Sky E.

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 1

Black Butterflies
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 2

Sky E. Gross
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


Black Butterflies

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


In looking at the world and at the self. It is this very achievement I sought in the years preceding the writing of this The use of masculine pronouns and possessives was chosen arbitrarily – the text refers to both genders 1 5 . let it be 'society'. however. the 'he' (the 'other'). distinct from a world-out-there. or rather the 'they' ('society')? Thus. or any category of entities or concepts. how much is this hierarchy contingent upon cultural settings – at both macro-level and micro-level? These are grand questions indeed. 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. and in the world of the self? The 'I' (myself). in it asking how do we know what we know. this essay is about epistemology. Can he regard himself as a experiencing subject. that one element should have been given understanding of what the human animal is in his own eyes 1. this work would hardly be original. or can he only relate to himself as an he conceive his experience of the world. which kind of knowledge 'counts'? And if one is considered more authoritative than another. how does he conceive his experience in the world and how does thing among others. and being able to attend to them. I believe.Sky E. 'nature'. Gross 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. at any level. That a more respectable place in these endeavours: the is. is a challenge in and on itself. the 'other'. 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.

greater homogeneity in respect to its epistemological and practical grounds: Biomedicine. While acknowledging the value of these endeavours. and highly regarded profession and body of knowledge. and sources of many theoretical innovations in the social sciences in general. and to try to understand Western culture in its own context.Black Butterflies essay: tackling. Its 6 . gender attributes. 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. One may oppose the reference to Western culture as if it were one whole. etc. The power of biomedicine in the Western world can hardly be overrated: it may be one of the most dominant. considering it is itself the source of the initial interest in – and conceptualisation of . with its own dynamics. hold one institution. and with its own historical development (each as defined by its own narratives).the issue. to however. Both relate to my choice to study the 'Western world'. important social stratification. in the most plain-spoken way possible. influential. there are two issues that I would like to address. The Western world is indeed a mosaic of different cultures. now wellaccepted subdisciplines. This has been acknowledged by endless works in the sociology and anthropology of medicine. religious beliefs. This may be a somewhat curious fact. Before entering the analysis itself. whether defined as based on national aspects. I have chosen to come back 'home'. the issue of human understanding of the world and of himself within this world. which can There be said is. and I must join these expressions of discontentment.

or objectifying epistemology). by me. Thus. I shall look at the ways in which it is resisted by a sense of truth as held by the experiencing subject. 7 . mind or body. 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. looking at the world from my own private perspective. 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. felt. in its modern and postmodern manifestations. There. Gross 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. and which is False? Once having ascertained biomedicine's tendency to reinforce the second way of defining Truth (adopting a body-centred. In my search for the most promising field of study. Or should I rather adopt a vision of myself as an object among objects. as an conscious individual?. many complexities began to arise: am I a subject. defining Truth as it is sensed. I defined another vector of interest: the focal point within which the Western modern individual defines his identity – mind and body. 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.Sky E. thought of. in a world defined by a general (and scientific) consensus on which is True.

to the micro. methods will greatly vary. exemplify. when based on more or less objective forms of knowledge. although remaining within the limits of qualitative analysis. the use of surgical. I will lay down an analytical first-person narrative to bear on processes of objectification associated with brain surgery. I will bring the analysis of an in-situ work where I observed the ways in which brain tumour diagnosis is reached. Although referred to in the coming section more careful presentation of the methodology will be presented in each of the three chapters. Thus. as experienced by the field-worker. I will suggest a conceptual framing whereby modern Western biomedical practice and research sees two forms of knowledge coexist and fight for authoritativeness: 8 . The sequencing will go from the macro. In this. to personal thought. Second. Accordingly. its aim will be to build a framework for a social study of knowledge. thereby avoiding redudancies and repetitions. and clarify the claims above. I will propose a historical outlook on the ethical debate regarding psychosurgery. by which the mindbody split infiltrates (as 'replicated boundaries') all layers of sociocultural phenomena – from broad historical movements.Black Butterflies The Three Papers In the course of this essay. I will use three different ways to substantiate. And third. to the reflexive – a representation of the theory itself. to micro-interactions. material means for treating the mind. although heavily drawing on philosophical insights. Surgeons of the Mind The first paper will serve as theoretical grounds for the overall analysis proposed in this work. First. as well as making the compatibility between the work and the methods explicitly evident.

Sky E. macro-level view of the conceptual issues running throughout this work. and social studies of medicine. This Cartesian split ('The Gnostic Split') will be pictured through a casestudy of the practice of frontal lobotomy ('psychosurgery'): the use of brain surgery to transform the mentally-ill. Drawing on philosophical and theoretical insights from recent works on discourse. This historical analysis will allow a bird-eye. phenognosis and ontognosis. 9 . This will turn to be essential to the understanding of the microdynamics associated with the epistemological forces at hand. 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’). the body. Gross phenognosis (knowledge based on subjective experience) and ontognosis (knowledge based on the enquiry of a world-out-there). i. 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. 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. yet fully sentient individual into a complacent ‘object’.e. It will assert the social embodiment of the mind-body problem using a broad perspective settled on the world of biomedicine. lacking the capacity for subjective experience. this paper will propose an analysis raising cultural aspects of mindbody dualism in modern and postmodern Western society. and how these have increasingly become depicted as scandalous within a more recent post-modern bioethical debate.

based on a sixmonth participant observation. i. asserting that a symptom’s source was orthopaedic rather than neurological). expert used. eventually prioritising reports from more authoritative expertises (e. look into the life of a neuro-oncology (brain cancer) clinic of a large hospital in Israel. and defining the discrepancy itself as a diagnostic sign (e.e. Negotiation: adjusting diagnoses via a preliminary exchange between experts and a consequent 'fine tuning' of the reports (e. Peripheralising: turning to other expertises to 'explain away' symptoms that do not fit with a well established initial diagnosis (e. in situ. 10 .g. and present these epistemological and practical complexities as they are uncovered in daily routine. leaving ambiguities unresolved. several mechanisms resolution are These Hierarchisation: ranking the relative validity and reliability of the different sources of information. The and paper their underlines roles in the the of technological assertion of and epistemological knowledge's include grounds of 'expertise' in the medicoscientific practice of diagnosis. the relation of power between phenognosis and ontognosis. and associated with the theoretical thrust of this work. And pragmatism: using information only as far as it provides sufficient grounds for treatment decisions.. radiologists being aware of clinical evaluations before finalising their reports). the degradation or amelioration of the disease). Sequencing: relying upon the temporal dimension. When questions of authoritativeness arise. It will point to the many challenges involved in the solidification of brain tumour diagnoses by different experts and forms of knowledge.g. imaging reports would be considered more reliable than phenognostic patients’ accounts).g. this paper will provide a closer. These five mechanisms will here be presented in the context of the daily work of the clinic.Black Butterflies Experts and 'Knowledge that Counts' Bringing these ideas to the realm of the clinical. authoritativeness.g.

symbols. Nevertheless. with its own body of literature and methodological sections. each chapter will be structured as relatively independent unit. the presentation of three stand alone journal articles. the textual content is refined and condensed to create a succinct and to-the-point exploration of the issues at hand. and then focus my attention on my observation of the brain surgery he had to undergo. this account will provide a glance into the ways in which clinical or clinically-situated exchanges are not only observed but also experienced. First. Gross The World of Brain Surgery In this essay.Sky E. With this in mind. I will first briefly portray my relationship with Ivan. in and of 11 . references are used only as far as they are directly relevant to the essays. practical necessities. in many ways. etc. and processes of socialisation. I will try to show how issues of objectification can be discussed from the viewpoint of the objectifying party. I will portray objectification as being of a fluctuating nature. Resisting a dichotomy between physician-objectifying and ethnographer-humanising. epistemological bases. I believe that neither of the papers. space. a brain cancer patient whom I have followed over a period of eighteen months. rather than a necessary by-product of professional tendencies. and secondly. Considering the breadth of the methodological and empirical bases for this work. 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'. As it is presented from a first-person perspective. I will propose a further look into the settings within which these discursive dynamics take place and come about through artefacts. as customarily composed and structured in the professional academic press. This is.

Black Butterflies themselves can provide sufficient ground for the conceptual schemes proposed here. 12 .

Sky E. Descartes will claim that a human being is not one entity. it has a place and a dimension. he would define how mind and matter were distinct: Matter has a spatial extension. 1992. The mind. but rather has different parts: some mechanical and some non-mechanical. Matter has proper characteristics and attributes. will thus constitute a form of 'ghost in the machine' (Ryle. including to scientific observation. Gross 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. Along the same lines. will have no spatial extension. one may find some that may be viewed as dualist and others as monist. in belonging to the latter form. Among the ways in which the problem was tackled. René Descartes (1596-1650) offered his definition of the mind as an entity outside of the realm of matter. no attributes. Matter is public and accessible to all. 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. 1967). giving birth to an immense body of works.. Kendler. Koestler. The mind. 2001). More specifically. and exists in the private world of the subject (Garber. 1982). in contrast. The most prominent philosophers would argue for this or that view of the problem.e. i. such as colour and shape. 1949. 2 Note: some of the material presented here is borrowed from my own Master's Thesis 13 .

