeting place for the different

NROs. There is, in fact, little cohesiveness or sense of 'team'

between the NROs, or the rest of the staff, for that matter. The

spatial arrangement may reflect that, while also contributing to

this state of affairs.

The Moses building has many floors, some of which are

underground:

The -2 floor includes the radiotherapy (RT) facilities and

completely lacks windows or direct access to the 'outer world'. It is

a dark, 'spaceship'-like floor, with instruments and names on the

doors that would not shame any science fiction movie. The

outpatient clinic is located on -1. One will also find there the

refurbished conference room serving the NROs on Sunday

mornings' meetings. As expected from a frontstage area, which

serves the general public rather than patients (whose pathological

state allows them some access to backstage areas), the place is

bright, easily accessible, and a coffee shop is located in the general

hall located on the East, leading almost directly to the hospital's

mall. A small but lovely patio separates the Western and Eastern

wings, i.e. the reception area and the conference room (which is,

interestingly enough, surrounded by glass walls from which the

conferences may be seen but not heard). Floor B is where Lise's

office is located – just near the corridor leading to the general

hospital. Again, this is the only floor where the activity has little to

do with oncology. No one could guess he had entered the "cancer

building", or as another patient called it: "the death wing".

The first floor is where the oncology inpatient unit is located,

and where the general hospital is directly linked to the institute's

building. This unit is where most neuro-oncology patients are

hospitalised, alongside general oncology patients. Naturally, this is

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where most of the rounds take place. The second floor includes

the haematology inpatient unit. At any given moment one-to-two

neuro-oncology patients are to be found hospitalised, usually due

to secondary complications of treatments. The third floor includes

a large, quite modestly but recently refurbished ambulatory

service. This is where patients are submitted to chemotherapy by

perfusion and return home at the end of the day, after a short

recovery and observation period. The onco-psychological unit is

also located on the floor, with a consultation room of its own. The

team of psychologists usually works with ambulatory patients,

perhaps much more than with hospitalised patients. This might be

explained by the longer life expectancy (and chances of recovery, in

some cases) of the not-yet- hospitalised patients as opposed to the

near-death, and often unconscious, condition of many inpatients.

Schedules and Organisation of Time

On each of the days in which the clinic operates, one or two

physicians receive patients. The reception hours tend to begin at

around 8:00, although most physicians turn up only by 9:00. The

last appointments are set for around 12:00, although this may

actually last until 15:00.

Sundays are organised around conferences and rounds. The

morning begins with a NROs' staff meeting. This may last until

10:00, or end by 9:00. If the former is the case, the group will go

straight to the next meeting (which is invariantly scheduled for

10:00) with the radiologists. If the latter happens to be the case,

they will take the opportunity to finish the rounds before the

radiology conference. The rounds usually do not take more than

forty minutes. The meeting with the neurosurgeons (the 'tumour

board'), usually begins at 14:00. There, the day ends as far as the

NROs are concerned. As most of the staff members (Lise excluded)

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85

also work as general neurologists, they will spend their 'free time'

as 'plain' neurologists.

The Neuro-oncology Meeting

The first meeting includes the NROs, the head nurse, the

social worker and the neuropsychologist. From time to time, fifth

year medical students are allowed in. The meeting is organised

around a briefing of each NRO on the cases he/she had seen over

the week. Each NRO presents about ten cases, while the others

listen and make suggestions as to treatment options or diagnosis.

This usually happens when the presenting NRO specifically says

that "this is a difficult case" or "that is an interesting case".

None of the NROs consider him\herself as mere clinicians,

and all are involved in research at one level or another. Thus, the

meetings also include research presentations (such as dr. Levitz'

presentation of findings related to "chromosomal differences

between infratentorial and supratentorial ependymomas"), and

reviews of state-of-the-art literature, at times by the NROs

themselves, and at others by peripheral experts such as the

histologist or the neuropsychologist. While the first is filled with

technical terms and arise much interest, the latter is often

regarded more as an opportunity to discuss patients' personal lives

and personal peculiarities: as cases are presented along with the

results of the neuropsychological testing, the team members would

take these on to describe curious encounters they may have had

with this or that patient. The neuropsychologist would typically not

get involved in these discussions but neither would she try and

resume them, however eager she may be to continue with her

professional presentation.

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The Patients

Patients –adults alone, as children are referred to a paediatric

unit- are referred to this clinic from all over the country, since this

particular centre is considered to be providing the most

professional and specialised care available (in fact, it has a

reputation of being among top neuro-oncology centers in the

world).

There is no particular social characteristic which makes the

patients' population remarkable. Most of the patients I see come to

the clinic for follow-ups. Some would only come once a year (once

every three months is more typical) to have their MRI done, and

consider the progression of the tumour. Patients under active

treatment will come up to once a week when under radiotherapy,

and once a month when on chemotherapy. New patients almost

invariably know about their condition beforehand. They have either

been referred to the NRO after a diagnosis has been given by

another physician, or did they already have an attack which

rushed them into neurosurgery – only then to understand they

have a brain tumour. Actually, the second scenario is much more

common.

The Consultation

The patient arrives at the clinic, gives his/her name to the

reception clerk. His/her file is then placed on a pile which will be

taken to the physician's office from time to time. The files of

patients due to have an appointment are drawn from the clinic's

archive the day before. The physician will find, upon his arrival to

the clinic, a list of appointments for the coming day. As the NROs

tend to be late, they will also find a pile of files – meaning that

patients are already ready to be seen. The physician would not see

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87

them in the waiting room (and they would not know whether

he/she had arrived) since he/she will typically use the back door

entrance to the clinic. This entrance demands making a small

detour, but allows to remain unseen.

The ways the NROs conduct the consultation is very similar:

as the patient enters and take a sit, the NRO would utter a "how

are you doing?" without really hearing the answer7. Using a

barcode reader, the physician will then enter the patient's ID

number onto the specialised software. Then, he\she will stare at

the computer for a few minutes. The NROs take great care in

gathering information in an orderly manner, usually as is

costumed to fill in the consultation report: the gender, age and

diagnosis, comorbidities, the treatment currently undertaken, the

current complaints, the report of the clinical examination (if there

is one, if not, the physician will suffice himself with a general

impression of the patient's condition). Then come the orders: how

to continue the treatment, if any test or consultation with another

professional is needed, and when the next appointment should be

made. One copy will be filed; another will be given to the patient.

There is no formal room for questions, and the patient is

expected to quick, to-the-point and assertive if he\she is

determined to obtain clear responses. Even when diagnoses are

communicated (often very bad news), or when complex treatment

orders are given, the patient may be hasted out of the room8.

7 At this point I would introduce myself as Sky Gross, a researcher from the Hebrew University, doing research on brain cancer and brain cancer patients. I would then ask whether I could sit in the consultation. All but one patient agreed.

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Family Members

The patients usually come with a family member. Close to the

time of diagnosis and often towards the patient's death, more

members of the family tend to join in. The family members are a

critical part of the consultation. They usually take on an active

stance, some answering the NRO's questions for the patient (even

in cases where the latter is well enough to answer himself). This

applies to technical questions such as the dosage of drugs taken

but also to more abstract questions such as the type of pain the

patient suffers from.

Something About Brain Tumours

Types of Tumours

At the most elementary level, one may define two general

types of brain tumours: Primary, i.e. forming in the brain itself,

and secondary (or 'metastatic'), i.e. originating from another

cancerous process elsewhere in the body. The types of cells

involved and the form of its spreading give indication to whether

the tumour is primary or secondary. Life expectancy differs

dramatically, that is, once a tumour has metastasised, there is

little chance in effectively controlling the process.

Unlike many other forms of cancerous diseases, there are no

known risk factors to primary brain cancer, and etiology is little

understood. There is thus no known way to prevent the apparition

of the disease.

8 Notwithstanding these comments, it has to be noted that at no point do the physicians use their time for personal or leisure activities. They are clearly overwhelmed. One cannot but be impressed with their efforts to keep pace with their extremely demanding schedule.

Sky E. Gross

89

The largest group of primary brain cancers is referred to as

'Gliomas'. Gliomas involve abnormal growth of glial cells (the

supporting cells of the brain) 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

relating to the current 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 .

Grade I-II tumours are considered benign, although may

become more aggressive at a later stage of growth. They can also be

located in or near a part of the brain which, if damaged, may cause

serious handicaps or even death. I saw only a few of these patients,

as they tend to come to the clinic for yearly follow-up only.

Grades III-IV tumours are referred to as 'anaplastic

astrocytomas' or 'glioblastomas', respectively. Anaplastic

astrocytomas typically progress to become glioblastomas (GBM) at

some point. GBMs are deadly, often giving the patient a life

expectancy of mere weeks.

Location of the Tumour and Functions Threatened

The brain is divided into six primary regions, each controlling

specific functions. The following is a brief overview of each region

and their correlating functions.

The Brain Stem. The area where the brain connects to the

spinal cord is called 'brainstem'. It controls vital heart and lung

functions such as breathing, digestion, heart rate and blood

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pressure, as well as the ability to remain awake and alert. It is the

pathway for all nerve function through the spinal cord to the

highest part of the brain. Problems in the brainstem often cause

symptoms such as double vision, abnormal functioning of facial

muscles, nausea, sleepiness, or weakness on one side of the body

(hemiplegia). However, since so many nerves go through the

brainstem, pathologies associated with this area can cause almost

any form of symptoms.

The Cerebellum. Located at the back of the brain above the

brain stem, the cerebellum coordinates balance, posture, and

coordination, and affects activities such as eating, walking, talking,

and eye movement.

The Frontal Lobes. The frontal part of the brain is

responsible for organising thoughts, planning, problem solving and

selective attention. It is also where higher functions, such as the

control of behaviour and emotions and moral judgment. The

posterior parts of the frontal lobes also houses nerve cells that

produce movement. Patients suffering from tumours in or near the

frontal lobes may not only have symptoms related to motor

functions, but may also suffer from extreme personality changes.

The Occipital Lobes. Located in the mid-back of brain, the

occipital lobes are 'in charge' of vision. The neural network takes

input from your eyes and turns it into the pictures that you see.

Presence of pathology in this lobe can cause partial blindness or

the inability to recognise shapes, colours, or faces.

The Parietal Lobes. Located behind the frontal lobes, and at

the top of the brain, the parietal area comprises a right and left

lobe, which together, control our sense of touch, our feel and

understanding of weight, size and texture, as well as much of our

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cognitive comprehension of the world. Pathologies of the parietal

lobes can cause numbness, tingling, and other sense-related

symptoms. 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.

The Temporal Lobes. Located on the right and left side of the

brain (near ear level), the two temporal lobes help us distinguish

smells and sounds, and may be involved in the experience fear,

and may impact short-term memory. The right lobe is primarily

responsible for visual memory while the left controls verbal

memory.

Treatment

The term 'treatment' is misleading. Except for a number of

first grade tumours, the progress of the mass is inevitable,

although it may proceed over decades. Treatment is thus meant to

prolong life or to better the patient's quality of life. The NROs are

unambiguous: there is no 'cure'.

There are three types of treatment, provided usually in this

order: Surgical resection, chemotherapy, and radiotherapy.

Surgery. Surgery is usually the first step. Most of the reports

I heard from patients place the beginning of the brain-cancer

'odyssey' at the point where the tumour made its first dramatic

symptomatic appearance. Almost invariably do they then report on

their being rushed to surgery. Surgical intervention 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

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risk involved in any serious operation, but against the neurological

deficits that may result from the assault on the brain.

Chemotherapy. Brain cancer has its own set of

chemotherapeutic agents. The reason for that is that the brain

keeps some of the body's material out, through what is called the

'Blood Brain Barrier'. Unfortunately, this barrier is not penetrable

by the chemotherapeutic agents known to be effective for tumours

across the body. One agent is, however, able to reach brain tissue

is in the form of tablets: Themodal©. The treatment is given for one

month at a time, at the end of which blood tests and imaging are

given. If the blood tests do not allow the continuation of the

treatment (typically – anaemia, low platelets count or

neutropaenia), if the treatment turns out to be ineffective, or if two

years have passed – it is terminated, and the patient will be

referred to radiotherapy. Themodal is self administered, at home,

does not cause hair loss, and has in fact little side-effects. In all

these, it will create but little a sense of "Cancer self perception".

Radiotherapy. Radiotherapy is typically administered daily

for a number of weeks, in the course of which the patient is to

meet the NRO weekly and give blood on a regular basis. The

radiotherapy causes many side-effects (which severity depends on

the dosage and the 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 also does not have remedial powers. However, it usually

does contribute to the shrinking of the tumour and does slow its

growth.

Symptoms Relief. Epilepsy is one of the most troubling

symptoms of the presence of the mass itself and the oedema

forming around it. The oedema tends to become more severe as a

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result of radiotherapy and surgery. Steroids are provided for the

relief of oedema, thereby providing relief in epileptic seizures and

intracranial pressure (a situation that may be uncomfortable at

first, but will eventually cause death). Epileptic seizures are also

treated with anti-epileptic drugs, some of which must be

continuously accompanied 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 part. These

symptoms have usually no treatment available, perhaps besides

steroids which would relieve some of the pressure on the part of

the brain involved. Steroids are eventually devastating for many

body systems, especially when given in high doses. It will also give

the patient a typical bloated look, making the surroundings

accutely aware of their condition.

Palliative and Supporting Care. When the treatment

panoply has been exhausted, there is no role for the NRO but to

follow from distance the palliative care provided to the patient,

usually 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 uncomfortable, when more basic

functions begin to deteriorate, especially breathing. But, 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.

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Part IVb: Experts and ‘Knowledge that Counts’

The World of Brain Cancer Diagnosis*

*An abridged version of this paper was published in "Social

Science and Medicine" 2009 in press, and available online

The brain has much significance in broad aspects of Western

culture as well as in its symbolic and physiological relations with

the body. Questions of self and the brain tend, however, to be of

little concern in the everyday routine of most members of society.

One instance in which the brain becomes a central focus of one's

life is when it becomes the site of life threatening pathology. Brain

tumours brings about the neccessity to visualise the brain

(through imaging tests not usually undertaken by healthy

individuals), to face consequences of brain pathologies (such as

motor and cognitive losses, but perhaps most significantly,

changes in personality). What I expected to find was thus a more

intensive questioning of the place of matter (brain tissue) in

individuals' own psychic life and sensation of self ('mind'). Yet, I

would be soon taken aback: almost no patient sought an

understanding of the mind/body conundrum as it applied for

him\herself - This, even with the most philosophically-akin

subjects. As is often the case in fieldwork, however, I unwittingly

revealed other interesting phenomena, i.e. those related to the

creation of a web of knowledge hierarchised and utilised in high

accordance with the gnostic split. This will be the focus of this next

study.

Introduction

The majority of medical texts represent brain tumours as

involving fairly clear-cut entities and categories of entities,

amenable to 'discovery' through different ontognostically-based

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practices. A closer look into the life of a neuro-oncology clinic

proves, however, that the solidification of neuro-oncological objects

is less than straightforward, in both epistemological and practical

terms. This study sought to provide such an in situ understanding

of the ways in which diagnoses are handled in medical experts’

daily routine via a deep insertion into the everyday practice of a

wide range of experts. The aim of this paper is double: first, to

underline the technological and epistemological grounds of

'expertise' in the medicoscientific practice of diagnosis, and their

roles in the assertion of expert authoritativeness; and second, to

propose analytical tools to approach the complexity involved in the

creation of knowledge,the potential frictions it may create, and the

mechanisms of their resolution.

Methodology

Over the last decades, a new approach to the study of

medicoscientific work has arisen, seeking closer attention to the

everyday practices of 'making science' (e.g. Latour and Woolgar,

1986; Lynch, 1988; Pickering, 1992; Rabinow, 1996). Drawing on

this now considerable body of research, this paper will present an

ethnographic study which allowed for a sustained in situ look into

the daily micropolitics of the diagnostic practice.

Being, in a way, the physician's home ground, the hospital

constitutes a precious setting for understanding the world of

medical experts (e.g. Anspach, 1993; van der Geest and Finkler,

2004; Mizrachi, Shuval and Gross, 2005). In this case, a lengthy

and laborious work of negotiation and clarification, namely with

the head of the clinic led to the gradual gaining of the staff's

confidence. Finally, a formal permission from the hospital's board

of ethics (the 'Helsinki Committee') allowed me to begin my work.

By the end of this process, I was accorded access to the most inner

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stages of the clinic, naturally conditional on the informed consent

of both the professional and the patients taking part in the

research project. Anonymity is ensured by the use of pseudonyms

throughout, again, for both patients and staff. Considering the

level of intimacy I developed with the patients, I felt more

comfortable using first names as pseudonyms, while referring to

staff members in a manner that would reflect their professional

roles, rather than on ad-hominem aspects of their work (i.e. Dr. X.).

In view of the intricate nature of the field of neuro-oncology

and the complex terminology used in interactions, I spent months

prior to my insertion in the field studying related medical texts. In

fact, it seems one can hardly communicate the 'real life' work of the

professionals without referring, however critically, to these

schemes. That being said, I had to repetitively make clear to

patients that I retained neither medical nor counselling role in the

clinic. This was particularly salient as I did, to the request of the

staff, wear the traditional white robe. Still, provided that proper

ethical directives were followed, and as cooperation was ensured,

this did not seem to eventually form any significant obstacle.

At the Clinic: The Diagnostic Process

According to textbook medical knowledge, a brain tumour

arises out of the proliferation and multiplication of a single cell,

which, for reasons little understood, undergoes molecular

mutation. At the histological level, these will reproduce, create

their own blood supply, and eventually become numerous enough

to apply pressure on adjacent nervous tissues. The tumour

presents itself through a neurological realm of signs and

symptoms, which may include epileptic seizures, total or partial

paralysis, speech malformations, visual disturbances, loss of

sensation in the limbs or, in some cases, personality changes.

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Reporting diagnostic information such as biopsy and MRI studies,

along with clinical impressions allow NROs to determine the

locality of the tumour, its size, the types of cells involved, and its

degree of malignancy.

At the clinic, this process begins with the first encounter with

the patient. There is a fairly ritualistic intake of new patients,

where the NRO assesses previous findings, gathers clinical history,

and performs a physical examination. If judged necessary,

immediate intervention is considered, albeit only once options are

discussed in conjunction with other experts, such as radiologists

and neurosurgeons, and, if applicable (viz. the tumour is

metastatic), with the primary oncologist. In either case, treatment

options (including, typically in this order: neurosurgery,

chemotherapy, radiotherapy, clinical trials, and palliative care) are

deliberated among a relatively wide array of biomedical

professionals.

Routine assessments of cases are typically performed in the

course of three weekly conferences. First, during the NROs’ staff

meeting: there, each physician is expected to present the files of

the patients he/she has seen throughout the week, his/her

colleagues offering their opinions and evaluations. The second

meeting proceeds at the MRI unit, where the radiologists go

through recent imaging tests while the NROs provide clinical

information on their patients. The formers then report their

impressions, first orally to the staff (“things look bad, tut tut tut”),

and later in writing (“a slight compression of midbrain structures

was observed”). The third meeting, the 'tumour board' –which

includes the NROs, neurosurgeons, and radiotherapists- seeks a

collective appraisal of the applicability of different surgical or

radiotherapeutic protocols ('treatment algorithms'). Its place within

the diagnostic complex is limited, and the approach is largely task-

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oriented. The only common participants in these three sessions are

the NROs, a fact that reinforces their centrality in the diagnostical

process. Indeed, as the integration of reports into a compiling

diagnosis requires the adoption of a common way to ‘speak of' the

disease, the participants (i.e. the reporting experts) are expected to

conflate their way to 'speak of' the disease to the NROs’, thus

placing the latter in a junction of significant power (Mol, 2002).

The interaction between professionals is critical both before

and after initial diagnosis. Patients attend the clinic up to once a

week while under a radiotherapeutic regime, and once a month

when under chemotherapy – typically referred to imaging tests

every few weeks. In fact, for a brain cancer patient, diagnosis is

literally a lifelong process; For the NRO, each diagnostic function

defines a point on a temporal line which presumably depicts a

logical evolution of the disease, usually towards a worsening in all

diagnostic values. The 'case', thus, remains in a certain state of

fluidity, where each re-assessment demands further exchanges of

reports through the web of expertise.

Medicoscientific Diagnosis

"In order to be able to offer each of our patients a

course of treatment perfectly adapted to his illness

and to himself, we try to obtain a complete, objective

idea of his case; we gather together in a file of his

own all the information we have about him. We

‘observe’ him in the same way that we observe the

stars or a laboratory experiment". (Foucault, 1963:

XV)

With the proliferation of diagnostic technologies, the practice

of medicine has become increasingly dependent on expert

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medicoscientific observation, adding to the intricacy of medical

work (Howell, 1995; Dew, 2001; Clarke et al., 2003). This is

accompanied by the need for a constant reshaping of the definition

and conceptualisation of disease, most prominently in fields where

diagnosis remains complex and critical (Reiser, 1978; Clark and

Mishler, 1992; Casper and Koenig, 1996).

Facing sets of signs and symptoms, physicians are expected

to 'reveal' the one underlying ontognostically-reachable element:

‘the Disease’. This quest aims at a reconciliation of accumulated

diagnostic data (e.g. clinical examinations, blood test results) and

the preconceived nosological scheme of knowledge regarding

diseases’ characteristics, expected course, and likelihood to

respond to certain treatments (Foucault, 1963; Lynch, 1988;

Moreira, 2000). This integration of pathology and nosology requires

a ramified process of creating, changing, communicating, and

alternating definitions of 'the Disease' as one epistemological object

(e.g. Berg and Mol, 1998; Mol, 2002; Moreira, 2004).

In many biomedical settings, this process involves a

multiplicity of experts: within each expertise, diagnostic elements

are observed, explained, assigned attributes and boundaries within

its specific 'styles of reasoning' entrenched within formal and tacit

knowledge (e.g. Good, 1994; Bos, 2004). As Polanyi (1998) and

others (e.g. Hacking, 1982; Collins, 2001) have shown, expert

conceptualisation of pathologies is further mediated by technology

(e.g. an MRI machine), a form of attention (e.g. the analysis of the

spatial characteristics of a tumour) and a hermeneutic agent (i.e.

what does this finding mean?) (Foucault, 1963; Berg and

Harterink, 2004). This ‘gaze’ then provides further interpretation of

reality within these styles of reasoning (Latour and Woolgar, 1986;

Latour, 1993; Haraway, 1997), and mediates the definition of the

disease as a thing-out-there, an object (e.g. Koenig, 1988; Rabinow,

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1996; Boumans, 2004). Different expertises are sustained within

their own technological, rhetorical, and epistemic systems

(Goodwin, 1994; Knorr-Cetina, 1999), each creating what shall be

referred here as 'expert-mediated objects'. These will then be

made comparable and manipulable within an established

nosological order, where they can be 'spoken of' in a common

language. They will they be placed within a delineated, organised

conceptual chart of identified pathologies (Lynch, 1985; Hacking,

1992), and amenable to integration or alignment with other

objects.

Both the ontological status and communicable qualities of

these mediated-objects are maintained by professional rhetoric in

the form of reports, i.e. the artefactual products of processes of

observation and translation (Young, 1981; Anspach, 1987; Latour,

1996; Bos, 2004). Reports may be as numerous as the number of

expertises involved, and create as many objects as the number of

gazes laid upon it (Berg and Mol, 1998; Mol, 2002; Beaulieu,

2002). While mediated-reports may 'make sense' in the context of

the single expertise, epistemological inconsistencies may arise once

these are juxtaposed, often demanding an implicit evaluation of the

forms of authoritativeness associated with each of its sources. As

this work will seek to demonstrate, NROs --being ultimately in

charge of diagnosis making-- tended to strive towards the assertion

of the nosopathological uniqueness and integrity of the 'brain

tumour' object. With this aim, they were seen to apply – often

implicitly and always subtly – several mechanisms, which will be

discussed later in the text.

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The Web of Expertise

In order to create the neuro-oncological object as a coherent

'ontologically asserted' (or 'ontognostically-based') referent (Bos,

2004), the NRO has to draw beyond his or her own field of

expertise well into the neighbouring provinces of knowledge and

technology. Within the scheme proposed here, this involved

exchanges between what I shall define as three relatively distinct

diagnostic positions: reporting, independent, and compiling

expertises.

Reporting experts provide expert-mediated objects aimed at

assisting in the overall assessment of each particular case. At the

clinic, these included several professionals, including the

histopathologist, radiologist, clinician, and neuropsychologist. In

Marfa’s case, for example, her file showed the radiology report on

the disease as an object with measurable spatial characteristics ("a

two centimetres neoplasm located in the left parietal lobe"); The

histopathologist, on a qualitatively distinct object ("a mixed-cell

oligodendroglioma with a necrotic centre"); The clinical, on a set of

observable patterns ("a contra-lateral hemiparesis with frequent

grand-mal seizures"); And the neuropsychologist on a series of

scores along different scales ("a normal IQ test; low tendencies

towards anxiety; normal results in the capacity to comprehend

abstract notions"). In general, the fact that these expert-mediated

objects are communicated in different forms seldom challenged, in

itself, neither the ontological status, nor the pathological definition

of 'the Disease'. However, reaching a sensible overall diagnosis did,

as shall be shown, require translation and juxtaposition of these

heterogeneous reports.

Independent experts remain external to the main expertise's

(e.g. neuro-oncological) sphere while being potentially involved in

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the assessment of a patient's condition, depending on his/her

known co-morbidities and general health status. Here, these

experts (such haematologists or general oncologists) served as

autonomous physicians holding their own clinical complex and

definitions of disease. Still, while conducted independently, their

diagnostic and record-keeping activities (including, typically, a

separate file) were occasionally integrated into the patient’s neuro-

oncological case, although chiefly in its margins. This placed them,

in relation to the NROs, at the periphery of the diagnostic web.

The compiling expert faces a multiplicity and disparity of

objects presented in reports gathered from independent and

reporting experts. Occasional disparity of mediated-objects,

however, can potentially threaten the establishment of an

integrated and congruent image of the disease as a relatively well-

defined entity. This tension positions the compiling expert (here,

the NRO) at a unique and most instructive junction which will be

expanded upon throughout the paper.

On the Ontognostic Authoritativeness of Reports

The last century saw biomedicine develop more and more

elaborate tools to assert objective grounds for its practice and

science, including dimensions such as accuracy, accountability,

validity, transparency etc (Boumans and Beaulieu, 2004). For

instance, medicine will seek to redefine itself from a focus on

'artisanship' based on personally-owned tacit knowledge, to an

emphasis on 'profesionalism' based on accumulated agreed-upon

scientific knowledge. 'Objectivity' is also sought through the

development of well defined protocoles, a growing use of technology

in both diagnosis, treatment, and follow-up, and a quantification

and standartisation of reports.

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The report is both an artefact allowing communication among

professionals, and a channel through which independent and

reporting experts translate the observed disease into expert-

mediated objects (Berg and Harterink, 2004; Joyce, 2005). As

suggested by Callon and Latour (2006), it is through such

translation processes that epistemologically distinct objects come

to be linked together.

In practice, the translation (i.e., in the production of

radiology, histopathology, clinical, or other forms of reports) was

often poor: the reports seemed to serve more as means of asserting

expert authoritativeness than to communicate information among

experts or to patients. For example, the clinical report was handed

over to the patient at the end of the consultation, whether asked

for or not. As the reports were characteristically composed in a

cryptic language, the patient typically read and re-read it once

having left the room, often baffled by the swiftness of the

consultation. As one perplexed patient said:

"This is a summary of my disease, so I know whether

I am better or not. I will show it to my children".

She would remain unsure of whether she was "doing well" or

not until having the report deciphered for her.

The radiology reports were no more 'user-friendly'. For

example, Alyosha’s MRI report read the following:

"CVB 3, in MRS CHO/CR=4/3, CR/MI=0.9".

This was obviously unapproachable, even for Alyosha, who

usually tried to keep informed. Indeed, reports, say Good (1994)

and others (Bourdieu, 1992; Beaulieu, 2002), tend to use jargon

and rhetorics which make them appear more reliable, conceal

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areas of uncertainty, and ultimately reify the experts' position as

holding exclusive knowledge and thus epistemological

authoritativeness. This can be said of reports produced by each

and every reporting expertise at the clinic. In the case of radiology,

however, this may be more salient: as the visual medium may

point to a lesser need of expertness in reading (it is "right there", "in

black and white" some patients told me when asked whether they

could recognise their tumour on the MRI), the need to assert the

uniqueness and complexity of their expertise was obviously more

critical. This will have clear manifestation in the form of a relative

indecipherability of the reports.

The Sight of the Tumour: Radiology

The radiology meeting takes place in the general hospital's

building, on the underground floor, where the MRI machines are

located. This is where patients are examined and results are

processed and interpreted by the experts. The NROs and MRI

experts stare at computer screens while patients’ ID numbers are

called by one of the neuro-oncologists. For each patient two MRIs

are uploaded on the screen: the 'before' and 'after'. The NROs then

all offer their opinion, hoping to be approved by the MRI expert:

"the tumour has grown", "the tumour has not changed", "wow, this is

a big one". The questions to be answered are of two kinds: spatial

and temporal. Where is the tumour? Between now and then, is it

larger, smaller, or unchanged?

There are two radiology experts: Prof. Soren and Dr. Martin.

Soren is a quiet but impressive man of about 60 year old, with a

beard that gives him the appearance of a wise oracle. Unlike his

junior colleague, he is never turned to by his first name, but rather

with his full title: "Professor Soren". Martin is younger and his lack

of experience is critical: in the field of radiology, tacit knowledge

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105

acquired through experience is which allows the expert to 'see'

phenomena which may pass unacknowledgded by others. Training

the senses may be the only way of reaching accurate

interpretations. Therefore, in practice, whenever possible, Soren

worked with the team, while his colleague continued working on

'general patient's reports. When Martin did replace Soren, the

meetings were tenser, and most of the final judgements on the

meaning of the image on the screen were given by the neuro-

oncologists rather than by the radiologist. Clinical information was

more often sought and drawn from when the picture seemed

inconclusive (i.e., if unsure of whether the tumour has grown or

not, a worsening in the patient's symptoms was used to settle the

interpretation – the tumour must have grown as well).

All four NROs were present at each of the weekly meetings, as

well as the head nurse. Joining them was Lise's secretary, Gila.

Gila sat with Lise's laptop, plugged onto the hospital's intranet,

and equipped with the software especially designed for keeping and

documenting patients' cases, albeit for the neuro-oncology team's

use only. Gila entered the evaluations she received from the group,

usually as summarised by Lise. She often did not understand the

jargon, thus not knowing what she was writing. She never made

any comment on patients, nor shown emotions when news were

particularly diffficult. In fact, she never expressed any interest

beyond what was directly dictated to her. In this sense, she served

more like a mediating device than an actual 'professional'.

The more formal report was composed by the radiologists

themselves before (forming the grounds for the discussion with the

NROs) or after the meeting (then formed around the reading

suggested in the course of the exchange). It included several

carefully operationalised components, each conceivably

contributing to the diagnostic effort: the location of the tumour, the

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colouring of its centre and borders, the number of foci, the

regularity of its margins, etc. This, along with the clinical and

histopathology reports, enabled a grading of the tumour, and a

characterisation of its cellular bases.

This report played an important role in the continual

examination and re-examination of the state of the disease; so

much as to have patients sent home --without being examined-- if

their MRI had not been yet deciphered by the expert. As far as the

team was concerned, it was arguably the most straightforward and

informative means of assessing the tumour's progression: “I see

now…” or “It's right there” were typical ways of referring to the

radiology-mediated object during MRI meetings. This has grounds

on several broader cultural stances, including the

medicoscientifical tendency to regard sight as evidence, with

'seeing' being almost inseparable from 'knowing' (Lynch and

Woolgar, 1990; Jenks, 1995; Draper, 2002; Dumit, 2004; Joyce,

2006) and vision as an unmediated perceptual source of

knowledge: the images themselves purportedly allowing an

ontognostic, non-interventional access to the truth (Foucault,

1963; Knorr-Cetina and Amann, 1990; Daston and Galison, 1992;

Cartwright, 1995), and ruling out phenognostic interferrences and

interpretations not intended by the reader (Bastide, 1990; Ala,

2004).

Although the MRI is by definition a mediated view of the

patient, there is a process by which the technicians seek eliminate

this very mediation by creating an object: the 'thing' that they look

upon becomes the ontognostic 'real thing' that needs to be

approached. This materiality is what enables them to approach the

thing, and make the subject of this thing transparrent (Duden,

1993; Boumans, 2004). It is easy for MRI technicians to forget that

there is a 'body' there (Rohrer, 2007), that is: that the screen shows

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an abstraction of something, a mediated 'something' rather than

the 'real thing'.