2001). that is. can be subdivided into interactionist or non-interactionist ('parallelism'). 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). to ask whether water is water or H2O. According to this view.Black Butterflies Much like Descartes himself. Trying. An additional important dualist theory is referred to as 'epiphenomenalism'. 2001). like monists and 'substance dualists' do. or non-interactionism). in turn. 2001). 1996). mental phenomena will be but a by-product of material substance. makes no sense to the 'property dualist': these are not two phenomena. in contrast. however. and 'matter' when approached objectively. there would be between the two a relation of function to matter (Ben Zeev. without having one affecting the other (non-causal dualism. one could define him as an interactionalist (Schimmel. but rather two ways of looking at one phenomenon (Kendler. Leibnitz (1646-1716). would see mind and body existing in parallel. a Hegelian 'foam on the wave' of brain activity. Monists. Dualist explanations. will speak of one dominant substance: this being either material (materialists) or spiritual (idealists) (Schimmel. 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. rather than one being a by-product of the other. 'Mind will appear when the question is approached from a subjective angle. an organ located deep within the brain). As Descartes saw mind and body as interacting entities (more specifically through the 'pineal gland'. With the rising power 14 . 'Functionalism' will hold a somewhat related concept: the mind-brain relationship would be comparable to drive-car relationship.

The mind is spiritual. Mind and body interact. for instance. identity theory.g. idealism has lost most of its vigour. in the broadest terms. With the development of modern science. In order to have them 'make logical sense'.Sky E. This is. Mind and body would not interact (non-causal dualism: e. Spirit can affect matter and vice-versa (causal interactionism). one would have to relinquish at least one of these assertions. The Cartesian Fallacy The mind-body conundrum can be defined around the logical fallacy arguably entailed by Cartesian dualism. or ephiphenomenalism). along with clear-cut materialism. Spirit cannot affect matter and matter cannot affect spirit. brings us four prepositions. have become ever more pervasive. these views. the basis for the different philosophical approaches described earlier: The body would not be material (idealism). Gross of brain research. With the evolution of experimentalism and the focus on pragmatism in the development of technologies. yet logically incompatible with the others: The human body is material. each considered 'true' prima facie. Benjamin (1988). 15 . The mind would be material (materialism).

For the sake of conciseness. This until recently.Black Butterflies positivism has gained much strength. where conceptualisations on the nature of 'the world' originate and manifest themselves. and in order to avoid ambiguities with related terms. The accumulation of scientific knowledge leaves little doubt: there is to the very least some correlation between the mental and the cerebral. as expressed in one of its most powerful discourses: biomedicine. were it the world of 'nature' or the world of the 'social'. With it. this seems to have revitalised concepts regarding 'mind' as a powerful entity. phenognosis. yet does not take us closer to resolving the problem of causation (Midgley. I will turn to picture the evolution and manifestations of these two epistemological forms 16 . The answer must thus be found in the realm of the cultural. I will present some aspects of Western modern society's marked cultural character. materialism – in its less or more extreme version – seemed to have led 20th century's Western thought. how is the world experienced). This process will stand at the very centre of much of this current work. I will show it to be based on movements between two distinct forms of knowledge. 1996). of the social. With this in mind. as a consequential actor in the 'world'. when modern physics (notably quantum theory) raised questions as to the ontological exclusivity of 'matter'. each holding claims to the ultimate Truth: ontological (what IS in this world. or to the very least. I will term the former ontognosis (gnosis – Greek for 'knowledge') and the latter. what are its fundamental essences). The question remains as to the idea of a causal relationship: is brain activity a result of mental activity or viceversa? Science keeps reinforcing the concept of correlation. and phenomenological (what is it like to BE. After proposing an essential definition for each. Along with more general trends of New Age culture.

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. will be able to convey subjective experience (Damasio. 1972. and only a particular bat would know what it feels like to be this particular bat (Jackson. 1994. no progress of science will ever allow being. 2000. Searle et al. the sensation of an itching toe. Introducing the Gnostic Split Phenognosis and Ontognosis My analysis will follow a philosophical division of the mindbody conundrum into two set of predicaments: the easy problem. 1982. Arguably. 2001). Gross within broader contexts. 1997). The 'hard' problem emphasises an epistemological gap between knowledge first-hand experience or (‘felt’) and public. or aching in the place of another. Edelman. however elaborate. true knowledge of 'what it is like' is an epistemological privilege reserved to the sentient subject.. 17 . to the bat itself: Only a bat would know 'what it feels like' to see with sounds. i.e. 1988. Young. whether experienced or not). between subjective knowledge (Ornstein. Gertler. 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. and scientific objective (‘observed’). affirming their relevance and consequentiality in the sphere of the sociocultural.Sky E. feeling. and the hard problem. and no map of the brain. or a tooth ache whose actuality could never be disputed by a dentist. Heil. in his famous article "What is it like to be a Bat?" eloquently notes. This 'hard' problem rightfully earned its appellation.. 1990). As Nagel (1974).

I will base ontognosis on a materialistic approach to the easy problem – portraying the world as essentially material. namely in the field of neurosciences. one may find such a view in Bennett and Hacker's famous essay. This. in the terms proposed here. regardless of whether the source is the world-outthere agreed upon by several individuals or one’s own hallucinatory world. 'I think'. "Philosophical Foundations of Neurosciences": "A human being is a psychophysical unity. act intentionally. I will adopt the notion of experience as addressed in the context of the hard problem. a claim most often originating from the world of science and biomedicine. Thus. of oneself) into which he/she will define and often declare to constitute the 'Truth'. reason. 'I feel' (phenomenological Truth). or 'This is' (ontological Truth). Metzinger. based on 'I know'. This locus of 'Truth'. will often be challenged and questioned by a claim for Truth based on 'There is'. This first-person’s position is also the focal point where facts become meanings and where data become experience. this first-person standpoint is the site where one turns acquired knowledge (of the world. regardless of whether the meaning assigned to a phenomenon seems ‘objectively’ acceptable or based on some sort of psychological distortion (Edelman and Tononi. an animal that can perceive. this again. emphasising the irreducibility of the subjective into material elements. and feel 18 . 2003).Black Butterflies Facing an outside world. 2001. on the other hand. With phenognosis. 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. For instance.

thus. first-person. action. S. it breathes life into it and sustains it inwardly. or rather. 1995a: 203).Sky E. The phenomenal body. must be viewed as one with the objective body: experience is experience of the body. a language-using animal that is not merely conscious. 1991): Maurice Merleau-Ponty (e. but also self-conscious – not a brain embedded in the skull of a body" (Bennett and Hacker. cognition. although the body could be seen as an mere object. while the body may be regarded as a mere physiological and natural entity (an 'objective body').G. the mind cannot be without body: both empirically and philosophically. rather than an entity IN the body. One such important – and relatively recent – attempt can be found in French philosophy and human sciences (Lanigan.] The Cartesian mind-body split has ever been the subject of philosophical attempts to either deny its existence or dissolve its problematic aspects. "[The body] is in the world as the heart is in the organism: it keeps the visible spectacle constantly alive. 1962) sought the resolution. 19 . it will. In other words.g. 2003:3) [my emphasis. While the body may be without mind. According to him and to many of his existentialist and phenomenologist predecessors. Gross emotion. perception. turn into a 'phenomenal body'. façade of the machine. 1945 in Lanigan. 'experience' or 'mind' cannot. emotion are all 'embodied phenomena'.unified with (rather than distinct from) this physiological entity. once experienced. and with it forms a system" (Merleau-Ponty. the conceptual annihilation of the Cartesian split. for phenomenologists such as Merleau-Ponty. 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.

In relation to the context of gender. 2001). While agreeing with this basic premise. or the 'experiencing flesh'). Along tangential lines. often relating epistemology to constructions of gender (e. have taken up these leads and engendered considerable research on the existential and phenomenological groundings of the self and its relation to 'the body'. these very works will be claimed to adopt a 'mentalist discourse' (seeing 'mind' as being superior to 'body') by which men are the 'mind'. a self problematised as dual (mind vs. and biomedically based knowledge on the other. Root and Browner. feminist literature took on the task of revealing conflicts between sentient knowledge on the one hand. 20 . culture. 1994:143). 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. These works generally sought to merge the body’s objective façade with the less tangible subjective experience of which it serves as the locus.Black Butterflies Social Studies of Medicine and the Body Scholars. 1994). that is. Webb. body) by external expert knowledge (most notably by medical practitioners. a fact that eventually only reinforces ideological and political dualisms. related to public realm. notably in the fields of the social studies of science. 1996. while women are the 'body' and belong to the private sphere (Williams and Bendelow. represents the body in a way that is socially contingent (Martin. as a system of thought both external to the individual and concurrently present within the individual. This was associated with an ongoing effort to account for possible gaps between 'sentience' and 'science' at the level of the self.g." (Csordas. According to these views (which were generally put under the umbrella of a 'sociology of the body'). dealing directly with the 'body in pain'. scholars of 'embodiment' will claim that the sociology of the body does not take into account the lived-experience of the body. 1998).