Once the visual is alleged to provide the most authoritative

access to the object of disease, radiology would undoubtedly

represent the epitome of diagnostic science (Gunderman, 2005;

Burri, 2008; Joyce, 2008). In fact, some will claim that radiology

may make things 'more real than real' or 'hyperreal' (Baudrillard,

1988; Frank, 1992), that is, more accurate than would any direct

assessment of the 'object itself', including phenognostic

assessments by the object itself (i.e. the patient).

'Space' is another crucial element in the assertion of the

authoritativeness of radiological knowledge (Leigh Star, 1989):

"Wow, it is indeed large, now I get it [why the

symptoms are as serious]!"

or:

"How can he even walk around with a tumour that

big?!"

These are types of phrases I would regularly hear in radiology

meetings. The diagnosis of a brain tumour, in the NROs' own terms

'a space occupying process', indeed involved an emphasis on

spatialisation: brain-cancer is a local, non-systemic disease,

unlikely to metastasise to other parts of the body; The symptoms

tend to be in correlation with the surfaces of the brain affected by

the disease; The site of the symptoms often directly reflects the

location of the tumour, its spatial characteristics, and to the rate of

its spreading.

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Often, however, when speaking of a patient's pathology, the

physicians would rather use 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 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 spatial attributes of the tumour are strongly tied to every

aspect of the physicians' work, including in the clinic. Radiology,

thus, as a space-oriented measure, has powerful epistemological

affinity and mimetic relations with the disease as it is conceived: a

spatial diagnostic technique, for a spatially defined pathology.

This is well examplified in the case of Simone, a 25 year old

woman, with advanced cancer. Her husband, Albert, accompanied

her along with her mother to Franz' office. Simone sat on a

wheelchair, completely lethargic, keeping an empty smile when

spoken to, only to go back and doze off again. Franz read the file:

Simone had just completed a round of radiotherapy, and yet, she

looked considerably worse. He looked at the MRI and without

uttering a word, turned the screen towards Albert: "Look", he said.

Yassar remained unsure of the thing he was supposed to 'look' at,

but understood that something must be wrong. This is when 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", Franz pointed at the screen, now more clearly drawing

around the edges of the tumour, "explains how she is", as if the

visualisation of the tumour actually explained anything. Albert:

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"Couldn't you suck it up, like in a biopsy?". Franz bluntly answered,

annoyed by the naïve question: "This is not a liquid! You would suck

up all the brain out!!".

This is when the mother burst into tears, now joined by

Yassar. I was interested as to whether actually seeing the tumour

made any difference: Just a few minutes before, Albert proudly

showed me how her hair had begun to grow again, asking a

rhetorical question: "she'll be alright, now, right?" to which I

answered with a smile. After the consultation, I asked him whether

he was surprised to see the MRI:

"Yes, after 30 days of radiotherapy, it isn't supposed

to grow. I don't understand".

"You didn't think she looked tired?"

"I thought it was the radiotherapy that made her

tired".

He was by now completely deflated. It was as if he finally 'got

it', did the picture make the disease more 'real'?

Sorting Things Out: Histopathology

The work of the histopathologists is perhaps one of the more

central in the diagnosis of brain cancer, as it is the most accurate

source of defining both the grade and the cellular basis of a

tumour. Thus, one of the first steps taken after the initial diagnosis

is to have a portion (or, in some cases, the entirety) of the mass

removed and sent to the laboratory expert. Within days, the

laboratory will produce a report on the assessment of two main

parameters: the tumour's grade (I-IV) and the tumour's cellular

basis (the type of cells involved). This assessment is extremely

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complex, especially in terms of correlating pathology with existing

(and continuously growing) nosological schemes. To mention only a

few criteria of histopathological categorisation: one form of gliomas,

astrocytomas, may be either well-differentiated or anaplastic, either

fibrillary, pilocytic, or gemistocytic, with low or high degrees of

cellularity, low or high degrees of pleomorphism, etc.

Patients, one must note, were seldom aware of such minute

details regarding their tumours – they would rather turn to plain

binary terms: about the mass being either cancerous or not, or

about their cancer being either malignant or benign. These

sophisticated schemes of identification and classification are,

however, central to the creation and preservation of the ontognostic

medicoscientific ethos (Foucault, 1963; Cicourel, 1964; Reiser,

1991a; Keating and Cambrosio, 2003). Histopathology’s ever-

growing categories of mediated-objects, its high tech procedures,

and its position at the cutting edge of research contribute to its

prestige as providing an exclusive corpus of knowledge.

Another characteristic appears to be involved in this assertion

of authoritativeness. In sharp contrast to the 'hands-on' clinical

evaluation, the removal of biological tissue and its analysis outside

of its human context allows 'social distancing'. The living person

becomes literally out-of-sight, out-of-site, and, in a way, out-of-

time, isolated from subjective time and space (and thus from

subjectivity itself) to create alternative sterile, motionless, and well-

defined areas where scientific work can proceed. This, in turn,

provides the laboratory a distinction drawn on a halo of pure

science, clear of the 'fuzziness of reality' (Foucault, 1963; Bourdieu,

1977; Thompson, 1995; Rosenberg, 1999). Removing the personal

particularities of the patient enables a more clear-cut alignment

with existing nosological categories, both within the realm of

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histopathology and within the broader neuro-oncological compiling

diagnosis.

Figuring it out: Neuropsychology

Unlike the psycho-oncologists, whose task was to provide

patients emotional support, the neuropsychologist (Keren) was

regarded as a diagnostic source. Keren was assigned patients that

seemed to suffer from cognitive or emotional deficiencies related to

the organic effects of the tumour, or to side-effects of the treatment

provided for the tumour. She administered psychological tests and

interpreted them; but also guided psychology students who are

obligated to practice giving these tests to patients.

Yet, Keren's job was no less practical than diagnostical: She

suggested technics by which the patient might find a way around

his/her neurological deficits and still maintain some quality of life.

Her contacts with the staff were very limited, and her reports were

usually filed, never to be read by the NROs. She was consulted in

rare cases to consider a patient's capacity to give proper consent to

medical interventions or his/her need of being referred to

psychiatric or psychological care. That being said, neuropsychology

played little or no part in the actual medical decision process.

Arguably with the aim of establishing medicoscientific status,

neuropsychological evaluations tended to be presented as highly-

detailed statistical reports. Still, such knowledge – however

justified and materialised in the form of standardised and

empirically confirmed scales and numbers - remained illustrative

rather than demonstrative. If the neuropsychologist was so seldom

consulted, it was probably based on the low authoritativeness and

epistemological profile of psychological methods (and 'psy-

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knowledges') in the medicoscientific complex (Rose, 1985; Reiser,

1991b; Hacking, 1992; Porter, 1995).

Relying greatly on statistics, numbers and standardisation

allowed a rising of psy-knowledges towards the level of

authoritativeness assigned to more conventional biomedical

sources. This allowed it to be distinct from other forms of

knowledge that would have been brought forward but which may

not have had the same communicative value. It would perhaps not

have been regarded as worth mentioning – just like a patient's

astrological map or his reading of his hands would not. The

knowledge was allowed in, as advertently or not, it was presented

through a filter of 'epistemotechnics' that would 'truthicise'9 it in

the context of scientific medicine Indeed, if psychology wants to

take full part in a purely medical practice (here: neuro-oncology), it

must relates to 'epistemotechnical' aspects of its work that put it in

the same (or close) epistemological level as medical science. Keren

was open about that: she insisted on sitting in team conferences

because she wanted her work to be treated as a meaningful and

"serious" contribution to the more medical clinical work- she

refused to have neuropsychology remaining as peripheral to neuro-

oncology as it was now.

Hands-on: The Clinical Report

The first component of the clinical exchange, the physical

examination, comprises a direct, usually non-instrumented,

assessment of a number of parametres. According to textbook

directions, although rarely meticulously followed in practice, these

include the tone of each muscle group, muscle power, and reflexes.

Changes in sensation will be identified by means of a probing of

different parts of the body, and coordination by observing body

9 'make true'

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movements. Also central to the examination is the evaluation of

gait, during which the patient will be asked to walk back and forth.

The clinician is expected to provide expert deduction and gather

relevant information from the patient, while drawing on haptic

skills and limited technological aids (Foucault, 1963; Porter, 1993;

Moreira, 2006). This 'low-tech' practice is believed to be highly

susceptible to errors and inaccuracies: the patient's body viewed as

disordered and 'messy' in conveying valuable data, and the method

itself based on phenognosis and overall 'primitive' (Joyce, 2005).

The second component of clinical practice, history-taking,

demands a systematic gathering of information (e.g. headaches,

seizures, visual disturbances, motor or sensory dysfunctions, pain,

nausea) which must be characterised by time of onset, duration,

location, frequency, severity, progression or remission,

precipitating circumstances, and associated complaints. A history

of administered treatments must also be sought, as well as should

a more general background of co-morbidities, past medical

interventions, and cases of severe illness in the family.

The lack of neutrality, objectivity, and preciseness attributed

to this practice is critical in the evaluation of the validity – and

thus authoritativeness – of knowledge portrayed in such reports.

Arguably, patients have a 'privileged access' to their own inner

world of experience, and are able to reach a phenognostic 'truth'

that is beyond scientific exploration (Heil, 1988; Gertler, 2001).

This impinges upon the ethos associated with ontognostic thought,

whereby the physician would necessarily have epistemological

supremacy as holding total and absolute knowledge of the

phenomenon of disease. In order to retain ontognostic

authoritativeness, the expert must bind his/her perspective to

observable and accessible aspects of the 'reality' he/she faces,

rather than to the patient's life-world: his/her belief system,

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background, personality, particularities, emotional issues, etc

(Cicourel, 1983; Mishler, 1984; Anspach, 1988; Gunderman,

2005).

The patients themselves cannot be assigned 'expertise', a

clear form of power, even in the context of reporting their own

subjective experience: doing so would challenge the hierarchical

physician/patient relations in the sacred biomedical space of the

clinic and would allow in a non grata phenognostic knowledge.

While the patients may influence the actual process of diagnosis

(e.g., overemphasise some minor symptoms in order to assure full

attention and treatment), they are denied any status of expertise:

the expert is the 'reader' of the body, the deciphering agent of the

narrative, both of which are –more or less-- reliable givens

At the clinic, written reports showed patients' accounts

preceded by a sort of 'disclaimer', noting their relative unreliability.

Typically, the reports included clauses such as: “according to the

patient...” or, quoting from one clinical report:

"[The patient] describes events of abnormal smells,

tastes, and panic feeling up to 10 times a day"

or,

"He complains of some difficulty getting his words

out in conversations".

A similar trend was found in oral exchanges: the 'had' – as in

"the patient had headaches"- was presented during meetings as if

of higher authoritative status than the 'described', and –to a lesser

degree-- than the 'complained of'. The first was assigned some

legitimacy as the reporting physician ipso facto provided a seal of

approval to the actuality of the symptom. The second portrayed the

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patient as able to observe, reflect on, and effectively communicate

the nature of the symptom by offering a description, rather than

speak of a vague, emotionally-laden complaint. These, however

subtle, variations provided clues not only as to the

authoritativeness assigned to clinical knowledge, but also to the

conceived credibility of different forms of clinical information: from

the more phenognostic sources to the more ontognostic.

The Patient

A clinical evaluation, as defined above, does not solely rest on

the examination of the patient's body, but also on the accounts

he\she may provide. This makes the definition of the

authoritativeness of phenognostic, first-person information highly

critical.

Observations of the field suggest that a classification of

patients into reliable ('good patients') and unreliable ('bad

patients') is most sensible. This classification has its basis on a

range of characteristics. In general terms, the ideal patient is

cooperative and compliant. Yet compliance does not merely involve

following 'doctor's orders'. The term, I shall argue, also applies to

the patient's ability or willingness to internalise the biomedical

gaze and its ontognostic claims for epistemological

authoritativeness (Gross, 2009a). He does not have to be

knowledgeable on the subject of his illness, and in fact, being too

knowledgeable may be seen as an annoyance. He still needs to be

able to ask intelligent questions, or to refrain from asking

questions at all, thereby re-affirming the physician's skills in

providing all relevant information. In general, the patient is

expected to be straight and to-the-point in reporting his

complaints, asking the right questions and responding in an

appropriate way to the the physician's inquiries.

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For instance, Adi turned from 'a bad patient' to a 'good

patient' when her reports, at first not taken seriously by the

oncologist, were truthicised with ontognostic measures. Shortly

after the oncologist declared her "better":

"There was one weekend – Thursday, Friday, and

Saturday, when I had insane headaches. I've been

living for thirty years, I never had such headaches –

you know, you bow your head to brush your teeth or

something… I felt my head will explode and drop to

the floor".

The oncologist told her she was overmaking it, yet:

"After [I applied] very intense pressure, he sent me

to do a head CT. I had several brain tumours. They

sent me for radiation right away and gave me

steroids […] I felt like telling them: 'You see, I'm not

faking it!!!' "

The 'good patient' reports symptoms that are compatible with

the physical profile of the assigned pathology. The reported

symptoms' alignment with the determined diagnosis is a clear sign

of the internalisation of the 'medical truth'. Was a patient to report

on symptoms that were not compatible with the diagnosis, he

would be expected to accept the superior epistemological status of

the physical sources, i.e. the authoritativeness of the 'observed'

(ontognosis) over the 'felt' (phenognosis). Such a patient will tend to

think some symptoms more relevant than others – or some

symptoms being simply 'psychosomatic'- if they would not fit into

the scheme proposed by the physician. He\she would then quickly

adjust his\her account accordingly.

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The 'good patient' must also report symptoms that 'make

sense': problematic accounts may include "feeling as if crossed-

eyes, but in the ears". The good patient also never argues with

neither the diagnosis nor the advised course of treatment. Lise's

account of an exchange she had with a patient:

"His wife doesn't understand the drug thing. She

argues with me and won't agree with me. She is

retarded, I think". [In my view, the woman did not

show any sign of mental retardation]

Although some information may only be sough from the

patient's account, such as feelings of numbness or pain, one may

distrust these first-person mediated, phenognostic accounts. This

has two major reasons: one, the person may simply be not truthful

(lie), and second, the person may not be aware of his own

condition. The field teaches us that the patient must provide

specific forms of accounts that eliminate, or diminish these two

considerations: he must speak of symptoms in a credible way -

talking about witnesses, referring to the 'right' symptoms according

to the 'book': this may include a "my head is on fire" as an

unsophisticated but accurate account of what a patient may feel

like after radiotherapy. In fact, it is considered most credible when

the patient seems to 'incidentally' report symptoms that, without

him holding true knowledge of it, would be compatible with the

textbook account of the disease.

A good patient will provide just the right amount of reporting,

being succint but informative. He must also not be "overly anxious"

(this being a typical term used), although, where brain cancer is

involved, one may wonder whether there is such a thing as being

'overly' anxious. There is also a right timing when the symptoms

must be mentioned: an eagerness to report symptoms may have

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one lose credibility, he may seem 'hypochondriac' or as more often

used – 'suffering from anxiety'. The staff members are well aware of

the suggestibility of patients, and will at time refer to it with some

sense of humor. Riba, the headnurse, told the team a story about

one of the female (deemed 'hysterical') patients:

"She won't admit it but she's getting better, so I told

her, if you don't feel well [as if trying to catch her

bluff]: go to radiotherapy."

She refused. Riba has the morale of the story:

"A month later she said she felt much better and

stopped telling these overly dramatic stories. When

we looked at the MRI, there was no real

improvement".

The team was amused, again reifying the epistemological

inferiority of patients' accounts over MRI results.

'Bad patients' will get raised eyebrows in exasperation when

leaving the room, some NROs going as far as sharing of the

experience with the team: "this patient is psycho" or "I hate these

wives that are sticky and pushy". 'Bad patients' tend to come from

less educated backgrounds, and often from lower socio-economic

status. They may arrive to consultations with too many family

members ("they must think it's a party!" said the headnurse about

one such family). Ultra-orthodox are quickly assigned to this

group, also because they are seen as making choices that give rise

to clear indignation: having too many children, too early, marrying

the wrong partners, turning to a Rabbi for advices and so on

(Gross and Shuval, 2008).