1993. In an attempt to do so. 2006). Still. he uses it as to show the preciousness of the leib over the korper as a source and grounds for culture. one of the leading scholars in the field. Lupton. Overall. 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 21 . objectively accountable) as broad discursive forces. even these 'embodiment'-oriented undertakings show little concern for the changing hierarchies between the two forms of Truth (subjectively experienced vs. Shilling. For instance. 1994: xiv). prediscursive phenomenon that plays a central role in perception. Thomas Csordas. while ascertaining the presence of epistemological conflicts in micro-settings where third-person and first-person views collide (IT vs. I will seek to provide such a complementary outlook. Williams. 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. I).Sky E. 1995. while Turner (1992) brings up the distinction between leib (the lived body) and korper (the physiological body). 1994. Gross Thus. the relationship between the two as 'Truths' is never analysed as such. 1996) have shown how much 'we are our bodies' and how much of the mind-body split remains unchallenged by current sociological work (Nettleton. Turner. using Foucault’s (1986) notion of discursive practices as entailing human desire for 'Truth' about the world and about the self. 1996." (Csordas.g. sociologies of embodiment (e. cognition. Crossley. action and nature to a way of living or inhabiting the world through one's acculturated body. Throughout this work.

the linking of subjectivity with power relations will reveal that it may indeed constitute a rising discursive force. paying little or no attention to the subjective aspects of disease. Phenognosis. 1999. This ontognostic epistemology is.. associated with the foundation of a powerful ethos. the clinic. 1982). however. Biomedicine has had indeed notable success in achieving this demarcation as highly respectable. and the surgery room. trustworthy. and economics (Gieryn. This distinction persists within a particular power structure where a hegemonic regime of truth is established. 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. 1980. 1986. and the drawing on highly evocative symbolic elements . the establishment of an authoritative system of rhetorics. Foucault stated that what troubled him since his first book was: "In what way are those fundamental experiences of 22 . should not be seen as comprising mere 'leftovers' of this biomedical ontognosis. Armstrong.Black Butterflies drawn from: the history of psychiatry. such as religion. 2005). politics. defining the forms of knowledge considered admissible while dismissing competing claims for Truth (Foucault. In the 1979 Stanford Lectures. 1983. 1983). and distinctive from other social spheres. When considering the development of post-modernism. Medical knowledge is essentially of a reductionist nature. 1972. Mizrachi et al.all of which serving to support its discursive supremacy. in turn. This will ipso-facto place non-scientifically based knowledge – including phenognosis in a subordinate position (Foucault.

but that does not mean that we don't have to get the question". and modern Western social order (e. When at all acknowledging subjective forms of knowledge. a "new wrinkle in our knowledge" (Foucault. therefore. Goldstein.e. 1992. Foucault's analyses distinguish between discursive events and prediscursive events – i. according to Szakolczai (2000).Sky E. Gross madness. 1999. individuality connected. why not consider 'Man' as a discursive event based on the phenognostic authoritativeness of human experience? Thus. that is. again making the relationships of power between 23 . Mizrachi et al. crime. I shall claim here that Foucault may have had the question misspelled: what if these experiences were not prediscursive. madness. rarely seems to be deserving particular interest. 1972.. suffering.g. Rosenberg. through the challenges it may present to the material-ontological bases of biomedicine. 1994). by which phenognosis itself would serve as grounds for legitimacy and. with knowledge and with power? I am sure I'll never get the answer. 'things' that are not based on discourse. These include pain. Eisenberg. death. for power.. as a consequent discursive formation in and on itself. Traditionally then. both his writing and more recent literature has. 2005). these works rather deal with them in oppositum to the hegemonic power/knowledge. Foucault’s own lifework can be defined as revolving around this issue of discursive subordination. even if we are not aware of it. and that have not been produced by the social. although. omitted the option of a symmetrical opposite. phenognosis. science. by and large. following his claim that 'Man' is but a discursive event. and experience of self. Rosenberg and Golden. 1977. but rather discursive? After all.

including – if ever considered. to pave the way toward a destabilisation of the grounds upon which ontognosis drew its force. while postmodernist thought may have notable affinities with ideas associated with the concept of phenognosis. 1994). Still. Thus. one cannot stress enough the distinctiveness of the two worlds of notions. 24 . whereby stands the value of the proposed reconceptualisation. Dickens and Fontana. This postmodern era would see critiques of science joining existential. and relativist influences in the social sciences (and in general culture. thereby allowing experience to ascend as a legitimate source of Truth. 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. phenomenological.Black Butterflies phenomenological and ontological forms of knowledge critically understudied. This shift had both roots and repercussions within what social sciences have traditionally referred to as the rise of the postmodern (Lyotard. 1989). 1984.phenognosis (Bourdieu. most particularly in art and literature). Harvey. This issue shall be clarified as this analysis develops. although overwhelmingly rooted in phenomenological thought. and provisional forms of knowledge. 1992. negotiated. more radical postmodernism will reject the whole idea of Truth. Grand ontological and metaphysical accounts lost grace to local. This lack of attention remains somewhat enigmatic considering recent historical developments.

professional. If. symbolic. replicated boundaries refer to the presence of epistemological groundings – here. detect. This work has led to the formulation of a theoretical framework for the understanding of such processes: the definition of replicated boundaries. 25 . classifications. actions. as a relation between two forms of knowledge. one finds a process of subordination of one form of knowledge to another. both synchronically and diachronically.g.g. in changes in the ways in which space is distributed (e.which will replicate themselves in several spheres concurrently. In broad terms. this will come about in the subordination of one professional sphere to another (e. forming a panoptical advantage in spaces where the more powerful form of knowledge is exercised). both at the macro-level and at the micro-level. The Gnostic Split and Replicated Boundaries If indeed the mind-body problem does stand at the basis of social phenomena. thus forming 'replicated boundaries'. and may encompass beliefs. Gross Introducing Replicated Boundaries The reconceptualisation of the mind-body conundrum will serve to assert the sociocultural correlates of the philosophical problem. spatial. 1995). symbols. interactional. etc. These spheres may include both lay and professional epistemologies and practices. how can one discern. one group of professionals losing their status). and so on. epistemological spheres? The systems of classification we hold ordinate the creation of boundaries at many layers of cultural phenomena (Abbott. or recognise its manifestations? How are phenognosis\ontognosis reflected in the institutional. for instance. and still keep structural similarities.Sky E.

biomedicine. hierarchies of sources of information in the forming of diagnosis). in the case of brain tumours .g. where definitions of authoritativeness remain crucial (e. Replicated Boundaries: The Professional Grounds Professions constitute social fields where particular organisations of knowledge are often manifested in a most palpable way. where the operation room becomes a well-bounded ontognostic shrine). I shall further claim that these bounding limits will not remain within the layer of the abstract. the apparatus used to keep each form of knowledge distinct in social settings).g. and assert that ontognosis' failure to conquer and subordinate phenognosis led to a rejection of the latter from the territories of the former. 26 .g. psychiatry). 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. neurology ('the profession of the brain') and psychiatry ('the profession of the mind').the conceiving of oneself as either body or mind) and in the more general discursive layer. The phenomenon of replicated boundaries will accompany us throughout the analysis. and most particularly. in the layer of the spatial organisation of biomedical areas (e. and will have powerful manifestations at several layers simultaneously: the splitting of brain and mind in the professional layer (e.g. in the symbolic layer (e. and that this was followed by the creation of robust limits to forestall any 'leaking' of the phenognosis into ontognosis' terrains.Black Butterflies The cases at hand will be used to illustrate this concept.g. in which I hope to be able to establish it as a valuable theoretical concept. the conceptual layer (e. that is. In the course of this study. neurology vs.

most often present in discourses related to the practice and epistemological grounds of medicine (Goldstein. it holds a degree of exclusivity in the relevant field of practice and knowledge. 1994). the unbreakable link between abstract knowledge and the profession would be based on the idea of the 'gaze'. First. Third. 1994). for instance. rather than a mere occupation. Foucault (1982) joins him in pointing to the importance of the professions in Western modern societies.Sky E. that is a disinterested practice that is based on altruistic rather than self-centred objectives (Wilensky. Medicine holds several ''core generating traits" (Larson. The need for professions to isolate themselves from other forms of culture and to gain power through knowledge involves processes of 'boundary-work'. For Foucault. There are several ways in which biomedicine. it is autonomous in the definition of its practice. as an ideal type of profession may 'do' boundary-work 27 . Second. it holds a body of abstract knowledge which must be mastered by its members. 1964. Parsons (1971:145) sees the professionalisation as a "criteria of cultural legitimacy". “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”. and sees it as the "single most important component in the structure of modern societies". it holds a 'service ideal'. Goldstein. And finally. Gross The rise of the professions is related to the processes of secularisation in Western society around the late eighteenth and nineteenth centuries (Parsons. As claimed by McDonald (1995: 160). 2001). Associated with the interest in professions and the attempts to define the phenomenon has always been the study of knowledge and of epistemological subordination. Goldstein. 1971. 1977) that enable it to be referred to as a profession.

Along related lines. by creating a clearer contrast between itself and its rivals. In my view. scientific challenged and redefined.. These relations find themselves replicated on several layers. rhetorical and professional modes of boundary formation around and in parallel to these forms of knowledge. hence my proposed definition of replicated boundaries. 2005): First by expanding its authority or expertise into domains claimed by other professions or occupations.Black Butterflies (Gieryn. In this case. 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. Thirdly. politics. Finally. Gieryn (1999) defined 'science' –the basis for biomedicine's authoritativeness . This involves symbolic. and subordination. split jurisdiction. by labelling rivals as pseudo or amateurish and exclude them from its turf. by monopolisation of professional authority and resources. bounded off from other territories such as common sense. Secondly. these 'nonscience' territories can all be seen as belonging to the subjective placed on 'a map of culture'. or mysticism. This essay presents in which particular notions of cases of professional truth were boundary-work. 1999. Mizrachi et al. Through the understanding of the enactment and then challenging of boundaries. I will show how specific demarcation principles of the scientific versus 28 . drawing a map of science is but replicating a map of a gnostic split. and truth. reason. as the interest of science is to remain the home of objectivity. From a more recent perspective. I will try to propose that Cartesian boundaries are involved in the demarcation of two forms of 'truths' – the phenognostic and the ontognostic. 1983.

Sky E. Gross
the non-scientific are related to a battle on the hierarchy of these two kinds of truths.