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One memorable case of such 'bad patienthood' is Benjamin

Abitbul's. Benjamin was recently diagnosed with a brain tumour,

and sent to more elaborate testing. Invited to receive the results of

his biopsy (and the qualification of the tumour's grade), he arrived

(from the provincial area of Tiberiade, more than 100 miles away

from Jerusalem) accompanied with no less than five family

members, including his wife, two sisters, a brother, and a sister-in-

law. He himself seemed embarrased to be followed by what the

staff will disdainfully refer to his 'Tiberiade' family. The group was

quite assertive with their presence, speaking outloud, passing

snacks and water from one to another. Lise, in charge of breaking

the news of Benjamin's impending death, applied her authority by

asking the crowd to keep away from the area of her office and by

refusing to accept more than one family member in the room, this,

although she would often have consultations with three or more

persons present. What made her furious was Benjamin's sister

turning to her in the corridor asking whether she could "on the

way" give her "just one calming pill, just so to make him [Benjamin]

less upset". Lise responded with a dry "no" and went on ("Does she

think it's like giving out candies?" she would later say). She would

later scornfully describe the incident to her colleagues: "These

people" were "impossible to work with" and "didn't know how to

behave". Little did she know the sister soon approached me with

the exact same request.

General Oncologists: Peripheral Experts

The oncologist that worked most closely with the NROs is

Doctor Sari, a middle aged woman. She is relatively assertive and

confident (although always cordial and gentle) with her patients as

well as with the clinic's clerical staff. In her exchanges with the

NROS, however, and not unlike other specialists, she tends to take

on a subordinate, passive, position.

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The physical basis of the clinic is in a general oncology clinic,

which facilities the NROs use three days a week. The rooms do not

hold any specific characteristics that would point to any particular

specialty (such as drug posters, anatomical illustrations and so

on), thus a simple change of the name tags on the doors is

sufficient to have the room become a neuro-oncologist's rather

than an oncologist's office. This is particularly interesting, since

neuro-oncologists are not trained as oncology specialists. Rather,

they are general neurologists (who, besides the head of the clinic,

Lise, all work as neurologists either in the hospital or in the

community), with some on-the-job experience in neuro-oncology.

Knowledge in general oncology is rarely required where brain

cancer is concerned. The brain responds to only a few

chemotherapeutic interventions, the diagnostic tools are well

defined, and seldom does the tumour spread to other organs.

The structure of the specialisation may also point to the

complexity and level of specificity assigned to knowledge of the

nervous system against knowledge relating to general

understanding of cancer pathology and treatment. This is in line

with the general trend of regarding brain-related disciplines as

most distinguished. Indeed, Levitz, on why he chose neurology as a

field of expertise succintly put it:

"It's a field that is most challenging in terms of

having to think. It's an intelligent field".

Thus, in many ways, the neuro-oncological clinic and its

related interdisciplinary web is organised along a nosological

concept, which also points top the importance of the nosological

difference between brain cancer and body-cancer. The clinic is an

environment which accepts specific nosological categories but also

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finds the chosen cases most instructive, perhaps as a by-product

of the nosologically-based criteria of inclusion:

"By operating a process of selection, it alters in its

very nature the way in which the disease is

manifested, and the relationship between what is

present is the disease itself, in the body that is

appropriate to it, which is not that of the patient,

but that of its truth" (Foucault, 1975: 26).

This perhaps defines best the importance of the nosological

complex that would define or be defined by the institutional-

epistemological separation of neuro-oncology from oncology.

The Neurosurgeons and the Tumour Board: Peripheral Experts

Once a week, the neuro-oncology staff (the four physicians

and the head-nurse) meets with the neurosurgeons. The name of

the weekly meeting, 'the tumour board' is somewhat enigmatic: as

if this was when the tumour would be defined, identified, and

characterised. This has in fact little relevance to what actually

ocurred in these meetings.

The neurosurgery staff comprises three middle-aged men,

assertive and at times even aggressive in their manners. The

athmosphere is quite different from the radiology meeting's: the

power dynamics put the NROs on contested grounds as far as their

expertise is concerned. This aside, the meeting is not diagnosis-

oriented, but rather centres on decision making: 'can and should

this patient be operated on?'. Each meeting focuses on no more

than three to four patients where surgery might be considered.

Then, clinical evaluations are brought up along with radiology

reports, and treatment options are deliberated. Although the NROs

are the ultimate decision-makers, and will never suggest surgery

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when deemed impossible or not beneficial by the surgeons, the

latter remain highly authoritative, probably due to the high status

brain surgeons have in the medical field and to the uniqueness of

the tacit knowledge they may have acquired over the years: a form

of knowledge innaccessible to the NROs.

One must remember, however, that the neurosurgeons play

no role in actually diagnosing the patient, and are therefore

somewhat outside of the scope of this scheme.

Mechanisms of Integration

The raison d'être of neuro-oncological expertise lies in the

contention that brain cancer is a distinct, well-defined, and

conceptually unified disease entity. Asserting the coherence

between mediated-objects not only reaffirmed the soundness of

each individual form of inquiry and validated the meta-diagnosis of

one particular case, but also served to support the general notion

of brain cancer as a cellular based, spatially spread, and

scientifically detectible form of disease, one for which a specialised

compiling expert should be ascribed. In other words, the

ontological, pathological differences between 'body cancers' and

'brain cancers' are replicated in the field of relations between

professions and profesionals: between oncologists and neuro-

oncologists. These boundaries are further replicated in the spatial

organisation of the clinic, as described at length in an earlier

chapter.

In terms of the web of experts, the hierarchical distinction

between neuro-oncologists and general oncologists was

continuously sought to be preserved not only by the NROs forming

a 'clique of their own' as one onco-psychologist put it, but also via

the establishment of disease categories and diagnoses pointing to

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the particularities of brain cancer over other oncological diseases,

and the affirmation of the diagnosis as requiring neuro-oncological,

rather than oncological, expertise. When faced with a collection of

disparate reports, the NROs thus sought to establish the case as of

a well-asserted neuro-oncological nature. In this sense, the meta-

diagnosis also served to delineate, and then preserve the areas of

jurisdiction and epistemological boundaries of the compiling

expertise (Abbott, 1988; Gieryn, 1983, 1999). This secured the

NRO's prerogative to elect and determine treatment options, to

provide reliable prognosis, and to centralise documentation and

records for future research: to be the compiling expert.

As claimed above, this endeavour involved five relatively

distinct mechanisms: hierarchisation, sequencing, negotiation,

peripheralising, and pragmatism.

Hierarchisation

Forms of knowledge, as well as the objects produced by this

knowledge, are created and sustained by having its different forms

become authoritative, and others subjugated, marginalised, or

excluded from the sphere of legitimacy (Foucault, 1980; Latour and

Woolgar, 1986; Latour, 1996). As shown throughout the text, the

forms of expertise associated with neuro-oncologic diagnosis

differed not only in terms of instruments and types of knowledge

applied to the mediated-object, but also in terms of their perceived

authoritativeness, and, consequently, hierarchical position. The

NRO, confronted with the task of incorporating the disparate

reports, could (and often did) choose to constrict the range of

available knowledge by discarding information from less

authoritative sources, settling for a diagnosis based on narrower --

albeit more solid-- foundations.

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This was the case with Ilya. At the radiology meeting, his

latest MRI took Lise by surprise: "this looks bad…", she told her

colleagues, "It’s amazing, he has no symptoms! This guy walks

around with a ticking bomb in his head, but is completely

asymptomatic…". In other words, the MRI suggested a progression,

while the clinical picture pointed to a more stable and benign

condition. The pictures were unquestionably there, thus the

'anomaly' had to be located at the clinical level, the less

authoritative of the two forms of knowledge. As well put by

Gunderman (2005:342):

"We radiologists sometimes find ourselves giving

more credence to the images than to the patient,

rendering the patient’s experience subordinate to

the images on the monitor."

Lise declared a worsening in Ilya’s state: now judged

ineffective, Tal’s chemotherapeutic treatment was discontinued.

Sequencing

Brain tumours are conceived as having a dynamic

constitution. First, it is granted that the tumour may progress from

one grade to another, may respond to therapy --at times long after

the treatment itself has been interrupted or concluded-- or may

simply remain unchanged. Moreover, symptoms tend to

accumulate and aggravate, and their response to medication may

decrease over time. Sequencing uses this set of temporal factors to

account for diagnostic changes without challenging the unity of

'the Disease', substituting ontological fluidity for temporal fluidity:

the object may not be stable as an entity, but still retains a

continual consistency as a neuro-oncology-mediated object.

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On one occasion, for example, Karl’s wife called Franz to

report that her husband had a new symptom: he felt 'tingling' in

his left arm. She was surprised as the MRI, taken two weeks

earlier, suggested a shrinking of the tumour. Considering the

authoritativeness assigned to medical images, Franz did not readily

discard the imaging report as unreliable. Rather, she answered

that the disease had probably worsened since. As MRI images were

never compared unless taken at least one to two months apart,

this was an assertion that, while sensible, was impossible to be put

to the test, and thus also impossible to challenge. Yet, as it allowed

the initial diagnosis to remain valid, it was accepted, to the very

least until other evidence came along (the next MRI suggested that

the tumour was indeed growing).

In general, in case presentations, the sequencing of the events

is very much put at the centre, and the temporal dimension is

central to the characterisation of the disease. Only with little

exceptions does it not make complete narrative 'sense' as the

development of one (or several concomitant) diseases.

Negotiation

It is during the weekly radiology meeting that 'negotiated

processes' (Moreira, 2006) could be observed. There, the four NROs

would sit behind a radiologist who gave 'live' interpretations of the

images. Led by the NROs' instructions, he focused on particular

sites, paid attention to specific patterns, all the while well aware of

'what it is we are looking for'. The clinical and the radiological were

often – again, never deliberately - adjusted 'on the spot', that is,

well before the written report was issued.

On some occurrences, the NROs were provided with non-

negotiated reports. These, compared to reports resulting from the

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MRI-NRO meeting, tended to be vague and obscure. One such

report was Friedrich’s. According to Lise, the clinical picture

suggested a slowing down of the tumour's progression, while the

MRI report remained 'incomprehensible'. She advised Friedrich to

phone her the subsequent Monday for a more definite answer. In

the course of Sunday's meeting, Lise briefed the radiologist on

Friedrich's clinical improvement, emphasising the fact that he had

recently received treatment. The highly negotiable nature of the

imaging report permitted the team to agree that the MRI showed

some decrease in the tumour's size.

The use of this mechanism was also evident where clinical

reports were concerned. The NRO, one may recall, performed a

dual role in the web of expertise: once as a compiling expert and

once as a clinical reporting expert. The NRO, when clinically

evaluating one particular patient, could thus favour interpretations

that were most consistent with his/her overall preconceived

impression. Hence, by the time the file reached the NRO as the

compiling expert, some degree of compatibility could already have

been incorporated into the reports, facilitating the reaching of the

meta-diagnosis.

Negotiation was less apposite where histopathology reports

were concerned. First, unlike MRI reports, which were delivered

also orally, the histopathology report was customarily

communicated solely in writing. Secondly, histopathology was

conceived, overall, as involving a lesser degree of human

interpretation, and thereby as being more rigid to processes of

negotiation. Thirdly, the NROs tended to regard themselves as

more competent in reading MRI pictures than in the deciphering of

cellular formations, thus having little to add to the

histopathologists’ interpretations. Finally, the importance of the

histopathology report was often only tangential to decisions on

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treatment, and was conducted significantly less frequently than

radiology tests.

Negotiation was also present in clinical exchanges with the

patients. For instance, when Misha came to hear about his latest

MRI and discuss his condition, he was almost literally told what he

'should' be feeling, and conseqently abided to this normative

statement. The MRI showed that the tumour had slightly grown

over the last two months. Looking carefully at the MRI, Lise

asserted:

"I don't believe you should feel any change"

Misha: "Well, I do have some headaches…".

Lise: "It's… I don't think it's really something".

Misha, mumbling: "OK…right..."

The headaches, a symptom now completely discredited, were

never brought up again.

Peripheralising

Sofya, a 52 year old woman with a highly malignant cancer,

was told by Franz that "the latest MRI shows [she is] doing better".

Now almost completely blind, holding her face in her two hands,

she mumbled in response: "but my head aches so much that I can’t

even touch the tips of my hair without feeling like screaming!". Franz

interrupted her short monologue: "That, I can’t explain". As she

attempted to persuade him that her pain was real, he referred her

to a dermatologist: "it could be a different problem", he concluded.

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Here, as in other cases, the independent expert was sought once a

diagnostic element could not be accounted for within the neuro-

oncological sphere: the dermatologist could, however, explain

away the 'hair ache' without openly dismissing the patient’s

complaints on the one hand, or challenge the already well-

established diagnosis on the other.

This dermatology-mediated object could then be incorporated

into the view of the neuro-oncological disease, albeit in its

periphery. Such objects could then serve either as

contextualisations of the meta-diagnosis or as evidence of its

accuracy. As these objects belonged to a sphere of expertise

defined as 'independent'- i.e., extrinsic rather than intrinsic – the

NRO held considerable leisure in their re-interpretation or,

alternatively, their thrusting aside. Overall, the place of

independent-expert-mediated objects was to a large extent

assigned by the compiling expert, providing the NROs a certain

degree of slack in their meta-diagnostic work.

Pragmatism

In neuro-oncology, treatment options are comparatively

scarce. They include a few forms of chemotherapy, a limited array

of surgical interventions, and relatively little room for intense

radiotherapy. The primary brain tumour will almost invariably be

fatal to the patient: more than half will succumb to the disease

within the twelve months following diagnosis. Only one fifth will be

expected to survive for more than five years (Coldman, Phillips and

Reid, 2004). In practice, once treatment options run out, the NRO

usually ceases to be involved. The patient will then be offered

supportive and palliative care, typically in a hospice or among

his/her relatives. This being the case, elaborate and minute

diagnosis may, in some cases, seem somewhat less crucial. This

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was the case with Grushka, a 84 year old woman, whose precise

type and grade of tumour were unknown. The group was

unanymous: she will not have her tumour biopsied, rather, she will

be given something for her symptoms, i.e. a large dose of the most

common steroid used in brain cancer: dexamethazole©.

In effect, patients themselves were little interested in precise

diagnosis. Treatment prospects seemed more salient: "Will I have to

go through chemo?" "Will I lose my hair?". Simon, for example, spent

months visiting the clinic without showing any interest as to

whether his tumour was graded III or IV. Although undoubtedly

aware of the grading system, he "never thought of asking". Indeed,

for many patients, beyond general notions of improvement or

degradation ("Has it grown?", "Am I doing better?"), formal diagnosis

remained futile.

As a rule, the neuro-oncology clinic saw patients only once a

brain-tumour diagnosis was reasonably established. At this point,

however, the diagnosis remained vague: "There is a finding in your

brain, we are still unsure of its exact nature" was a classical

opening. Patients rarely demanded much more details, and, more

often than not, avoided using the term 'cancer', to rather refer to

hazy notions such as 'my condition', or 'the lump'. Oren, for

example, was surprised to hear me refer to the 'oncology clinic'

when we set a location for an interview. He said he never noticed it

was a clinic that "also deals with cancer"- this after five years of

follow-up.

Recently diagnosed patients tended to use the more hesitant

"I was diagnosed with…" than the definite "I have…". Both patients

and physicians entered a sort of unspoken pact, where the precise

diagnosis was regarded by both as merely tentative. In line with the

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"pact", the physician would respond with such uninformative

remarks as:

"Let’s not jump our horses"

"Let’s talk after we have some further tests done"

or,

"We’re never sure of anything, but we have to do

what needs to be done".

In the course of more than one hundred such consultations

observed, only a few patients inquired into expected consequences

of their diagnoses: the "how long do I have, doc?" question was

never raised, under any variation. When at all, prognostic

information was only vaguely sought, with a "can this be treated?",

rather than "will I live?". Physicians themselves never went beyond

a general: "it’s all just statistics", or "each case its own". While

family members did occasionally sought online information on the

expected lifespan of their loved-ones ("for practical reasons", they

would typically claim), as far as patient-physician interaction was

concerned, precise diagnosis did not serve any prognostic aim. In

fact, one of the younger patients, a computer programmer well

acquainted with the web, told me he read "a lot" about his

condition. As to his life expectancy:

"Really?! Do they [the websites] say anything about

that?! It must be in small letters, or I must have

missed this line [where life expectancy was

mentioned]…".

In the case of Alexey, an 18 year old boy, he would go on and

on about becoming a physician. Although aware of many aspects of

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his condition, he seemed completely oblivious to the fact that his

life expectancy was of a year or so, during which he will probably

be increasingly handicapped. The prospect of medical school was

poor, as was his life prospects in general. However, like many other

patients, he would simply deny this reality.

This trend was also evident among another significant group

of patients. These were referred to the clinic after the treating

oncologist (being, here, the compiling expert) suspected the

presence of cerebral metastases. At this point, the neuro-oncologist

(here, serving as an independent expert) tended to provide an

assessment that was more quantitative than qualitative: the

tumours were either present or absent, single or multiple, active or

stable. Patients were then less concerned about the precise nature

of the neuro-oncological aspect of their disease. Gabriel, a 66 year

old man, just heard about his melanoma (skin cancer) having

metastasised to his lungs and brain. He "doesn't want to know too

much":

"The only information I have is what my sons tell me.

As far as I'm concerned, I don't need to know

anything beyond the tip of my nose [places his finger

on his nose]".

Also, as the presence of metastases remained an almost

definite death sentence, as far as the NRO was concerned, a more

pragmatic approach was be adopted, focusing on treatment options

and palliative care rather than on elaborate diagnostic

undertakings. The disease may itself be loosely defined as

belonging to a more general diagnostical category.

In these cases, NROs often favoured the use of as little

information as needed for the determination of the most

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advantageous course of therapy. In practice, this stance of

pragmatism typically involved tacit avoidance of definite and

elaborate diagnosis. Still, while unspoken, an official diagnosis

invariably appeared on the reports, stating, for example, whether

the tumour was defined as a grade-IV or –III, whether a

glioblastoma multiforme or an anaplastic astrocytoma. This was in

many cases, however, little more than a bureaucratic formality,

which the NROs regarded as of weak empirical validity. In these

cases, the NROs accepted the fluidity of this definition and

proceeded to consider treatment options. Perhaps most

interestingly, pragmatic considerations could eventually have some

bearing on the overall diagnostic process: once a tentative object of

disease was defined, other forms of diagnosis could align. This

process of alignment usually involved reporting and independent

experts: these would typically treat this diagnosis as ascertained,

being little aware of the looseness of its epistemological grounds.

Concluding Words

As part of a larger attempt to consider issues of dynamics of

knowledge and their relation to social phenomena, this study

demonstrated the significance of the web of expertise in the

production of diagnosis, most particularly where the latter tends to

be ubiquitous, and involve highly heterogeneous epistemological

forms.

While widely acknowledged in past literature, little research

was based on thick descriptions of expert exchanges in the

backstages of a hospital setting. The ability to witness the

processes of diagnosis from various angles, including different

actors and different settings, allowed for a thorough and detailed

presentation and schematisation of the microdynamics of a central

aspect of medical work, i.e. the undertaking of diagnosis.

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As defined above, expert gaze incorporates sets of

epistemologies and technologies, both of which mediate diagnosis

and reduce a multileveled phenomenon into one single manageable

object. The replicated flows of artefacts, concepts, and

interpretations among experts were shown to have an important

role in asserting both reporting and independent expert

authoritativeness, but also in reifying the legitimacy of neuro-

oncology as a compiling expertise. Participant observation of the in-

situ workings of the clinic suggested that this reification involved,

on the part of the compiling experts, the use of five mechanisms of

consolidation: hierarchisation, sequencing, negotiation,

peripheralising, and pragmatism. These mechanisms were shown

to involve different cases at different conjunctures, and with

different sets of expert relations, emphasising the complexity of

diagnostic work.

Many of the patients discussed here died before this

manuscript was finalised. Others will soon die, some more in

comfort than others. All being said about the ontognostic 'reality' of

these 'objects of disease', it eventually comes down to the effort to

save patients’ lives, to give them more time with their family and

loved ones, to make their last moments more bearable.

I propose concluding with an afterthought. The analysis

presented here may seem abstract. In an ironic, yet mesmerising

way, by reflecting biomedicine’s utopian vision of diagnosis as

sterile from non-scientific spheres (e.g. phenognostic forms of

knowledge), this work was narrated in a way that suggests the

presence of a similar bias. Yet, it is through exchanges between

experts, through mechanisms of diagnosis and decision-making,

that actual, experienced lives are altered, prolonged, or less

painfully ended. It is through dynamics of knowledge exchange, of

human exchange that the enterprise sustains itself. One cannot,

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and indeed should not, lose sight of the fact that ethos, symbols,

technology, epistemology, and eventually the experts themselves,

do not live in an abstract world of theory, or objective insularity.

They are encroached in the flesh, in the suffering, in the existence

of actual men and women.

A discussion of these very issues will stand at the centre of a

later section of this work, when the individuality and subjective

depth of one particular patient will be brought to the fore. This

section will be based on a notion of the brain as an intermediary

between matter and consciousness; brain is both the assigned

locus of phenognostic knowledge, and an ontognostically

observable 'thing'; it thus only makes sense to place the brain at a

most significant juncture of this work.

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Part V: The Brain Exposed

On Neurosurgery and the Nature of Objectification

Introduction

"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….thus the articulation of

medical language and its object will appear as a

single figure". (Foucault, 1975: XI)

As described earlier in this work, modern Western culture has

always held an intricate view of the body: while still being

considered as an object among others, the body will keep its

singular phenognostic status as the locus of a subjective

consciousness (Sartre, 1956; Merleau-Ponty, 1962; Lanigan,

1995a, 1995b). Focusing upon this dualist epistemology, social

studies have repeatedly shown how biomedicine, as a dominant

discourse of modernity, tends to refer to the body in terms of the

former, discarding the latter (e.g. Martin, 1994; Cartwright, 1995;

Lock, 1997). Indeed, over the last decades, a significant range of

research has accumulated, associating biomedicine’s practices and

epistemological bases with stances of depersonalisation and

objectification of the patient (e.g. Scheper-Hughes and Lock, 1987;

Thornquist, 1997; Scambler and Higgs, 1998). Arguably, this

tendency toward objectification will have biomedicine centre its

attention upon the body as a material, ontognostic entity (e.g.

Eisenberg 1977; Mishler et al. 1981; Dew 2001), where it would be

treated as a machine, observable through expanding scientific

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technologies and knowledge (e.g. Arney and Bergen 1984; Synott,

1992; Walters, 2004). According to this claim, the observable and

ontognostically-graspable body will take precedence over which

remains beyond biomedical epistemological reach, i.e. subjective

experience (Babbie 1970; Armstrong, 1983, 1984; Csordas, 1994;

Good, 1994), and thus favouring the ontognostic over the

phenognostic.

These lines of argument have become the dominant voice in

broad areas of social study of biomedicine, and the portrayal of

biomedical epistemology as reductionist and materialistic is by now

little questioned. The split between experience and the body is

perhaps most salient in studies of patient-physician interactions

(Murphy, 1990; Toombs, 1990; Wiltshire, 1999), where these

interactions are typically portrayed as consisting of a dialectical

exchange between two voices: the voice of medicine and the voice of

the life-world. As the former will relate to the body in abstract

decontextualising terms, the latter will see to the patient’s

experiences as grounded on his/her social and personal life as it is

narrated from a subjective position, and based on phenognosis as

a source of knowledge (Mishler, 1984; Young, 1997; Barry et al.,

2001). An overbearing claim – albeit often implicit – in these texts

is that since medicine seems to disregard this life-world, it remains

to the researcher to be attentive to it and to relate to it in a more

empathetic manner: either by pointing to what he/she considers as

an excessive attention to its supposedly symmetrical opposite (the

body), or by applying more sensitivity toward the complex,

subjective, personal aspects of human existence. Indeed, in

important works studying the body as a site of conjunction

between the two spheres (e.g. Turner, 1992; Csordas, 1990, 1993,

1994), the researcher is typically portrayed as more aware to the

phenognostic, lived aspect of the body, as if a necessary

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consequence of his/her position (e.g. Featherstone et al., 1991;

Haraway, 1991; Berg and Akrich, 2004).

Phenognosis, however is not a mere pre-discusive form,

necessarily applied unless 'disciplined' by ontognosis. It is, as I

have argued before, a consequential discursive force, which

requires fit contexts upon which to attach itself in order to gather –

and retain- power. This means that a phenognostic-based attitude

toward the 'other' is not a mere default position, held in non-

medicalised settings by not medically-socialised individuals. It is a

discursive power in and on itself.

Although biomedicine might indeed use a dualist, or

materialistic view of the person, it is neither a constant position,

nor is it a necessary by-product of epistemological, historical,

technological, or even political characteristics of the profession.

Rather, the patient is defined and redefined in interactions,

alternating subject and object positions, passive and active

stances, and definitions as either patient or person (Berg and

Akrich, 2004). Taking this a step forward, I will argue that one

cannot, and must not, exclude the researcher from these

microdynamics. The researcher, however reflexive and empathetic,

is hardly immune to objectification tendencies. If the body is

imbedded in contexts within which it appears, and if dependent on

its characteristics and positions, both ethnographer and biomedical

practitioner will find themselves in transition between stances of

objectification and empathy. Any participant observation in the

social studies of medicine will have to address this issue prior to

the actual insertion into the field.

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Methodological Notes

I will present this movement using a first-person narrative of

my own relationship with Ivan10, an informant encountered in the

course of my fieldwork at the neuro-oncology clinic. Six months of

intensive participant observation pursued by a year-long follow-up

allowed a close rapport to develop. As I accompanied this 32 year

old man throughout his battle with brain cancer, I attended the

many clinical exchanges he had along the way, and eventually

accompanied him into the surgery room where I would witness his

brain exposed. There, where a last attempt to prolong his life was

undertaken, it seems the complexities of our relationship would be

taken to their extreme.

An interesting feature of this case is that, while becoming

increasingly intimate with both him and his close ones, I also had

continual access to the purely biomedical aspects of his condition -

this by attending staff meetings where his case, among others, was

discussed. Along parallel, yet at times intersecting lines, I followed

his disease as an ontologically-asserted physical entity but also as

it was experienced by a person with full subjectivity, as an illness

(Kleinman, 1988). Tied with the development of his illness

trajectory, I gradually took on the role of a confident and provided

some of the mental and emotional support he desperately sought.

Ivan became a principal research subject and, to some extent, a

friend.

In an attempt to understand this fluctuation in my stance

toward him, I use this essay to reveal my internalisation of

different roles, at times as part of the clinical team, at others, as a

lay (i.e. non-medical) researcher with strong personal relationships

with the subject. I depict the ways in which my own experience

10 As with all names mentioned throughout this work, this is a pseudonym

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139

was altered by replicated11 ritualistic and symbolic elements, often

said to serve as facilitating medical objectification. These elements

may be discerned in many arenas where the body prevails.

However, and as made ever more evident in this work, I shall claim

that one organ holds particular features, features which make the

analysis around it more complex, but also more promising: The

Brain.

The Sacred Brain: The Matter of the Gnostic Split

The brain is not just another body part. It is the site in which

all bodily activities, sensual perceptions, cognitive and emotional

processing take place. If, according to some theories, the social is

imbedded in the body (e.g. Frank, 1990; Turner, 1992) and the

body is what is situated in the world (Merleau-Ponty, 1962) the

brain is where 'the world', 'the other', 'the self' all meet. It is where

subjectivity and objectivity ultimately link: a conceptual pineal

gland.

Western medical thought is largely based on an organ-

oriented view. Its ontognostic components are further based on the

concept of efficient causation – of biological processes being linked

together as sequences of cause and effect. The brain plays a central

part in this anatomical-causal complex, in being both the causal

source of every bodily process (from blood circulation to muscle

coordination), and the point which every bodily process eventually

affects. It is the source of action and the endpoint of both internal

and external sensory input.

Social science literature has brought us several illustrations

for the centrality of the brain in biomedicine. First may be the

conviction that, although biologically viable, brain-dead individuals

11 The idea of replication of boundaries is discussed in the introductory chapter and will be developed here at later stages of the analysis.

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have lost their personhood or humanhood, and can be referred to

as beating heart cadavers or neomorts (Youngner, 1989; Okhuni-

Tierny et al., 1994; Kaufman, 2000; Lock, 2002). The central

position of the brain in Western society can also be seen in its

cultural emphasis on reflexivity, and "the paramount cultural and

material importance of the mind" (Webb, 1998:1). Webb, for

instance, analyses cases of brain injured individual and explains

their expulsion from modern society by referring to the particular

features of the brain as an organ rich in meanings that are central

to Western society (Webb, 1998). Another example can be found in

Popper and Eccles' work (1977:177), according to which it would

be clear that a transplantation of a brain onto another's body

would amount to the complete "transference of the mind, of the

self" into the latter. Then, the brain, rather than the body as a

whole, holds paramount significance in the definition of selfhood

and subjectivity.

At a different level, the brain can have primacy over the body,

such as in cases of phantom limb syndrome, when the brain

creates a seeming perception of one's body. This leads amputees to

experience sensations (e.g. pain, tingling) as having their source in

the limb removed. This phenomenon may be explained by the

presence of neuronal representation of the arm or leg at the level of

the brain, which, when cerebrally activated, can 'feel' as the 'real

thing', external to the brain. A related (and, in a way, reverse)

condition is of 'asomatognosia'. This takes place when a person's

limb 'feels' like an external object 'glued' onto one's body, having

nothing to do with his/her perceived 'self' (i.e. Tsementzis, 2000;

Greenberg et al., 2002). In these cases, patients may go as far as

calling this limb by a name, such as 'Joe' or 'Mary' (Sacks, 1985;

Feinberg, 2006). This phenomenon has its source on disorders of

brain activity, again providing a vivid instance of brain's

domination over the body.

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141

This idea of the brain as the apex of subjective/objective

liminality, will have clear ritualistic expressions in the surgery

room. It will create multiple dimensions within which the

subjective will be dealt with, replicating the liminality and the

boundaries created as a result of this liminality. Based on the

following ethnographic description, I shall turn to the analysis of

these dimensions.

The Story

'Prelude'

I had barely begun my fieldwork when I met Ivan. The last

patient had left Lise’s office and Ivan's dossier laid on the top of the

pile. I looked at his name and remembered his case, which was

just brought up during the last staff meeting: my field notes read

"Ivan Katz is a 31 year old patient with a grade II

oligodendroglioma", a type of brain cancer with a life expectancy of

seven to ten years. He was diagnosed in 1999. We were now at the

end of 2006.

The day of our first interview, set at a coffee house near the

hospital, was incidentally the day when Ivan experienced the first

epileptic seizure he had in the last two years. As far as I could

gather from the situation, he was probably emotionally drained

from having to recall his seven years experience with brain cancer

and, ten minutes into the interview he left the table to freshen up

in the bathroom. On his way back, however, he collapsed. Lying on

the floor of the staircases, he regained consciousness surrounded

by strangers, mostly nurses and other hospital employees. As I was

later told, he immediately asked for me, calling out my name and

describing me to the security man. The latter reached the coffee

house and almost out of breath, asked me whether I knew a 'Ivan

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Katz'. "He doesn't feel well" was all he said as he was leading me to

the staircases. I naturally found myself helping him to the

Emergency Room (ER) – the access to which was much facilitated

by the fact that I was wearing my white gown. We were able to use

– unquestioned – the back entrance, usually reserved for staff

members.

There, we were to spend the next seven hours together. I

knew that the seizure was a clear sign of relapse. I was told a few

days later that the chemotherapy ceased to be efficient and that his

tumour was growing. The following year would be his last.

On the day of this dramatic interview, Ivan had an MRI taken.

Later this week, I would be the first to see the image, as I regularly

participated in staff meetings. There was little need for professional

deciphering: the tumour grew considerably, a fact which explained

the seizure. As to my question on the specific episode and its

timing, the physicians all categorically ruled out any causal

relation between the seizure and Ivan's emotional tension at the

time – the subjective was not allowed into the loop of causation. It

was the tumour "having its will when it had its will". Ivan would

continue to see this as a direct reaction to his emotional

experience, while I remained indecisive, although continuously

troubled by the question: was this a purely bodily phenomenon –

with its own causes and effects - or was I to take Ivan's account as

a fact, as The Truth?