Black Butterflies 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.

"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


Sky E. Gross
referred to as Cartesian, through the study of the practice of frontal lobotomy 3 (‘psychosurgery’): a modern endeavour using 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.

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

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

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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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 32

positive/negative stances. Gross overarching themes: the criteria for the evaluation of the procedure. the drawing on symbolic aspects of medical practice. including interventions on children as young as four year old (Valenstein. A fourth matter included questions of human experimentation. and symptomatically diverse mental pathologies. some going as far as claiming the latter to be infeasible in the case of such extreme mental transformation: in terms of personality. and physical functioning by the severance of brain tissue not targeted by the procedure. Third were issues of obtaining informed consent from mental patients. nosologically. with practitioners having limited tools to predict the outcomes and calculate the risks of such an intervention. and finally. Another issue was the immense power accorded to the psychosurgeon in social and political spheres: Critics. cognitive. in fact. First was the inadequateness of theoretical and empirical bases.Sky E. the rhetorical devices employed. And finally was the theme of abuses and aberrations observed through the implementation of the different procedures. Second were the procedure's mutilating aspects and the irreversibility of its effects as it inflicted great damage to both affective. I then defined the debate as rotating around a number of issues. 33 . often associated the procedure with contemporary Hitlerian concepts of euthanasia and eugenics.using a method of trial and error on groups of patients diagnosed with etiologically. the patient giving his consent may not be the same person going through the postoperative phase.

Here. I suggest the story must be told otherwise. 1997.g. reference to the introduction of drug therapy) may account for the decline in the use of the technique. I will propose a more contextualised. Huynh-Dornier. Bouckoms.of the procedure. Snaith. Indeed. from inferior to superior technology (the use of better instruments). which will describe not just past-proponents’ but also contemporary critics’ arguments as equally contingent upon the particular Zeitgeist within which they took form.Black Butterflies 1980a. while historical accounts of the technological and scientific contingence of the abandonment of psychosurgery (e. 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). yet debates over its legitimacy – morally. 1992. 1994.aspects of these developments. Sabbatini. The focus will be thus on transitions in the depiction –rather than usage-. This will eventually represent psychosurgery as a mere by-product of a darker era in medicine and psychiatry. and scientific understanding (knowing more about the brain). 1997). less presentist view. True. 1980b. namely specific epistemological shifts. and on broad epistemological --rather than mere technological-. a fact which cannot be explained away by the pointing to scientific advances. Browsing through the literature. Kucharski. 1984. Berrios. lobotomy may have lost its place to psychoactive drugs. they offer little to the understanding in the shift in the debate itself and the values it brings forth. ethically. epistemologically – carry on. On Psychosurgery 34 . I will seek to portray psychosurgery as neither justifiable nor condemnable. 1988. and will insist that the procedure’s ascribed legitimacy is in line with other sociocultural developments.

Sky E. Gross
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 cofounder 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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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


Sky E. Gross
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, many 1979). texts, With mainly the in rise the of lay anti-institutional press, began to and antigovernmental movements in the late sixties and early seventies, 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 antipsychotics, 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 37

Black Butterflies
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, selfcontent 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.


This 51 year old woman. 39 . 2001).Sky E. Suffering from chronic diarrhoea and of a lack of proper hygienic manners. the head of a large Swiss mental asylum. Burckhardt (1890. Gross This report led to the more ambitious (and controversial) experiments of Gottlieb Burckhardt.. The first patient. mainly in isolation. As Burckhardt himself put it: “Though her intelligence seems to have been lost. She has been hospitalised for the last 16 years. Each operation seemed to have had a calming effect on the patient. behaviour that involved the patients’ lack of control over themselves (Stone. She was particularly difficult to maintain under control as she spent many of her days screaming in the halls of the asylum. she had to be assigned with two nurses around the clock. transforming her from an excited patient to a calmer dement schizophrenic”. 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. was considered to be "the most dangerous and difficult" patient of the asylum. was impulsive and violent. and did not seem to be responsive to any kind of treatment known at the time. She once almost strangled to death one of the nurses. diagnosed with schizophrenia. Frau B. Almost 15 grams of her brain tissue were removed. in Stone. in the course of the next fourteen months. 2001:83) then began to wonder whether it would make any sense to: "…extract this impulsive emotional element from her brain mechanism. Four surgical operations were conducted on Frau B.

40 . 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. convince the psychiatric community of the beneficial potential of this avant-garde procedure. (Burckhardt 1890. Thus pure reason becomes pure objectivity. Burckhardt suffered from harsh criticism and was forced to bring his experiments to an end. They reassert an ethos. however. none of the more modern psychosurgeons wished to have their practice associated with it. The positive effects on the subjects' hallucinations and agitated behaviour did not. forgotten. stating he could have turned asylum’s chronic population into calm and satisfied mental patients. perhaps most conveniently. in Stone. one will not survive the operation. It was not until the 1930’s that psychosurgery began to resurge. Considered as utterly unscientific. 2001:83) Of the other patients to go under Burckhardt’s scalpel. and another will commit suicide shortly after. its origins in Burckhardt's work were. a way of thinking the world. Yet. 2001: 85) Burckhardt died convinced of the potential hiding behind this new technique. but rather.Black Butterflies she is now calmer and less dangerous”. (in Stone. they will use my experiences and go the way of cortical extirpations and achieve continued better and improved results”. although claiming: “I will not let myself be discouraged and I hope neither will my colleagues.

while 'pure' neurology pursued the incorporation of functional (or 'mental') diseases into the medical field. to the benefit of both professions. 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. 1968. As knowledge on the anatomy and structure of the brain began to accumulate. a unification of the fields was undertaken. psychiatry remained associated with psychological – i. 1954. form of medicine (Abbott. have found their physical basis in brain pathology. 1988. neurology has grown to encompass an enlarging group of brain 41 . As more and more once believed to be mental disease. 1992). Pressman. 'neuropsychiatry' of the early 20th century became dominant in research on the cerebral basis for mental illness (Marti-Ibanez et al. 1988). on the other hand. Gelfand. Neurology of the mid-1930s was among the most prestigious and fast-growing academic fields (Abbott. Comprising a rather small group of physicians. the soiled. Lishman. 1997). Eisenberg. introspective accounts. By the 1920s.e. could attain diagnoses through quantifiable.. Gross pure science: neurology as a mainstream biomedical and scientific endeavour on the one end. albeit less prestigious.. 2000). the emotional. communicable. 1988. Shorter. and the fuzzy. such as psychoanalysis (Fadda. 1988. and Shapiro. to neurology as an expertise founded on complex 1997. Inside the category of pure reason reigns order and inner classification. Psychiatry was to rely on subjective. 2000). neurology sought an alliance with psychiatry. Price et al. a more commonly practiced. non-medical— disciplines. and Seli abstract knowledge 1997). Once the physical lesion of a disease was understood. Neurology. However. and scientifically reliable signs (Audisio. or symptoms. (Alexander and Selesnick. 1995. it was passed over from psychiatry’s managing know-how. and outside: chaos.Sky E. the subjective psychiatry on the other.

mainly directing day-to-day life conditions for mental patients (more 'technicians' than 'experts'). 42 . growing apart from the medical model that has excluded them and marginalised their practice. shaped the separation of psychiatry from neurology. Medical treatment for actual 'psyche-related' disease will be inconceivable. In other words. as the epistemological bases of both of the fields were deeply affected by this psychophysic separation. turning psychiatry into a mere nursing specialisation. The psychic nature of disease will be attributed to any mental syndrome for which no apparent 'physical' cause could be found. While the former abandoned any aspirations regarding the integration into the more mainstream medical model. One of the effects is the large group of psychiatrists leaning towards new psychoanalytical stances. then conceived as mental asylum practitioners. since the basic definition of such a disease is related to the absence of known brain-pathology.Black Butterflies (and central nervous system) pathology. while the latter will be left in the hands of psychiatrists. Indeed. The physical nature of disease will be attributed to any brain-related pathology which physical basis can be understood and clearly tagged. and physical – and therefore treatable within medicine – disease. diseases such as aphasia and epilepsy have been relocated from the blurry field of psychiatry to the more medical-like field of neurology. Early 20th century saw two groups of psychiatrists beginning to emerge: while the more psychoanalytically-oriented (originating from would insist on a 'psychogenetic' psychological processes) explanation of mental illness. The former group of diseases will belong to neurology as a medical expertise. over the years. the separation between mental – and therefore non-medical – disease. another substantial group will persist in its search for the organic and neurological bases of mental illness. This process is not a simple labour separation process.

At the time. The 'primum non nocere' principle cannot hold in the face of horrifying mental suffering. I certainly belong to the second category". 2000). and 43 . Psychosurgery stood at the very centre of this task. the areas of professional jurisdictions gradually aligned themselves around a distinct. (Gottlieb Burckhardt.Sky E. While neurology adhered to purely scientific ontognosis. This quest will be the main drive of psychiatric research into organic-based cures to mental illness. Gross the latter will strengthen its efforts to differentiate itself from the 'philosophical therapy' to resemble a more scientific model of medicine. however. Psychiatry suffered from a lack of clarity as to its basis of legitimacy. hanging in the midst between ontognostic and phenognostic grounds. though implicit. psychiatry remained in an awkward position: treating psyche-related illness. Merino. The other one says: it is better to do something than nothing. cures that were believed to be able to form a bridge over the ever growing gulf between psychiatry and neurology. principle: the gnostic split. Thus. 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. relentless efforts were made to medicalise (and thus 'truthicise' or 'make true') psychiatry. Building the Heroic Ethos "Doctors are different in nature. yet holding on to an organic epistemology. 1980. Light. One kind adheres to the old principle: first do not harm. leading to a severe identity crisis present to this day (Armor and Klerman. Torrey. 1975. 1968.

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. thus becoming a cure rather than a care specialisation (Sargant. Swayze. Was psychosurgery to be proven beneficial. the eventual 44 . 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. Witz. and others felt they 'had to do something'. 1983. 1976. radioactive isotopes were unknown. Moniz. 1997. The Founding Tale "For the physical therapy of mental disorders they [the neuropsychiatrists] had the malaria treatment of neurosyphilis and prolonged sleep. 1983. This 'something' took form in what was to become the psychosurgical intervention. Gieryn. 1999. 1985. 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. and control of the autonomic system by pharmacological means was just beginning. 1992. In practice. 1998). Electroencephalography was in its infancy. and of psychosurgery in 1936 brought about a revolution in diagnosis and treatment. Shorter. it would allow the discipline to become medicine-like. The introduction by Moniz of cerebral angiography in 1927. 1999). Abbott and Meerabeau. shock therapy by insulin and metrazol almost coincided with leucotomy. 1995).Black Butterflies Burckhardt.

during their presentation. 1947:417) Freeman. among others in the field. by Egas Moniz: "[At the Neurological Congress of 1935. one of its most powerful and diligent proponents. the same animal would continue in the experimental situation long beyond the patience of the examiner. if the animal made a few mistakes. Freeman persistently re-established the ethos of psychosurgery's 'discovery'. without the least indication of being upset emotionally. Before the operation. After the operation [the excision of the frontal lobes]. Gross extension of which is not yet in sight". making mistake after mistake. shake the bars and refuse to continue in the experiments. the tale of its burgeoning was reiterated in the work of Walter Freeman. Throughout the years. 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.Sky E. 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. Jacobsen and Fulton] noted a profound alteration in response to frustration in the chimpanzee with both frontal poles excised. In fact. Within several important publications. roll in the feces." (Freeman and Watts. he is 45 . it would scream with rage. Freeman (1956:771). in London. depicted Moniz as having stood up in admiration of Jacobsen and Fulton's presentation. urinate and defecate in the cage.

having little grounds on reality.Black Butterflies claimed to have returned to Portugal. his home country. according to Pressman (1988). This founding tale is present in numerous reports. Out of the Laboratory Psychosurgery's initial association with neurology. not incidentally did Freeman observe that Moniz' 'Eureka' was sounded in the course of a prized academic neuro-anatomical presentation. while. 1956:769) 46 . The drawing of the events seems to serve as a constitutive myth. 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. Walter Freeman and his associate. much less than as a historical account. the portrayal of Moniz' deductive mind offered the endeavour a halo of insightful scientific thought. rather than psychiatry. would (and eventually did) provide a powerful stamp of legitimacy. […]". (Freeman. 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. James Watts (1947:417) begin their presentation of ten years retrospective on psychosurgeries by presenting the founding tale again. and to have soon begun his experiments. Thus. and in response to empirical data advanced by two of the world's most prominent neurologists: John Fulton and Carlyle Jacobsen. In a way.

Moniz will then take part in the quest for the Holy Grail of science: the mind. For instance. If we wish to drift away from this organic orientation. Marchand and his colleagues reported that frontal lobotomy would allow to "enrich our anatomo-physiological knowledge of the human brain. we will enter domains that seem to us entirely unacceptable". linking the practice to the body of accumulated knowledge on brain localisation. by being able to spatially define the mind. if only by asserting its position within an ontognostic 'normal science' (Kuhn. the texts of the period defined the benefits of the practice not only in terms of the relief it could allow the mentally ill." (Marchand et al. science could replace explanation by classification. 1936a:41) Indeed.. and clinical facts" (Moniz. Moniz himself sought to advance psychosurgery's position within his contemporary’s work on the localisation of cerebral functions. 1936a:55). This presented psychosurgery as a symbol of a genuine scientific quest for 'Truth' through objective observation and 47 . thoroughly underlining his leaning on "anatomical. but also in terms of the potential accumulation of knowledge on the brain and its functions. (Moniz. 1936a:40) "Psychic life is exteriorized in a different manner. Gross 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. 1949:515). but completely comparable to other functions of the organism". There. physiological. (Moniz. "In the brain there are regions that are particularly related to mental activity. 1970).Sky E.

and 48 . 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". 1937. and in a definitive manner. as a bold empirically-oriented endeavour: "[if our experiments prove to be successful] we would have put in relation. and the parts of the brain that take part in their production. Thus. (Moniz. He explains: "Here was a brilliant discovery belittled through political antagonism and possible professional jealousy. the antagonism was based on three purely "subjective" grounds: political antagonism. and to support the rhetoric placing the procedure on an ontognostic-based legitimacy. 1936a:55) In sum. the mental functions. It would be a great progress as a primordial fact in the study of the organic bases of the mental functions". the 'factory of Truth'. professional jealousy. the underlining of this empirical basis served to reinforce the founding myth.Black Butterflies methods of trial and error. as out of the laboratory. Men of Science Freeman (1956:770) speaks of the basis of the resistance to the 'discovery' by the medico-psychological society in Paris.

Interestingly enough. often in the face of considerable opposition. 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. the year this article was published. 1956:771) or. (Freeman. Gross "philosophical tenets". His was an inner life of thought rather than an outer one of action" (Freeman. 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. including attempted piracy and murderous assault. in 1956. hampered by physical handicaps. indicates true genius". "…He was also able to present to the scientific world the results of his meditations and experiments. and gave expression to his thought in measured terms. like Moniz. Freeman.Sky E. was but a misunderstood genius. rather he lectured or presided with courtesy and dignity. The intellectual vigor of the man. Moniz himself is presented as being "extraordinarily modest": "He was never flamboyant in his speech. 49 . however harsh. Reifying his own status as a 'true' man of science. Freeman himself will be facing powerful antagonism.

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. The ontognostic foundations of biological psychiatry (or 'neuropsychiatry') can be traced back to Franz Joseph Gall’s phrenological theory. linked brain and skull structure to personality traits (Barker. "Psychic life is exteriorized in a different manner. If we wish to drift away from this organic orientation.Black Butterflies Locating the Mind Moniz. 1995). (Moniz. but completely comparable to other functions of the organism". 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. 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. at the beginning of the 19th century. which. Indeed. 1968) Gall (1808:5) himself will claim to seek to: "…grasp the material conditions of the immaterial 50 . 1936a:42) These claims did not grow in a vacuum. we will enter other domains that seem to us entirely unacceptable". 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.

Gross principle.Sky E. Kraeplin.that the brain was indeed the seat of both mental functions and mental pathology (Young. emotion) still lingered. localisation was still able to replace a nebulous notion of the mind as a vague spiritual essence. and seems to undermine our research". reject speculated metaphysical explanations. including electrical stimulation. and later. Barker. he is unambiguous: one needs to apply strict empiricism. Liepmann. World War I further produced clinical evidence on the various effects of head traumas. Charcot. thus contributing to already the dominant trend of cerebral localisation. which manifests itself through its action. Kolb and Whishaw. post-mortem investigations. persuaded many central figures -such as Meynert. 2003). one would find the key to understand the workings of the brain. This provided psychiatry a clear epistemological primacy over claims based on phenognosis. Although the understanding of 'higher' brain functions (such as thought. different imaging techniques. MacMillan. such as Broca’s and Wernicke’s in 1861 and 1874 respectively. although developed along different lanes. 1996. and assert its fundamental form as purely material. and keep in line with scientific methods. was itself based on a view of the brain as the physical seat of psychic activity. 1955[1920]). 51 . In fact. Freud and Alzheimer . 1970. Studies used more and more elaborate methods. Freud's work. By progressing from observation to theory. in his well known "Beyond the Pleasure Principle" (Freud. All would suggest some important correlations between function and location. Later studies of brain localisation. 1995. imagination. experiments on animals. even in the context of mental disease. This is precisely how psychosurgery's early proponents sought to portray their undertakings.

psychoactive drugs). considered then as the epitome of the scientific ethos. The cutting of brain tissues. for instance. and. for instance. Porot (1947:126).Black Butterflies thus justifying a denigration of subjectivity. A more thorough study of the literature supports this assertion. describes the surgical proceedings of Freeman and Watts: “The surgery is usually conducted with local anesthesia. 1977). 72% of the cases operated on had a "macroscopically pathological brain". After the surgery. may have well served as a source of authoritativeness grounded on materialist ontological concepts. Thus. now served as a rebuttal to the practice. for example. X-rays are performed in order to precisely localize the plan of the section. by endeavouring a mapping -however primitive and restricted. Psychosurgery took on this lane of scientific studies by asserting. According to Puech (1949:117). reducing it to mere products of brain function. the spatial grounding of the mind as well as its material ontology. will claim that psychosurgery 52 . undoubtedly more than any other non-localised attempts to treat psychopathologies (such as shock therapy from the early 1930s.of the mental. de facto. Much of the work on psychosurgery involved notions of gross anatomy. once the localisation of mental illness was largely discredited as a scientific endeavour. The films are put against the trepan holes”. However. a few practitioners going as far as to weight the brain tissue excised in the course of surgery. Baruk (1956). as general and imprecise as it may have been. the idea of gross intervention into the brain to alter mental status began to seem unreasonable (Koupernik. the technique drew significant attention. in the second half of the century. This anatomical knowledge.