In medical terms, however, there was little doubt that Ivan's

condition was deteriorating. As a behind-the-scene, backstage

observer, I was well aware of that. However, as my research placed

Ivan –rather than the medical team- at the centre, I had to wait for

him to reveal this unfortunate development: for me to convey the

results to him directly would not only be a breach of ethics. It

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would have merged which has become the two spheres within

which I operated: the professional, biomedical (and thus

ontognosis-oriented), and the personal, experience-focused (thus

perhaps more phenognosis-inclined). At another level, it was the

clinical (his seizure) and pathological (the MRI), which spoke of the

disease, even while Ivan still did not (as he was not, at least

consciously, aware of his condition). The disjunction became ever

clearer: Ivan was both a talking corpse, sending cues in the forms

of signs and symptoms, and an embodied subject, eventually

mediating the knowledge of his disease via his conscious self. This

double, and very much dualistic, perspective became omnipresent

in all exchanges related to him: Ivan was both person and patient,

subject and body.

As the months went by, more aggressive treatment became

inescapable: Ivan went through radiotherapy; his hair fell out; he

gradually lost his ability to communicate properly, to focus his

sight, to remember phone numbers. His seizures grew both in

intensity and frequency, now up to a five times a day. Toward the

end of the year, he became hemiparetic12 and suffered an almost

complete loss of sensory and motor capacities on the right side of

his body. After the last chemotherapy round turned out to be

almost lethal, the Jerusalem team gave up on treatment. They had

nothing else to offer. Palliative care was all that remained.

Ivan, however, refused to give up without what he considered

as a fair fight. He and his family turned to another hospital, now in

Tel Aviv, seeking advice. There, the team offered one additional

surgical intervention in order to remove a part of the tumour. That,

they thought, might possibly allow for the chemotherapy to be

more effective. The surgery was to take place a month later.

12 A neural weakness on one side of the body, typically leaving the other completely functioning

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Ivan was amused when I first asked him whether I could join

in on the operation. He dared me to go through this, and swore me

to talk to him afterwards about "what [he] looks like inside". I

wondered whether knowing what his brain looked like would add

anything to his understanding of himself, or to my understanding

of him, and as to whether he would have had the same request was

another organ the target of surgery. When I inquired about it, he

responded that "it wouldn't have been that cool". As far as I was

concerned, the baring of the 'organ of the self' bared nothing of his

'self'. I could only speak figuratively, and tong in cheek, on how

large his brain was, as if it reflected his intelligence. Sadly, the size

of his brain had more to do with the space-occupying presence of

the tumour. His brain said nothing.

The story of our relationship and the difficulties I had in

positioning myself in relation to Ivan found their epitome during

the day of the operation: all seemed to be encapsulated in those

hours before, during, and right after Ivan’s brain surgery.

The S-day

The morning of the surgery, the pressure Ivan’s swollen brain

applied on the inner walls of his skull was so severe that he had to

keep his eyes shut in agony. The increasing doses of steroids had

his face so puffed-up that he looked like a giant squirrel. I looked

curiously, a bit detached, at this grotesque figure being wheeled to

the OR, his hands nervously petting his skull. On the top of his

head were scattered a few chick hairs, huge bold blemishes, and a

long purplish scar at the centre of which stood a bulging bump of

fatty tissue– both remainders of his first surgery, eight years ago.

I myself could now hardly recall the way he looked 'before',

when his body did not declare that it was a cancer patient's. In

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fact, as Ivan bought his first hat, after having lost most of his hair,

he proudly told me how he "gave the man [the salesperson] a heart

attack" when telling him he was buying it "for the radiations". He

now did not only feel like a cancer patient, he looked like a cancer

patient.

Throughout, I had to remember to hold Ivan's left hand rather

than his right, where he was completely insensitive to touch, but

somehow, in these moments, all clinical details of his case seemed

to evade my mind – I was with him, at times detached, at others

immersed in his experience. He looked at me and made a slight

attempt to smile from time to time, but raising his heavy eyelids

seemed extremely painful. Not able to make genuine eye contact

with him, I kept asking myself who this body was, and whether it

was at all somebody's.

I followed the wheeled bed down the elevator along with his

parents and sister. We reminded ourselves of the evening Ivan, his

mother, and I spent at the hospital inn (where he was staying for

the course of his radiotherapy). There, as we were chatting about

this and that, Ivan ran to the window: Jerusalem was covered with

a white blanket of snow. So little snow ever falls in Israel, that we

were all three captivated by the scene. Reaching the door to the

surgical area symbolised the breaking of our serene silence and

sense of 'normality'. As if suddenly awakening us all, the nurse

abruptly halted, firmly instructing us to be careful not to cross this

boundary and to say our goodbyes now, here. The family kissed

Ivan, and asked me, in tears, to take care of him, as if reminding

me to treat him as a friend, rather than as a patient, even now, as I

was about to cross into the biomedical realm.

I followed the nurse to the Intensive Care Unit (ICU), where

patients were kept and monitored right before and after surgery.

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After a short inquiry as to my relation with Ivan ("who are you to

him?" was the typical phrasing – to which I responded by

presenting myself as a researcher from the Jerusalem clinic), I was

requested to wear disposable shoe covers and a non-formal yellow

coat loosely tied on the back – an attire available to all family

members and close ones who happened to be allowed into the ICU.

Ivan’s bed was positioned between two other patients’. His

eyes still painfully shut, I quietly arranged his pillow – this familiar

(albeit futile), gesture of concern. As I rubbed his good arm, the

anaesthesiologist approached his bed and began asking questions.

Since Ivan found it difficult to answer -his speech being highly

hindered at this point – I intervened and answered myself. I used

the medical jargon I knew so well by now, and provided clear,

short, efficiently phrased information. My answers surprised the

anaesthesiologist who, only at this point, asked me who I was. I

explained my position as an anthropologist, and my affiliation to

the Jerusalem neuro-oncology team. The scarce attention he gave

to my response seemed to reflect his lack of interest in 'gate-

keeping', a fact compatible with the analysis of his position in

relation to the the replicated boundaries as provided later in this

text.

Shortly after Ivan had signed the consent forms (which he

could obviously not see at all), the surgeon then arrived, a young,

impressive man wearing his 'scrubs'. As he approached the bed, he

announced Ivan that he will shortly be brought to surgery. Much

more careful as a gatekeeper, his gaze pierced my eyes: "and who

are you?", I answered that I was a doctoral student conducting

anthropological research at the neuro-oncology clinic in Jerusalem.

I immediately stressed that I was given permission by Professor

Zosima (the head surgeon) to attend to surgery. He smiled and

replied "of course, no problem at all". Treating me as courteously as

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one would a guest in his own home; he called on who turned out to

be the OR head nurse: "This is – what is your name again?...". Once

I have reminded him of my name, he turned to the nurse again:

"... [This is] Sky Gross, she is from neuro-oncology in

[the name of the clinic in Jerusalem], she will be

joining us. Can you show her where she can get

ready?"

The nurse reluctantly showed me to the changing area. She

searched for her employee card (only a few of the personal were

allowed access to this high-status outfit) and used it on an

automatic machine from which sterile uniforms, carefully bagged

in plastic, were dispensed.

The nurse handing me the blue nylon pants and shirt found

me a bit embarrassed: was I to wear the uniform on top of my

current clothes? No. I must take off my casual clothing and wear it

directly on my bare skin. Entering the changing room dressed as a

lay person, I remained there virtually naked for a few moments, my

identity in Dantean limbo until I wore the uniform, now my

uniform. I could feel it on my skin as I unwittingly adopted a

slightly different walk (faster than usual) and handled my body

differently (less eye contact and a more upright position). As I

passed through the ICU, I was told by one of the surgeons not to

forget to put the hair cap and mask on before entering the OR.

These were available only very near the entrance to the OR, an

even more restricted area, and consist of the last piece of garment

promising me a place in this in-group. My position as an outsider

would be hidden behind these clothes: fully camouflaged, I could

then identify myself and be identified as a member of the

biomedical team.

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Under the Skin

As I was struggling with the hair cap – reminding me how

little I 'really' belonged there, Ivan's bed was wheeled up into the

OR and 'prepped' for surgery. Upon joining the staff, I found him

unconscious, draped from head to toe, his large blue eyes shut

with tape, his puffy face concealed, his body scrapped clean and

sterilised. All I could see was an idle body. Ivan lost all awareness

as the staff completed his transformation into a living corpse. His

body was at the centre of attention, but Ivan was nonetheless

completely absent, unaware his brain was being picked and

probed. As Ivan increasingly waned as a subject I shifted roles,

from accompanying him to accompanying the surgeons. From

where I was now standing, I could see the back of his head, his

open skull and his brain, the material, graspable loci of his

subjectivity. Was he to open his eyes at this moment, he would not

have seen me, nor would he have recognised me behind my mask.

Deep into the realm of idle objects, I could not pet neither of his

arms now, as both were insensitive, anaesthetised.

The room was relatively free of tension. The staff (which at

this point included a junior surgeon, a surgical intern, an assistant

nurse, a head-nurse, a practical nurse, an anaesthesiologist, and a

neurophysiologist accompanied by his assistant) moved freely

around the room, talking, organising their gear in relative leisure.

When the first stage of the actual operation began, the room

gradually turned silent. I applied myself as I followed the knife

going over the long crescent-shaped scar and two centimetres

further down. I remained standing over the orifice, feeling

surprisingly little awe or disgust -as one would perhaps expect

from an 'outsider'- but was rather directed by an acute sense of

curiosity. The skin was pinned to the sides, allowing the opening of

a fist-wide cavity at the centre of the wound. The cutting revealed

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five pieces of bone stapled as to form a sort of jigsaw puzzle, a

remainder of the previous intervention.

As the two junior surgeons removed the white eggshell pieces

and dropped them into the stainless steel bowl, only a thin layer of

tissue, the dura, kept the majestic organ in. Swollen and eager to

escape its captivity, the brain herniated and literally broke out into

the open air. The staff showed interest in the unusual extent of the

phenomenon. For me, it was as if I could now see why he was

under so much pain: His brain was about to burst out of his eyes'

orbits, literally. I could empathise with his pain as he moaned and

groaned, yet something about the sight of this bulging lump of

flesh made it more 'real'. When I heard his mother tell me, a year

before that her son's head was a closed box, and she was afraid his

brain will 'leak out', I found this portrayal curious. Although I

never questioned the subjective truth he communicated, still, the

physical, the ontognostic, the visible seemed to provide me more

'evidence', and seemed thus more authoritative. In the surgery

room, I held on to a model that is classically claimed to pertain to

the world of physicians: valuing visible, material phenomena over

patients' reports.

The Peak of Surgery

As the team was getting closer to the handling of the actual

brain – and entering deeper into the body, the ritualistic aspects of

surgery became more dominant. For instance, only once

objectification reached its peak did the head surgeon make his

appearance. After intensive and extensive scrubbing, he sat on a

high chair, carefully prepared in advance, covered with a sterilised

sheet, curiously resembling a king's throne. The junior surgeon

also took a sitting position at this time. He sat on a similar chair,

albeit at a less central position, beside (rather than directly behind)

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Ivan's head. Other members of the team remained standing, with

some level of freedom of movement which was only rarely taken

advantage of. At this point, the OR became silent, still, and tensed.

The lights were turned off, except for a beam of pale light

illuminating Ivan's Skull. The LCD screens, from which the site of

the operation was 'broadcasted' to the OR audience, were turned

on. From one of the screens, the head surgeon could observe a live

MRI picture of Ivan's brain as he inserted his instruments. He then

set 'coordinates' which will serve him in the spatial handling of this

complex organ.

As I was to realise later on, I found myself disenchanted. I

knew how the brain looked like, but I did not know how Ivan's

brain would look like. At some level, I expected it to look like him,

like Ivan. It did not. Seeing the brain without seeing the mind,

observing its actuality, its fleshiness, one has to admit: in the OR,

the mind is nowhere to be found.

Time went by as the surgeons were methodically vacuuming

tumour tissue and were carefully closing blood vessels, and I

became increasingly focused on the physical biological

presentation of the tumour. I felt I had developed a relationship

with Ivan's brain, a relationship that was in many ways

independent of its carrier, Ivan the person. After all, in the course

of the last eighteen months, I had almost as many direct

encounters with Ivan's brain as with Ivan himself. This was

perhaps most striking when the surgeon showed the latest MRI

image on the screen: its shape, its shades of grey were all-too

familiar as I recalled the many staff meetings it had appeared in. I

remember the remark, which made the team giggle: Impressed by

the tumour's current size, I said I knew it13 "since it was this little!",

as if I had been speaking of a child. Was I taking lightly the sight of

13 In Hebrew, the 'it' and the 'he' are interchangeable

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this immense lump slowly killing a beloved person? Was I talking

about Ivan at all?

As discussed earlier in this work, prognosis is a form of

knowledge which is habitually held away from patients, and this

for various reasons, including the detrimental health impact

receiving bad prognosis can have, the inadequacy of medical skill

and knowledge to deal with issues related to emotional challenges

and lifestyle choices associated with a patient's management of

prognostic information. In cases of life-threatening brain cancer,

prognostic information (and at times, even diagnosis) is clearly,

although often not explicitly, unwelcomed by the patient. The latter

expects his physician to act as a 'responsible adult', and manage

his condition without burdening him with details he is not able to

deal with (such as one's impending death). This trust is a form of

'you know best' reflecting upon a surrender of full and complete

conscious involvement in the matter under exchange: the

knowledge of one's own state of affairs.

Brain surgery is often performed with the patient fully awake:

This serves the surgeon as he\she is able to hear reports from the

patient, and thus localise functions in the areas neighbouring the

site of intervention. Ivan's surgery was planned to be performed

thus, since his tumour layed in the midst of critical senso-motor

function areas. His condition, however, was decisively too

deteriorated and the idea was abandoned hours before the

intervention. As his phenognostic account became of little value,

Ivan had to be treated as an ontognostic source: a more 'objective'

– and objectifying—measure was used, and a neurophysiologist

was asked to join the team. Wires were attached to Ivan's legs, and,

as the surgeon moved an electrode on the surface of Ivan's brain,

the neurophysiologist reported on movements detected - meaning

essential motor tissue was stimulated. Ivan's body was

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electronically probed and mapped, making the mediation of a

subject redundant. The clinical gaze involves the creation of a

spatial dimension which will create the disease as an entity, the

body as an ontognostic-based 'thing':

"… a space whose lines, volumes, surfaces, and

routes are laid down, in accordance with a now

familiar geometry, by the anatomical atlas".

(Foucault, 1975:8).

These postoperative hours spent in the ICU were perhaps the

most tensed to the family – this was when I found myself most torn

between my two roles: I came in and out, reporting to the family

whether Ivan was awake, since only once he regained

consciousness were family members (one at a time) allowed in, and

supervision was loosen. Once alll would have access to Ivan as a

tangible, palpable, source of knowledge into his own wellbeing, my

mediation was little needed.

While perhaps not unusual in the field of medical diagnosis,

the fact that the organ involved in this latitude-longitude definition

was the brain, that the functions observed were speech and

movement (both typically associated with purposeful volition), and

that the process took place in 'real-time' made this event

particularly intriguing.

Closing up: The last stages

Once the thrust of the surgical intervention (i.e. the removal

of tumour tissue) over, the head surgeon told the juniors to "close

him up" and left the room. As the pieces of bone were placed back

and the skin stapled, lights were turned on again, and movement

became freer. As if now having gone through an initiation ritual,

the younger surgeons included me in their small talk. Overall, the

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tension was released, masks were taken off, cables and electronic

devices were removed, and Ivan's face and body were again visible.

I followed the head surgeon as he went over to discuss the

operation with Ivan's parents. The despair with the intractability of

his condition and "the impossible mess the tumour made in his

brain" was reserved to backstage discussions. Not entering into

details, the surgeon gave a relatively reassuring impression: Ivan

survived and the surgery did buy him some more time. Only when

directly questioned did he admit that, considering what they

observed in surgery, they will not be able to offer him any more

chemotherapy. Again, I knew what my informants did not: the

surgery was in vain – this serious and dangerous intervention only

gave Ivan a few more weeks, which he will spend in nursing and

palliative care.

The operation lasted more than five hours, during which I

remained standing – directly looking into Ivan's skull. However, it

was only a few hours later, once having taken off 'my scrubs',

leaving the hospital, and searching for my car in the parking lot

that I began to feel a throbbing pain in my legs and a general

feeling of physical exhaustion. It was as if I now returned to myself

as a lay person, i.e. not only mentally but also in terms of how my

body felt to me.