McNay. 1970. accessible to dissection and rearrangement. 1991). for instance. by definition. demands a suppression of the subjective. 1994). Dew. 53 . ontognosis lies within an overwhelmingly materialistic episteme where the primal focus of attention is the body (Eisenberg. literally. Gross should be morally forbidden since it would transform a functional disorder into an irreducible disease. depersonalised. Csordas. An ideal form of these processes occurs in the operating room.Sky E. to excise sentient experience. 1999. the scrubbing rituals preceding the entry into the operating room and the elaborate draping of the patient which absorbs him/her into a small. This 'symbolic theatre' thus creates a demarcated space within which ontognosis prevails 4. Fox. 1981. 2001). The idea of physical intervention into the realm of the mental began to lose its association with a momentum of scientific advances. a surgical blade was employed. Surgery. 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. 1992. to subordinate it --by means 4 This point will be further developed at a later chapter. As noted. These include. and the reduction of the human body from a sentient whole into a seemingly lifeless object. objectified body-part upon which the surgeon holds complete visibility (Hirschauer. 1997). 1991. This predisposition involves a form of objectification by which the human body is stripped of its subjectivity and transformed into a plain object (Babbie. 1977. In the case of psychosurgery. Medicalising the Mind: Symbolic Correlates of Ontognosis This trend soon moved from the field of research to the field of practice.

as well as to its materiality. More significantly. a more subtle paradigm of mindbrain activity. but also substantiated it by providing it direct and unequivocal evidence. but ipso facto.Black Butterflies of a simple sway of a knife-. rather 54 .to the realm of matter. as well as less serious and permanent side-effects. it was not only reductive. safer alternative. in and on themselves. psychopharmacology proposed what was. at least in appearance. Although equally based on ontognostic views and although equally establishing a domination of brain over mind. did not raise nearly as much outrage as psychosurgery. Although most biomedical practices do hold implicit reductionist bases. First were the symbolic aspects of its administration. Again. however. 1994). This may explain why other measures. altering the spirit through the severing of a physical essence provided clear evidence to the spatial subsistence of the mind. psychopharmacology offered a less costly. The introduction of anti-psychotics in the mid1950s 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. seldom do they constitute. Clearly. such as psychopharmacology. such powerful proclamations on the very nature of mind-matter relations. This brought about psychosurgery’s transition from a state-of-the-art endeavour to a second-line treatment at best. with more readily visible and immediate results. As practiced. some of its characteristics were more compatible with phenognostic views than its therapeutic predecessor’s. Psychosurgery. involving the body as a whole. it also created and recreated this 'operable mind'. did not only comply with ontognosis. however. this ontognosticallyapproachable mind. it also reduced: It brought the mind onto the surgical table based on it being deemed operable.

On a more psychoanalytic note. This stood in clear contrast to the protruding intervention and intrusion of an external. it would satisfy an unconscious need to be punished. spatially defined area where 'the mind' would be seated. In contrast. thus. The mechanisms of ECT's action are still poorly understood. Another form of physical therapy for mental illness should perhaps be mentioned in this context: Electroconvulsive therapy (ECT). introduced in the 1930s and still of widespread use in treatment centres around the globe. in some cases where psychotic symptoms became unmanageable (Braslow. Gross than a small. the shocks would be so unpleasant to the patient to have him cease his 'bad behaviour'. 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. 1997).Sky E. Second was the fact that the mechanisms by which the psychoactive substances actually affect the brain are still little understood. although two main sets of explanations were brought forward: psychological and physiological. The technique was relatively short lived. This would be highly effective in cases of severe depression. and to a lesser extent. allowing the 'mind' to retain its mystique as being too complex for science to grasp. 55 . better known as 'shock therapy'. According to the former. involves the induction of electric stimulation 5 causing the patient transient seizures. it may well account for the lesser magnitude of the debate surrounding drug therapy. technical. would be more than just therapeutic: its characteristics would be more in line with epistemological assumptions on the nature of the mind. and artificial object: the lobotomist's knife. This technique. While this may not be enough to explain the replacement of one treatment by another. Psychopharmacology’s superiority over psychosurgery.

Weiner. but readopted with the disenchantment from psychopharmacology. rather than on gross anatomical processes (as claimed by proponents of psychosurgery). the usage of the technique will become less common with the apparition of psychoactive drugs. but rather temporary losses of memory or transient states of sedation or psychocognitive 'numbness'.Black Butterflies to its functionally optimal level. Furthermore. First of all. there is no actual opening of the skull. the physical explanation is regarded as more sensible. 1977. 1986). Not surprisingly. reducing side effects such as memory losses. and general anguish to the patient. however. 1984). the effects are believed to be (at least in the public eyes) less irreversible than psychosurgery. and less ontognostically ritualised procedures seem to find a more accepting attitude in the laps of a publicly scrutinised psychiatry. limb fracturing. non-localised. Secondly. The latter. less direct. there are several symbolic characteristics which may serve as a complementary explanation for ECT's more lasting state of legitimacy. As with psychosurgery. by now. the 'organ of the mind'. these effects would not include actual personality changes. nor direct contact with the brain. as in the case of psychopharmacology. 1997). the procedure has greatly improved. remains in use to this day and is still given a place of honour in the panoply of psychiatric treatments (Alexander and Selesnick. Since. As with psychopharmacology. Finally. Another factor may be the general acceptance of the idea of brain function as based on electrical exchanges. from the 1970s onwards (Friedberg. 56 . The debates over both psychosurgery and ECT followed psychiatry throughout its development as a legitimate 'cure' expertise (Valenstein.

1950. it would be claimed that a systematic. Babbie (1970:14) tells us. the group of patients operated on was nosologically heterogeneous: there was no common pathology that could be given to proper experimentation (Malizia. 1994. not on questions of right and wrong (or what would be moral or immoral).. Lopez-Ibor and Lopez-Ibor. Ballantine. Pressman. 57 . it was evident that psychosurgery held a strong ontognostic position of legitimacy. Bockoven et al. 2001). 1997.Sky E. White. 1998. is ideally amoral: its role is to judge on questions of truth and falsehood. 1992. the disapproval of psychosurgery focused on the delicate process involving the choice of lesion as well as on the intricate selection of candidates. Science. 1977. 1975. and not of ethics: Opponents insisted that the practice of psychosurgery was justified by poor research methods. 1950). More specifically. Secondly. which made the attribution of success or failure less than certain (Bockoven. Feldman et al. 1980). empiricallybased assessment of outcomes was unattainable. and more than a dozen different sites targeted (Huyn-Dornier. Kolb and Whishaw. the patients were typically under several therapeutic courses. 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. Indeed. 1998). While initially. none the least because more than twenty different techniques developed over the years. initial disapproval of the practice belonged to the realm of science. a similar number of theoretical rationales proposed.. Gross Losing Grounds: Away from Ontognosis The Traps of Rhetorics: Facing the Debate Throughout the first stage of the debate. Thirdly.

a device used as a way to pit (as one would do an apple) selected sections of the brain (Moniz. 1936a). keeping relatively insulate from the spheres of public debate. 58 . rather than addressing ethical and moral questions. 1950. the practice proved to be in discordance with a valid scientific model by which results could lead to a falsification of the theory (Popper. Gildenberg. Practitioners. 1936b). Although these responses did allow for some justification for psychosurgery’s shortcomings. 1972. both with the dosage of alcohol he injected into the brain. Egas Moniz. and with the choice of medical apparatus. psychosurgery surrendered itself to public scrutiny. thereby diminishing both frequency and severity of its side-effects (Fairman. Beginning with the use of a Berthelemy's syringe. 1975). continued to urge the development of better and more precise surgical techniques. Hitchcock et al. staying in touch with empirical facts and ongoing observations. who reported his attempts as representing but a first success. the initial questioning of the practice will result in an abrasion in its status as a pure scientific endeavour. The responses to some of these claims involved a drawing on the words of psychosurgery's mythical father. he went on to design a specialised instrument: the leucotome. still needing refinement (Moniz. The procedure indeed grew more precise and less hazardous. The discussion remained almost entirely restricted to the 'science' of the practice. The Traps of Science: Methods and Rationalisations Moniz conducted the first operations with a methodical approach. and for a more effective choice of candidates. 1953. 1965). This portrayed the procedure as correctable and dynamic. Greenblatt and Solomon. De facto..Black Butterflies In these respects.