Just a Story

The account of the past is almost inevitably tainted with

current interpretative schemes, focusing on concerns that are

particularly meaningful to the teller. Thus, one important aspect of

narratives is that they are typically told in hindsight, which makes

past events appear as if naturally leading to the 'now' as it is

understood (Mattingly, 2008; Williams, 2008; Gross, 2009b). The

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narrative form allowed me here to create coherence and continuity

in the sequencing of events and the unfolding of what I believed to

be their significations (Ewing, 1990; Becker and Kaufman, 1995). It

also allowed me to create a common thread of meaning around a

series of noteworthy moments or 'events' (Polanyi, 1985; Mattingly,

1998), and to thereby justify current claims: First, that my

experiencing and perceiving of Ivan as a subject and object was of

a fluctuating nature; Second, that this reflected on and was

reflected by contextual elements within which our interactions took

place; And finally, that these contexts all involved some extent of

boundary definition (replicated in the conceptual, spatial,

professional, symbolic layers) between two seemingly opposite

sources of Truth: phenognosis and ontognosis. I shall now like to

unfold some of these points as they arose in the field, and as they

relate to recent and contemporary work in adjacent subjects.

Liminalities and Replicated Boundaries

The OR as a Space of Multiple Liminalities

The OR might be regarded as the epitome of biomedical

practice, as restricted both physically and symbolically from

everyday life, and secluded from the less distinct areas of the

hospital (e.g. Wilson, 1954; Goffman, 1961b; Foucault, 1975;

Moreira, 2004). This is where the invisible becomes visible, the

inaccessible accessible. The OR is also a space where states of

liminalities are omnipresent, and most particularly liminalities

where scientific thinking ceases to exert its conceptual control

(Van-Gennep, 1960; Douglas, 1966; Turner, 1969). This includes

the patient oscillating between life and death, and between forms of

'presence': i.e. a state of simultaneous presence (as a body) and

absence (as a person).

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This liminality and confusion of categories demand a clear

ordering of things through elaborate rituals. As has been well

shown in previous studies (e.g. Katz, 1981; Katz and Kirkland,

1988), OR rituals are associated with the need to facilitate the

transition between categories of things by clarifying their

distinction, more particularly the distinction between things that

belong and things that do not belong in the OR, the sacrosanct of

biomedicine.

Rituals, however, can do more than create boundaries. They

may also convert mundane objects into entities that belong to the

'sacred' and are thus less likely to form objects of liminality. For

instance, when transformed from a sentient whole into an operable

body, the patient can be allowed into the OR (Katz, 1981; Fox,

1992). The medical personnel itself also goes through processes of

transformation: these might include scrubbing rituals preceding

the entry into the operating room and special attires worn by the

staff (Moerman, 1979; Felker, 1983; van der Geest, 2005). Along

with specific rules and practices, these allow a conversion of the

life-world into an object that can be dissected and manipulated in

the setting of the OR (Gaines and Hahn, 1982; Hahn and Gaines,

1985; Hirschauer, 1991).

I shall claim that rituals serve to restrain and manage

subjectivity in a way that would minimise the soiling of the purity

associated with the ontognostic realm of 'things'. While the

discussion of objectification in medical contexts is omnipresent in

the social sciences of medicine, and while the issues of purity and

danger (and their relations to social practices and categories)

constitute one of the pillars of cultural anthropology, the wedding

of the two subject of interest has never, to my own knowledge, been

directly attempted. Here, I shall advance the idea according to

which the gnostic split is symbolically, practically, and

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epistemologically replicated as comprising a 'dirty' element

(phenognosis) and which can be regarded as its mirror reflection:

the 'pure' element of biomedical ontognosis.

If phenognosis is the matter out of place (Douglas, 1966), it is

not only categories of life and death, of inside and outside which

boundaries must be reinforced and safeguarded, but also

categories of subjectivity and objectivity: of sentient person vs.

present body. In this shrine of objectivity, the subject must be

either subdued (anaesthetised), hidden (draped), or made sterile

(disinfected). In other words, in settings such as the OR,

ontognosis will be seen to annihilate, dominate, or restrain

phenognostic presence. This is in fact much similar to the type of

boundaries shown to be drawn and replicated in other layers of the

gnostic split, e.g. between an 'ontognostic neurology' and a

'phenognostic psychiatry', and as shown by Mizrachi, Shuval and

Gross (2005), between an ontognostic biomedicine and a holistic,

at times 'spiritual', approach to the patient. In all three cases, the

subjective will need to be conquered, as its epistemological

resistance contests ontognostic authoritativeness.

In the case of surgery, however, boundaries cannot and will

not remain blurred: surgical intervention is the pure manipulation

of matter. Whichever is not clearly assigned to this sphere must be

either eradicated, constrained, or subordinated.

The Temple of Ontognosis: The OR

Questions of objectification arose in the field around several

elements. These worked in unison to replicate a movement from

the subjective to the objective and from the personal to the

biomedical. First, with anaesthesia, which transforms the sentient

self into a passive body; Second, with sterilising practices, which

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separate the OR from a 'messy' outside world where body and mind

are meshed up (and where forms of knowledge can be confused as

well); Third, with spatial definitions, which create clear boundaries

between areas of objectification; Finally, with components such as

clothing, language and technology associated with this stance. I

shall now discuss each of these.

Keeping Phenognosis Out: Sterility

"Rituals exaggerate the discontinuity in the

operating room and they proclaim definite

categories. An instrument is either sterile or

nonsterile; it is never almost sterile or mostly

sterile. A person is either scrubbed, gowned, and

gloved, and, therefore, sterile, or he is not scrubbed,

gowned, or gloved, and, therefore, not sterile." (Katz

1981:345-346)[my emphasis, S.G.]

According to Katz (1981) and others (e.g. Cassel, 1987), the

lengthened minutes of scrubbing immerse the professional into a

state-of-mind by which the patient turns into a physical entity

interacting with and endangered by other physical entities: germs.

Along these lines of arguments, Listerism and sterility would play

no role other than promoting practical aims of preventing

infections. My observations, however, suggest that these rituals

cannot be explained away by simply turning to this 'germ theory'.

More specifically, I will claim for an association between levels of

objectification (by different professionals, at different stages) and

the demand for elaborate scrubbing. The "precise and beautifully

choreographed ritual" of scrubbing (Cassel, 1991:91) involves

transformative practices in regard to the experience of surgery

(Landzelius, 2003), namely in keeping a view of the body as

belonging to the world of matter, whether germs are involved or

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not. In more concrete terms: the more one would treat the patient

as an object, the more one would be required to be sterile, that is,

to abide to this "stylisied, arbitrary, repetitive, and exaggerated"

behaviour (Katz, 1981:349).

Throughout the course of Ivan's operation, the

anaesthesiologist kept holding his mask rather loosely. Ivan

securely anaesthetised and his vital signs stable, the

anaesthesiologist sat at one corner of the room and engaged in

online crossword puzzles, occasionally joining me and offering me

trivial information on this or that procedure. As a rule, his active

presence was required only at the temporal edges of surgery, i.e.

the entering of Ivan into the anaesthetised condition and his

gradual emergence into full consciousness: Then, he would take on

a more religious attitude towards his scrubbing attire. It is then

that he would have most contact with Ivan's body, but it is also

then that the boundaries between conscious and unconscious,

between dying or viable would be most challenged.

Interestingly, I was the least sterile. Although I did wear a

sterilised surgical robe and did put on a mask and cap, I was not

asked to wash my hands ("that's OK, you don't have to" the junior

surgeon declared). This was especially curious as I was, at one

point, asked (by the looser gatekeeper: the anaesthesiologist) to

touch Ivan by holding a cotton ball over his perfusion wound. The

fact that I was only partially scrubbed placed me in an in-between

state where I was allowed to concomitantly hold an outsider's state

of mind, as well as an insider's. This again suggests that sterility

guidelines are not followed in a mere attempt to physically keep

things clean of germs. They are intimately associated with patterns

of observance of the place of subjectivity in the OR.

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Anaesthesia: Subduing Phenognosis

The effect of anaesthesia on objectification is undoubtedly

powerful. When sedated, a person's state of wellness becomes

defined in terms of pulse rates or levels of oxigenisation as shown

on a computer screen (Collins, 1994a). By eliminating the patient's

subjective presence, anaesthesia creates a lifeless body to be

manipulated, as if in the absence of its owner. In submitting

him/herself to sedation, the latter will convey his faith in the

expertise of the surgeon as a 'worker of the body' into whose hands

one can literaly place one's existence. Yet, this faith is not granted ad

hominem – i.e. trust is not bestowed upon a particular person or

persons, but to a basin of knowledge and an embodiment of skills: to

the praxis as well as to the epistemological soundness of biomedicine.

The consent forms are typically signed to never be read, the summary

the surgeon14 may give the patient, never to be really seriously

considered. The patient often willingly accepts but always ceases to

resist the overpowering of his/her own subjective experience

(Mizrachi Shuval and Gross, 2005). In the surgery room, the patient

surrenders any claims for epistemological supremacy: phenognostic

claims cannot be made if subjective knowledge is not generated, i.e.,

when one is unconscious.

This is in fact precisely at this point, when the critical

spectator turns absent, that the team is able to make the

transition to a backstage form of interaction (Goffman, 1961a;

Pilnick and Hindmarsh, 1999; Hindmarsch and Pilnick, 2002).

They do provide powerful grounding to the change in the patient’s

'presence' (or rather 'absence') in the social interaction taking place

in the surgery room. Still, they focused rather on the team than on

the patient, and did not offer an analysis based on the observer’s

position.), which could not have been enacted in the presence of an

14 Or, as in Ivan's case, the anaesthesiologist

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outsider: the patient. Backstage, the language becomes more

technical and inside information is more freely communicated15 –

including, as in this case, alarming news on the patient's

prognosis. For instance, while Ivan was deeply sedated, the head

surgeon called me over and showed me, right on the surface of the

exposed brain, the extent of the damage, announcing as if of a

matter-of-fact that the tumour was enormous and that Ivan's

prospects of survival were grim. This is a statement that could

hardly be made in the presence of a patient or his/her loved ones.

Perhaps most strikingly, Ivan himself was absent (i.e.

anaesthetised) as his death sentence was declared.

As discussed earlier in this work, prognosis is a form of

knowledge which is habitually held away from patients, and this

for various reasons, including the detrimental health impact

receiving bad prognosis can have, the inadequacy of medical skill

and knowledge to deal with issues related to emotional challenges

and lifestyle choices associated with a patient's management of

prognostic information. In cases of life-threatening brain cancer,

prognostic information (and at times, even diagnosis) is clearly,

although often not explicitly, unwelcomed by the patient. The latter

expects his physician to act as a 'responsible adult', and manage

his condition without burdening him with details he is not able to

deal with (such as one's impending death). This trust is a form of

'you know best' reflecting upon a surrender of full and complete

conscious involvement in the matter under exchange: the

knowledge of one's own state of affairs.

It was thus little surprising to see myself perplexed when

confronted with instances where my own knowledge regarding

Ivan's diagnosis greatly surpassed his. Not certain if the patient-

15 This is also when the team's sense of humor was more readily exercised. However, I must admit, that never in reference to Ivan. I was not impressed that this was merely due to my presence.

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physician 'pact' regarding prognosis applied to me, I was again to

wonder as to the nature of our relationship: As I knowingly

withdrew information from him, I found myself in the role of the 'I

know, but I know better than to have you know what I know' – an

expression of epistemological power I did not wish to hold against

whom I wished to remain a subject rather than a 'patient'. This

backstage stance was increasingly difficult from my position as an

ethnographer.

Another issue arose when, as Ivan's subjectivity has been

made to disappear, or made irrelevant, it refused to enter the

stream of my own. This stood in contrast to what Alfred Shutz

(1970:31) termed the 'we-experience': experiencing the other

experiencing. I could not create an intersubjective relation with

what seemed as a 'thing'. Intersubjectivity is present only when two

subjects experience a common situation. If one of the parties

become absent, my attitude becomes simply phenomenological –

that is, based on my own experience of a world of matter.

Space and Liminal States

As Young (1999) asserted in her work, the spatial

organisation of the hospital reflects conceptual elements central to

biomedicine's epistemological bases. In my study, the ICU, for

example, clearly served as a space of transition between the

outside and the inside, and as described above, between the sacred

and the mundane. The ICU was where a taxonomic order that has

been loosen and endangered in the OR could be reconstructed

(Turner, 1969; Turner and Turner, 1978; Landzelius, 2001). Still

in a state of limbo between life and death, and most vulnerable to

unforeseeable and rapid deterioration, the patient is there followed

with elaborate rituals and monitoring, until fully awake, 'stable'

and 'out of danger', i.e., when re-becoming a 'normal body'

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(Kaufman, 2000). At the point where there is less danger to the

ordering of the orthodox state-of-being (Van Gennep, 1960;

Landzelius, 2001), intensive surveillance is relieved. As life-world

modes of interactions become available (the patient regains

consciousness and is able to report on his/her subjective

experience), and biomedical, ontognostic monitoring becomes less

essential, the patient may be released to the outer circle of the

'sacred' space: into the ward. These postoperative hours spent in

the ICU were perhaps the most tensed to the family – this was

when I found myself most torn between my two roles: I came in

and out, reporting to the family whether Ivan was awake, since

only once he regained consciousness were family members (one at

a time) allowed in, and supervision was loosen. Once alll would

have access to Ivan as a tangible, palpable, source of knowledge

into his own wellbeing, my mediation was little needed.

Going Native

There are other elements affecting my own stance of

objectification, elements belonging to one of the oldest concerns of

anthropology: the adoption of the research subjects' ('emic')

viewpoint, and the keeping of an outsider's ('etic') distanced

position. One way to attain a deep understanding of the native’s

perspective is to find oneself within this perspective, or go native.

Whereas this argument seems well developed in other fields of

anthropology and ethnography, it seems little attended to in

mainstream social studies of biomedicine. According to Collins

(1994a, 1994b), this lack of understanding of the physician’s life-

world (or verstehen) leads to significant biases in ethnographies of

medical settings. Achieving, to the best extent possible, an emic

look into the surgeon's world would then allow a more elaborate

and accurate depiction of the field. In an attempt to achieve such

an understanding and become an expert observer (Bolton, 1995), I

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undertook an elaborate preparation which included the study of

the technical and more theoretical aspects of the profession. I

acquainted myself with the different aspects of neuroanatomy and

clinical neurology and was able, through the internet, to watch

sequences of both general brain surgery and tumour resection

operations. I achieved some fluency in the native language and

acquired somewhat more tacit knowledge such as the ability to

distinguish between brain tissue and tumour tissue and the ability

to visualise the actual wound with the MRI images laid up on the

screen.

This knowledge allowed me to avoid, at least partially, what

Bolton (1995) defined as the inherent bias of non-medically

informed anthropologists: The incapability to really understand

medicine, thus to really enter the physician’s state of mind. In

biomedical settings the expert observer will perform as a native-

ethnographer, and will provide valid contributions, which might

not be available unless abandoning this lay naïveté which is often

overbearing in anthropological accounts of medical practice (Collin,

1994b). For instance, non-physician anthropologists tend to

romanticise the physician, to underrate instrumental aspects of

medical practice, and overrate the reductionism of medical texts.

Considering the methodological advantages of expert observation,

this enculturation has also affected my view of Ivan as a subject,

and my readiness to adopt a biomedical perspective when

approaching him in the OR: this eventually allowed me to

understand the shifting nature of objectification from a less

disciplinary distanced perspective.

Medical education includes the teaching of the ability to keep

role distancing, or hold clinical detachment from patients as human

beings (Goffman, 1961; Fox, 1979; Smith and Kleinman, 1989;

Good, 1994; Walters, 2004). It allows physicians not only to treat

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the case more objectively or to be less sensitive to awkward and at

time repelling tasks, but also to refrain from developing emotional

attachment to patients, an attachment that is often emotionally

straining (Hafferty, 1988; Leder, 1992; Good, 1994; Frank, 1995;

Francis and Lewis 2001). Without having gone through clear

medical socialisation to distancing, I was still able to sustain the

surgery observation without extreme emotional response. For me,

distancing was a fluid state-of-being highly contingent upon the

setting. Thus, as this case shows, distancing is not only a skill

taught in medical school, nor is it simply a form of tacit knowledge

acquired through practice. When undertaking the task of surgical

intervention, the specific rituals and symbolic elements work to

suppress feelings of identification and compassion. It worked not

only upon the 'medically taught' participants, but upon the lay

observer as well.