Gross The procedure was such that a hole would be drilled into the patient’s skull (depending on the patient. Based on Moniz’s reports. and dissociate 'pathological' neuronal connections. this would be performed under local or general anaesthesia). the steel thread attached to the leucotome would be manipulated to cut through the white matter (where neuron cells are linked). Moniz decided to concentrate his efforts on the frontal lobes of the brain. 59 . An ablation of the frontal lobes will not result in irreversible psychological damage.Sky E. Rather faulty or not. Based on those assumptions. according to him. 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. Moniz presented an elaborate theoretical basis for his work. which are. it is necessary to disconnect the underlying nervous ties. and the device would be inserted into the frontal lobes of the brain. Then. Psychological activity is mainly located in the frontal lobes of the brain. To alter one’s pathological fixed ideas. and cut through pathological nervous connections. the lack of flexibility leading to pathological "idées fixes". a basis which he would carefully associate with neuroanatomical advances of the time. the basis of pathological ideation. although we are still unable to precisely locate and differentiate the different functions. Mental disease is due to a malfunctioning of these sets of connections.

psychosurgery's most fervent supporter. This brought Freeman to propose. a certain measure of affectivity would be lost. 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. In fact. based on electroconvulsive shocks.Black Butterflies The Traps of Symbolics: Freeman and the Ice Pick Some years later. making the pathology less significant for the mentally disturbed patient. who conveyed his 60 . The psychosurgeon would then manipulate the instrument in swift vertical movements and sever groups of nervous connections. further in the back of the skull. Freeman ignored much of the developing models of neuroanatomical functioning. The operation barely lasted a few minutes and allowed Freeman to perform dozens of lobotomies a day. he went as far as to suggest psychiatrists employ the procedure within the setting of their own private practices. an explanation that was considered weak to the very least and improbable at best. Freeman's instrument was a mundane. most particularly with the introduction of a 'psychiatrist-friendly anaesthesia'. In fact. and into the frontal lobes of the brain. nonmedical object. at the time. This and more. 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. Walter Freeman -himself not qualified as a surgeon. from 'primitive' areas. as well as rational and imaginative thought) from the more irrational. and. affective lower parts of the brain. 'Transorbital Lobotomy'. By so doing. This was.contemplated on transferring psychosurgery from the sacrosanct operative room into the mundane world of the asylum. Transorbital-Lobotomy turned the practice into a form of 'non-surgical surgery'. in 1947. unlike Moniz.

as he is completely unaware of his condition and may. as we have recently reported. claiming it unbearable to witness this: "…. The lack of medical caution in the care of the postsurgical patients was also apparent in many of the reports: "…In the first hours. decried transorbital-lobotomy. with Freeman administering electroconvulsive shock for anaesthesia. 1975. 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. 1986). Freeman's co-author in major psychosurgery publications. Freeman contributed to the vulgarisation of 61 . as well as its detachment from the powerful ethos and symbolic aspects of medical practice and science.Sky E. and up through his brain. Freeman chose to perform some of the surgeries in his own consultation office (Bernstein. 1986:257). which can lead to unfortunate consequences". Valenstein. while supporting psychosurgery until his very last day. and taking no time to wear gloves" (quoted in Valenstein. et al. 1947:127) The drifting away from the rituals involved in surgery. one has to watch the patient very carefully. holding an ice pick for a surgical instrument. undoubtedly contributed to psychosurgery's declining legitimacy as an endeavour based on scientific. James Watts. tear away his bandages and put his fingers into the surgical wound. (Porot. Ironically. Gross patients from mental asylums into his well-equipped operative room. ontognostic demarcation. Neurosurgeons soon objected this trend.theatrical sideshow..

and reflected upon the loosening of medicine's epistemological demarcation from the spheres of political. ethical issues began to surface. 1998). 1983). power and prestige (Rudin and Zimmerman. Goldbeck-Wood. In this text. The role of conquering the realm of the mind could not be left in the hands of mere 'technicians'. away from political. 1996. ideological. 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". hence the rise of the larger field of 'bioethics'. was an erosion of the autonomy usually attributed to scientific practice. and professional interests. A suggestion within the same range 62 . Public scrutiny will lead to the practice's loss of absolute authority and a decrease in its scientific autonomy. and its association with issues of science and the social (Gieryn. From the Medical into the Social and Back Again By the 1970's. 1988. 1978. and this is precisely what Freeman portrayed himself to be. 1983). ideological. Snaith. and thus. Parallel to the development of the critical debate on psychosurgery.In fact. the authors proposed a surgical intervention that would solve the social problem of violence: psychosurgery.Black Butterflies the practice and to its consequent decline (Pressman. A powerful public scrutinising both created. placing it on pedestal. and professional interests. 1997). 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.

constituted now but a malice intrusion into an illegitimate area (Chorover. 1970). Dr. 1980). Equally. This would remain an issue of concern to this day. a lobotomy 'survivor'. It took ten minutes and cost two hundred dollars" (Dully and Fleming. and more particularly. will open his 2008 biography with: "In 1960. 2008: ix) Another troubling element was amplified by the air-du-temps of a post WWII Western world: The association of the technique 63 . and. I was given a transorbital or 'ice pick' lobotomy. My father agreed to it. 1975. where individuals would be controlled through electrical brain stimulation (Delgado. the father of the American lobotomy. Kaimovitz. the psychosurgical treatment of certain cases seems to have been more controversial than others. That being said. such as in instances of criminal deviance. and reflected the changes in the assigned power of medicine. told me he was going to do some 'tests'. as Howard Dully. 1978. the very involvement of social interests in the provision of medical treatment became increasingly objectionable. 1969. This led to a perception of psychiatric treatment as a means of social normalisation. Mark and Ervin. to a perhaps even larger extent. when I was twelve years old. encompassing a vision of a utopian 'psycho-civilised society'. and further reinforced the view of an omnipotence of the institutionalised power over the individual. Scheflin and Opton. Walter Freeman. in sharp contrast to the formerly accepted vision of a 'psychosocial' medicine (Breggin.Sky E. The outrage was immense. My stepmother arranged it. Gross appeared a year earlier. however effective. where homosexuals and children were chosen to undergo the operation. of a medicine of the mind: its intervention into the social. 1980).

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. with the eugenic notions of sterilisation and euthanasia of deviant population. A second problem is based on the assumption that psychosurgery brings about basic changes in the patient’s self: does it not mean 64 . black and Jews". this powerful enterprise of revealing the mind through a science of the brain. The relation with localisation. at the head of which would stand neuroscientists accompanied by 'surgeons of the mind'.Black Butterflies with attempts to apply 'Brain Control' over the general population. The period of World War II. 1949). an association not totally unfounded. The ability to see through the mental would create a dangerous panopticon. Freeman himself would declare that the best candidate to undergo lobotomy would be "women. especially those locked behind the closed doors of the world of the asylum. and therefore as expected to have lesser difficulties in adapting to their new post-operatory personality (Brisset. it seems to be even more complex in the context of psychosurgery. brought a certain sensibility regarding issues of mind control. Yet. and questions of social control over individual differences. associated psychosurgery with what was seen as a perhaps equally dangerous trend: control through omniscience. Those were described as having a lesser degree of initiative. The fact is that informed consent is difficult to assert in the case of mental patients. Psychosurgery found itself connotating with such controversial ideas.

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).Sky E. in him\her having an – at times radically. who was going through episodes of violent rage during which she would rhythmically hit her head on the ground or on the wall. this 65 . After the surgery. The diagnosis as such. Moreover. we can see a large heterogeneity in the nosological categories of the different patients. his\her values and preferences. This claim is also likely to be based on the fact that the first patients to undergo psychosurgery suffered from severe psychiatric symptoms. Her parents were forced to attach her hands and legs to her bed as well as her head and chest. Since indeed.different constructed image of him\herself. the intensity and duration of those symptoms were the main criteria for selection. had little to do with the decision as to whether or not proceed with the operation. then. especially considering that the effect of 'pacification' and the general agreeableness of post-operative patients may have been. 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. or would bit her hands and knees and scream for hours. after all. Gross that the patient agreeing to go through the operation is not the same person coming out of it. the very target of the procedure. Back to Society: The Social Cure “…[Interesting is] the case of a 15 year old young girl. the aggressiveness and agitation of the institutionalised patients still formed the main criteria for the decision to operate.

Black Butterflies
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 sphere medicine' a was evident in the context were of psychosurgery, where the position of medicine vis-à-vis the social formed central issue. Practitioners 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
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 67

Black Butterflies
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 taxpayer. 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 of claims: psychosurgery, therapeutic as an important but a constituent psychiatry’s arsenal, was

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
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:


imagination. 1965:654). As discussed earlier. 1963. They laugh easily and flare up in anger on slight nagging or frustration. A disconnection between the two areas will pacify the emotional tone. desires. Hallucinations may still be present. and the consciousness of oneself. but seldom weep. They cannot be insulted. The rationale Freeman (1951) provided for the workings of prefrontal lobotomy seems to reflect this notion. at the price of a loss of horizon and perspective […] Neither hopes nor fears. […] Life is enormously simplified by the relatively complete obliteration of the need for introspection. “The outstanding feature [of the emotional set that characterizes people who have been operated upon] is a lack of self-consciousness […].Black Butterflies "The lobotomized patient achieves his normalization at the price of the vertical component in his being-in-the world. or associated phenognostic experience. the frontal lobes inhabit the functions of foresight. of any higher-level functions. or. 70 .” (Freeman and Watts. but will not necessarily be experienced as 'true' to the individual. according to Freeman. (Vidor. 1947:416). nor regrets can present themselves in his greatly reduced temporal horizon…". while their emotional tonality is provided by the limbic system located deeper within the brain. no matter what one says to them. they do not take offense. in Freeman.

Sky E. He reports: "We have noted with those who have injuries of the frontal lobe disorders of voluntary attention skills and of mental synthesis. 1968). the highest manifestations of psychic life are altered". […] in sum. they are unable to group and orient the different elements of a given problem. the effects of psychosurgery on patients' personalities would be related to the damage incurred to the frontal lobes. This is which places them at the centre of "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. Bouchard. such as hunger or sexual drive. Gross The Homo Vadum's Brain According to many contemporary psychosurgeons and neuroanatomists (e. 1936a:31) 6 These assertions are generally believed to be correct to this day 71 . that is. controlling 'lower' needs of the organism.g. doing purposeful acts. 1936a:30). Moniz (1936a) linked the frontal lobes to the higher human functions of planning. 'the seat of higher functions'. acts that are beyond reflexes and Moniz' book: automatic responses 6. 1955. The frontal lobes were further claimed to be related to the ability of learning from experience. They are in fact incapable of the most simple of intellectual tasks. Porteus. (Moniz.

and a thinning. 1946:457: “None of the patients regained full insight in the full sense of the word. Frank.Black Butterflies "It is […] certain that the frontal lobes tumors present. 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. more plain. and a centre of 'reason' will remain central to the description of psychopathologies related to lobotomies. or entire lack of dreams. due to this emotional asymbolia. The gains of psychosurgery. Interestingly. although later research will refute the presence of the first effect. or its importance. They become. of hypochondriac. or is able really to appreciate what the operation was for. lesser control over emotional responses. 72 . […] The specific [personality] change was a poverty. the greatest frequency of mental disorders". 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. or be abstractly angry in a sustained fashion. (Moniz. melancholic and other forms of delirium: occult forces that lead patients at times to acts of despair". matter-of-fact like”. the image of the frontal lobes as a form of super-ego. intellectual disorders and second. or disappearance of dereistic experience-they cannot daydream about their wishes. above tumors of other lobes.