Still, as elaborated in Anspach and Mizrachi's work (2006),

and as seen in this particular field, the researcher might

experience a tension between his16 position in his disciplinary field

and his position in the ethnographic setting. Most particularly, in

the social studies of medicine, one may find oneself holding

incompatible ethical imperatives, depending upon the field he

regards himself as being a part of (Dingwall, 1980; Goodwin et al.,

2003; Dickson-Swift et al., 2006). There is little doubt as to the

effects of professionalisation and disciplinary field (Anspach and

Mizrachi, 2006) on the positioning in the field of a researcher.

Here, however, I have focused on the setting itself, rather than on

the disciplinary or professional background of the different actors.

The ways in which the field itself influenced my mode of attention

to the patient suggest that the setting holds immense power in

affecting the view of the patient as a subject, but not only that. It

also showed that relating to phenognostic forms of knowledge is

16 I again use the masculine stance here, so as not to impair the readability of the text

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not a 'natural' unquestionable given: it requires, like any other

discursive formation, a ground upon which to assert its power and

act to apply itself in the field.

Gnostic Shifts and 'Theories of Mind'

Objectification can be seen as either 'medicine's biggest fault

or, in terms of daily interactions, as a natural, perhaps

unavoidable, part of one's exchanges with the world. While the

former view relates to the more detrimental effects of referring to

another as an object, the latter returns to the philosophical

fundamentals: can 'the other' really be seen, experienced,

understood as a subject?

From his17 very own birth and throughout his infancy, the

human being learns to regard himself as distinct from the

surrounding world. This is when he realises himself as a subject

facing objects, including his own body (Mead, 1934). This type of

objectification is an inevitable consequence of the gnostic split, as

it binds attempt to understand the 'other' as a subject. According

to Western tradition, there would be two ways of 'knowing the

world': the phenognostic first-person perspective which provides

subjective certainty, or the ontognostic third-person perspective

which has been made secure by scientific method. In either way,

whether experienced first-hand or scientifically ascertained, the

other will seem as an object, as well may be one's own body

(Gallagher, 2000).

This problem has been addressed by philosophers, namely

around notions of solipsism and the presence of a 'theory of mind'.

The first relates to the fact that one can only be confident of his

own subjective presence: as far as can be ascertained, others can

17 Here again, based on considerations of style and readability, I will use the masculine form

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be automatons claiming to 'feel' and experience an inner world of

their own. 'Others' can alternatively be characters in a dream one

would be the protagonist of. The idea of a 'theory of mind' turns to

the understanding of the mechanisms by which human beings DO

ascribe 'minds' to others. According to many philosophers, thus,

one would hold a 'theory of mind' according to which others are

subjects if they happen to have characteristics deemed to belong to

a 'minded' thing. Some will have broader theories of mind to

include animals (which may squeak in pain when tortured, thereby

seeming to have a subjective presence). Others will have more

limited theories of mind, leading to the objectification (considered

more or less 'morally just' or 'scientifically justifiable' among

different cultures and societies) of entire categories of human (and

non-human) forms of existence, including comatose patients (or

'vegetables' accordingly), foetuses (or 'unborn babies', accordingly),

ethnic minorities, women, the aged, opponents in conflicts, etc.

Considering the inclusion of non-human categories – such as

animals, and in some religions, 'things' others may consider as

objects (i.e. objectify) – in theories of mind, I find the

'objectification' preferable to the 'dehumanisation' outlook.

However, as in the modern Western World 'things' considered as

holding subjectivity tend to be anthropomorphised, and as, in the

modern Western World, human deemed subjective beings tend to

be referred to as 'persons', I will have to treat objectification,

depersonification, dehumanisation as strongly linked notions. In

the setting of the clinic, and perhaps to a larger extent in the OR,

these can almost be used interchangeably. More than that: as more

'object'-looking one is (e.g. being still, being insensitive and non-

reactive to pain), the more he would be dehumanised; The less

'person'-looking one is (e.g. wearing uniforms, having masks over

one's face, blending in the crowd) the more he would be objectified

(treated like one piece of a faceless whole); The less human one

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acts (being cruel, disregarding basic taboos, acting 'like an

animal'), the more he will be depersonalised (and can thus become

a target to violent acts of indignation).

The instances where Ivan most resisted objectification were

when he looked, acted, and was treated like a person. This

included his increasingly grotesque appearance as his disease

advanced, and his draped inertness in the OR, as he was attached

to non-biological electronic, digital, and mechanical devices

(creating a sort of cyborg as the mechanical extended to his own

body). It also included the sense in which he was 'reachable', or

respondent to communicative stimulations, such as touch, sounds,

words, and so on: e.g. his hemiparetic state outside the OR and the

effects of anaesthesia inside the OR. Not only was his ability to

perceive affected by this, but his ability to respond was as well.

This had to do with the level of pain he was suffering from, as well

as his cognitive and language processive deteriorating skills. Again,

his responsiveness to communication was gradually altered

throughout the general course of his disease and in the more

specific setting of the OR. In all cases, he acted and appeared as

less than a full ideal-type person, and this had deep effects on

stances of objectification, on both my part and the biomedical

staff's.

Conclusions

In the case presented here, both the biomedical team and

myself, as a researcher, eventually found ourselves within a

complex, yet basically dualistic attitude, as if in a dynamic flip-flop

between the patient as object and patient as subject. With Ivan, the

boundaries between absolute objectifying distancing and complete

personal identification seemed to be in a continual flux, and

replicated over different layers: This was true on this first day,

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when I only knew him as a medical case, and remained no less

salient as our relationship developed. In fact, I created Ivan's body

as much as my own presence is created by the network of objects

and relationships: both are of a fluctuating nature, contingent

upon the setting and my own role-taking. Indeed, the tendency

toward objectification is affected by ritualistic practices and

symbolic elements. The ethnographer is not immune to these

influences and might find herself involved in the objectification of

her research subjects, perhaps no less than biomedical

practitioners are claimed to.

The OR has its own rituals and is in many ways an extension

and intensification of biomedical epistemologies, practices, and

symbolic elements. This involves the transformation of a life-world

into an object which can be manipulated. The patient is then

absorbed into a small, depersonalised, objectified body-part

(Hirschauer, 1991; McNay, 1991). Often defined in terms of a loss

of human concern over another, objectification is overwhelmingly

used in a pejorative tense. Here, however, I sought to show how it

might be a necessary, undeniable, and unavoidable part of

biomedical work. Neither is objectification a process limited to

biomedical settings, nor is it exclusive to physicians: anyone can

objectify anyone. Ethnographers, in particular, often sway from

objectification to empathising positions (Fabian, 1983; Clifford and

Marcus, 1986; Pratt, 1986; Wiltshire, 1999). Using insights from

my own ethnographic work in a neuro-oncological clinic and a

neurosurgical unit, I raised the need for a multi-faceted approach

to questions of objectification, taking on the concept of

epistemological fluctuation in ethnographic studies of biomedical

exchanges. This interpretation of exchanges in biomedical spheres

points to the inherent tension between these two tendencies

(objectification-empathy), two roles (physician-ethnographer), two

perspectives (biomedical-personal), and two phenomenological

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states. I claimed that, on occasion, and highly dependent upon the

symbolic and ritualistic setting, the most empathetic actor may

take on a position oscillating between these two attitudes,

experiences, and forms of rapport. The ethnographer does not

merely observe, nor does she merely participate in transformative

rituals- she also experiences them, and is phenomenologically

affected by them. There is no 'pre-discursive' experience of the

'other' as a sentient entity: objectification is present as it is

encroached in a form of knowledge\power, yet so can be said about

the adoption of phenognostically-based attitudes. The not

medically-disciplined actor does not necessarily adopt a

phenognostic discourse as default: It iself needs to be encroached

in a form of knowledge\power in order to sustain itself.

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Part VI: Conluding Words

The Bounded Brain

The brain is the apparatus through which we experience the

world and relate to it, and is the ultimate locus of our selves. This

makes it both organ and concept, both biological and

hermeneutical, both object and site of meaning. Hence, knowledge

about the brain can never be universal, or fundamentally 'true',

but only interpretational and culturally contingent. I suggest, thus,

that a deep and attentive study of the notion of 'brain' is likely to

offer unique, meaningful insight into the fundamental questions

troubling the sociocultural world of modern Western society, and

the world of academics seeking the understanding of Western

society. Still, the association of the mind-body split with broader

social terms such as professions, science, history, bioethics,

discourse, is not nearly as problematised as one would hope, and

theoretical work on the issue has too seldom been undertaken. My

contribution wishes to stand precisely within these nascent fields

of studies.

As shown here, the brain can be regarded as an interim, a

colossal pineal gland, the site of the clashing of two ultimate

realms: the world-out-there, and the inner world of experience.

This clash, I have claimed, would be reconceptualised in a way to

assert clearly bounded categories: science and non-science, reason

and emotion, objective and subjective, at both ontological and

phenomenological levels. This work presents instances where these

boundaries are encountered, challenged, and replicated. The

understanding of these processes, I hope, allowed a refinement and

elaboration of concepts of scientific vs. subjective forms of

convictions, and the role these forms of knowledge may take in

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both diachronic and synchronic perspectives on the sociocultural

world of biomedicine.

Somewhat unorthodoxly, I chose to present this analysis in

the form of three relatively independent essays - each with its own

body of literature and theory, each with its own empirical

foundations. This also demanded an intense focusing on which I

considered as the most essential aspects of the phenomena at

hand, as required in professional academic publishing. I believe

that this served not only to portray research in advanced scholarly

language, but also to distil my ideas, to carefully extract the most

powerful points I chose to advance, and to most thoroughly

consider their actual contribution to selected bodies of literature

and areas of concern.

The significance of the association of the papers stands at

their similarities rather no less than at their diversity. Indeed, it is

almost a truism to say that the consequentiality of theoretical

advances cannot be tested upon its elucidating one phenomenon or

another – it is its applicability and relevance throughout a full

array of empirical worlds that endow it with promise. In this, three

fields were chosen as epitomising the theoretical suggestions made

throughout this text, while still holding a substantial empirical

range.

First, I proposed a detailed picturing of the adoption and then

relegation of psychosurgery as a decreasingly 'purely scientific'

ontognostic medical procedure. This was shown to represent a case

of 'replicated boundaries': an occurrence in which boundaries are

drawn and concurrently replicated at several levels. This work then

took us to the in situ understanding of the assignment of

authoritativeness to different diagnostic forms of knowledge as

more or less purely ontognostic. Finally, I offered here a first

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person narrating of the effects replicated symbolic and ritualistic

Cartesian boundaries had on the objectification of a research

subject in the context of the operating room.

In all three cases, phenognosis was sought-after as a site of

knowledge to be tamed and conquered by science and biomedicine,

rather than a mere pre-discursive default. As it remained still

beyond the reach and control of the ontognostic endeavour, it was

to be kept strictly outside of the practical, epistemological,

rhetorical and symbolical of the ontognostic realm. Phenognostic

resistance to this reduction to the realm of matter created a clear

threat to the discourse of objectivism as potentially omniscient,

hence the great attention given to the creation and sustainment of

these boundaries.

I here sought to show how the boundaries are created in

several layers: The patterns of boundaries were drawn by

epistemology and reflect the rejection of the polluted, as was the

case in and around Ivan's brain surgery, in and around the debate

on psychosurgery and in and around complex processes of

diagnosis.

Cartesian boundaries were presented not as a philosophical

but as a cultural phenomenon: a phenomenon where both

professions and rituals, where both macro-levels and micro-levels,

where both institutions and personal thoughts were looked upon to

identify the replicated boundaries of 'Truth' around an obstinate

gnostic split.

A Contemporary and Future Look onto the Gnostic Split

Conceptions of the body are socially contingent and reflect the

critical elements of the culture in which they are formed and kept

alive (Kleinman, 1988; Martin, 1994). As mentioned, my aim here

Sky E. Gross

173

was to refer to the mind-body problem as one such conceptual

complex. In terms of its social revelation, one thing seems to be

clear: Western culture has not yet overcome the gnostic split, and

still holds on to the two forms of 'truth'. This dualism continues to

create areas of contest where symbolic actions as well as rhetorics

are used to reassert an uncertain, not-commonly shared, unstable,

idea of 'what the world is'.

Over the years, the mind-body problem has indeed enticed

endless contemplations, and has been overwhelmingly portrayed as

the most perplexing epistemological chasm of post-enlightenment

society (e.g. Crick and Koch, 1990; Rosenberg, 1992; Chalmers,

1995, 1996; Searle, 1998). Withstanding all efforts of reconciliation

– notably in the field of neurosciences, artificial intelligence, and

functional imaging studies - this explanatory gap remains

insoluble, and is still of critical consequence in broad domains of

research (e.g. Levine, 1983; Nagel, 1986; Dennett, 1999). Still, and

despite some exceptions (e.g. Williams, 1996; Martin, 2000), a clear

disparity hangs between philosophical advances on the matter and

efforts made by social sciences to recognise, define, and study its

sociocultural grounds and implications. I shall claim, however, that

a number of recent developments have created a more urging need

to attend to this conundrum, These include the exponential growth

of neurosciences and the rising power of post-modern and New Age

epistemologies.

Long before the 1990's 'decade of the brain', long before the

neuroscientific revolution of the 1960s, the cerebral organ has

raised considerable interest from both medical and scientific

endeavours (Hyman, 2000). As has been well addressed

throughout this essay, the brain indeed holds peculiar attributes

which makes it such a fascinating object of study: It is, after all,

Black Butterflies

174

the apparatus through which we experience the world and relate to

it, and is the ultimate locus of our selves.

The last decades saw a growing interest in the physiological,

chemical, biological, and electrical bases of mental activity, as well

as an exponential growth in neuroscientific technological

developments. Over the years, research has gain tremendous

successes in identifying the physical correlates of thought,

emotions, personality, and sensomotor activity. Today, it would be

nonsensical to deny the presence of some form of correlation

between mind and brain. Yet, it would seem almost as nonsensical

to claim that our sense of existence can be utterly reduced to the

brain. In other words, it seems unlikely that scientific advances in

the understanding of the brain will ever be fully able to reduce

subjective experience to the mere realm of matter. Subjectivity and

our sense of 'being-in-the-world', 'what it feels like' to be, to see the

sunshine, to experience pain, is doomed, if only by definition, to

remain in the private world of inner sensation and beyond the

reach of objective query. Science finds there its ultimate boundary,

and the most important threat to its ultimate authoritativeness. As

well put by Horgan (1999:4): "Inner space may be science's final –

and eternal -frontier".

Other sociocultural developments raise a need to deal more

substantively with the mind-body problem. Most significantly

perhaps would be the rise of the post-modern. The post-modern

movement provides definitions of 'Truth' which have by now

become widely accepted: Whilst the 'modern' had truth as a 'thing

out-there' ready to be unveiled by scientific efforts (ontognosis), the

'post-modern' claims for a multitude of 'truths' contingent upon

perspectives, cultural biases, and relations of power. This calls for

a more accepting stance towards claims to truth based on

subjective impressions and inner experience, i.e. phenognosis.

Sky E. Gross

175

Many New Age movements will take this stance even farther.

These may go as far as to portray 'experience' as not only a

legitimate source of Truth and as holding strong authoritativeness.

Phenognostic sources may have predictive elements, may be able to

alter an ontognostically-known 'reality' and work beyond the forces

of the world-out-there (in ways considered 'supernatural', i.e.

beyond ontognostical metaphysics). In many cases, when scientific

evidence will not support a claim based on subjective experience,

the latter will be considered superior. Science, for example, may

have a strong case against the probability of the divination of the

dead. The believer, however, will claim that, as it felt true to an

experiencing individual – it IS true. Here again, two sources of

truth will interact and fight for authoritativeness, and now both

will share a common battle ground: Modern Western

epistemological culture. This social and cultural phenomenon

should stand among other areas of concern in which contemporary

social scientists are engaged.

In sight of a possible contribution to these works, this study

sought to assert a claim by which the mind-body problem deserves

to be seen as more than a philosophical problem. It also presented

a theoretical framework on which to ground future studies in the

field. I will hope to see social sciences relying upon philosophical

advances in the understanding of the mind-body problem and go

beyond to apply them to the understanding of related social

phenomena.

Black Butterflies

176

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