Corporeality. Indeed. over the years. Indeed. 1949). the position towards the Homo-Vadum began to change. 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. without which. As sentience prevailed as a discursive force. this formerly amoral scientific endeavour turned immoral. Normative functioning could no longer compensate for the damage inflicted upon the Homo-Vadum's phenognostic sense of truth. of the turning into a HomoVadum. With the gradual rise in the authoritativeness of phenognosis. did seem to intensify over the last decades. Some will add the notion of "postoperatory personality"(or "moria") to describe the combination of 73 . this would often be counterbalanced by certain personality changes. Existential ideals of self-fulfilment became ever more dominant. the fear of loss of the human. the patient could not have reorganised his psychic scheme (Mayer-Gross.Sky E. childish. Yet. a growing body of literature referred to the patient's inability not only to reflect upon his/her own condition and behaviour. passive and dependant. 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). some will claim that the beneficial effects of the procedure derive precisely from those personality transformations. Reports describe the post-lobotomy patients (as many as 91% according to one source) as being apathetic. lacking motivation and spontaneity. Pain and Phenognostic Truth Perhaps not unsurprisingly. Gross Let it be noticed that Frank added in the same paper that "no cases were considered worse".

or whether his remarks embarrass his associates”. yet incapable of sentience. the experience can be borne with equanimity” (Freeman and Watts. no longer caring whether his heart beats or his stomach churns. (Porot. 74 . and internalising sensory information. These patients had a tendency to be unconcerned by subjective aspects of their being: while acknowledging drives and feelings. as termed here. rather than internal (experience-based Truth – phenognostic knowledge). 1947:129) The Homo-Vadum. the quality that translates mere stimuli into full-fledged qualia and by which experiences feel pleasurable or painful.Black Butterflies symptoms observed after psychosurgery has been performed. “[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. 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 preoperative self. 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. was thus to a certain extent aware and conscious. both as to his body and as to his relationship with his environment. they reacted as if these cues were external (based on out-there sources of Truth –ontognostic knowledge). 1946:445). […] he loses interest in himself.

1936.[…] [Only when] the individual lapses completely into a dream world of psychosis with no 75 . […] She fell and sprained her ankle. comply with an ontognostic agreed-upon Truth as to a world-out-there. 1947:427) Madness and Ontognosis The concept of 'madness' is intriguing in this regard. the patient complained so bitterly and was so apprehensive that it was impossible to make any headway in treatment”.Or: Sky E. by definition. (Freeman and Watts. but instead of shrieking with apprehension and refusing to cooperate. There was moderate lipping of the vertebrae. A 44 year old woman was first seen in November.S. She winced and cried out when the knees were straightened. but no other significant changes. However. at which time she had spent two years in bed because of “arthritis”. Gross “L. After being lobotomised: “Within three days the patient permitted manipulation of the limbs. affect. This phenognostic experience cannot. and the crepitus was very considerable. she showed interest and willingness to help in the efforts that were made to aid her. hence its characterisation as deviant in thought. but nevertheless kept on walking”. "More difficult to influence satisfactorily are those persons who have drifted away from the world of reality. and/or perception.

and thus expressing an incapacity – or unwillingness. providing them with the ability to perceive. psychosurgeons who did refer to the personality dimension argued that the creation 76 . in fact. This recognise what is collectively considered as True. Some proponents went on to claim that the inflicted personality changes allowed patients' intelligence to actually become more effective. resistant to the reasoning of ontognosis. deduction and accomplish all mental operations that concern productive activities" (Wertheimer. at least as far as studies of the time could show. in line with the idea of the 'social cure'. When intractable.Black Butterflies struggle against the manifestations of disease. is he to be considered too emotionally deteriorated to be aided by psychosurgery." (Freeman. in turn. and respond to the world more 'rationally': "After a prefrontal lobotomy. engineering or scientific work. The Homo Vadum and Society Still. a person who was previously trained for the practice of law. 1948:497). 1943 in Fleming. 'madness' remains. justify the use of techniques intended to secure willing or coerced subordination of what is seen to be a faulty or muddled phenognostic experience. 1944:490). their phenognostic consciousness deteriorated: the patient would know but not experience. Here. As psychosurgery did not seem to have negative effects on one's intelligence. remains capable of calculation. analyse. while typical patients' sensitivity to ontognosis grew.

depicts its protagonist as resisting the system of the mental asylum only to be eventually lobotomised. Questions as to normalisation and the creation of Homi Vadum are apparent in other areas of culture. the idea that a 77 . proponents of the technique used the descriptions of the Homo-Vadum as a validation of the beneficial results of psychosurgery. a Truth that does not have to be subordinate to the gaze of the world-out-there.side effect. As an act of mercy. for it enabled the return of the insane into the laps of a normative society. The 'hero' was finally defeated: lobotomised and turned into a HomoVadum. At the peak of its popularity. notably in fictional literature. This classical piece of literature became one of the strongest manifests for the liberation of individual thinking from the hands of a normalising society. a 'thing'. One must consider that.Sky E. he was now both literally and symbolically at the hands of the more authoritative power: Ontognosis. Its mere popularity demonstrates the claims presented throughout this analysis. Ken Kesey's influential novel "One Flew over the Cuckoo's Nest". Eager to empower a group of mental patients to trust in their own phenognostic sense of Truth. Gross of the Homo-Vadum was a moral act par excellence. practitioners depicted psychosurgery's effects as pointing out to the success of the procedure. Rather than referring to the patient’s acquired condition as a regrettable – albeit perhaps unavoidable . his friend would euthanise him. Surgery left him barely conscious: a mannequin. a Truth that cannot be challenged by external authorities. based on an ontognostic conception of humanity. in what they believe to be right. turning a socially incompetent individual into a HomoVadum was a valuable accomplishment. published in 1973. namely. the central character was calling for an alternative source of power: a Truth that feels true to the individual.

1949:320). The practice's discordance with emerging phenognostic conceptualisations of the self placed psychosurgery in the focus of debates on the significance of sentient experience. and the diminution of the fullfledged subject into a shallow façade of self: "exhibiting a purely objective mentality" (Golla. not as a prediscursive form.and ontognosis –based on observation of a world-outthere. in an era where questions of value are so often approached with a phenognostic view in mind. 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. but as a positive picture in and on itself. 1946:444). but rather as a full fledged discourse. Over the years. Concluding Words I have attempted here to present a historical motion involving two powerful sources of Truth. not necessarily as a negative picture of an objectifying gaze.Black Butterflies rise in the discursive power of phenognostic Truth would place free subjective thought. to be reasonable by ceasing to be does not make sense anymore. the procedure came to symbolise "the substitution of a soulless robot for the insane patient" (Mayer-Gross. phenognosis –based on inner experience. 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 78 . 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. Yet. above the ability to accept an agreed-upon ontognostic Truth. although deviant.

and on a sustained in-situ observation rather than on a more 79 . one is often advised to seek for an 'authentic self' through deep introspection rather than through external appreciation of 'reality'. and beliefs. to the individual. Indeed. all clearly not supported by empirical evidence). rather than diachronic view of the phenomena. faith. In the next section of this work. as long as they 'feel' authentic. Another example may involve the understanding of the credibility associated with states of trance. Along a similar line. these subjective experiences will be given high status as True. or sensing the presence of spiritual entities.Sky E. 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. 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. One may find similar trends in modern psychotherapeutic discourses. genuine. 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. it is precisely these exchanges and conflicts. The fact that these trends are all accompanied by oppositions and by countering phenomena may point to the power ontognosis maintains. non-mediated. This will be based on a synchronic. where one’s inner feelings are considered a priori legitimate. In effect. and to the complexity of the proposed forms of analyses. although often contrary to ontognostic evidence. 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. Gross Truth as experienced by individuals in specific states of consciousness (claims of re-incarnation for example.

Here. and different empirical points of focus.Black Butterflies macro outlook as proposed in this paper. formed and reformed at several layers of the world of the sociocultural. As I try to ascertain throughout this work. different methodologies. I shall provide an analysis along similar lines. 80 . different references to bodies of literature. albeit with a different field. the boundaries between phenognostic and ontognostic knowledge are created.

and a neuropsychologist. a social worker. in rounds in the inpatient ward. The Clinic: Spatial Characteristics The neuro-oncology clinic is an outpatient unit located in a general oncology clinic. a head nurse. The team consisted of four neuro-oncologists (NROs). The NROs were observed during routine consultations. Each office has. and in the course of three weekly professional conferences: one internal conference. and 7 with 5 different patients-were later transcribed verbatim. and 68 patients were informally interviewed. a metal name-tag-holder that can be replaced at need. Gross Part IVa: Experts and ‘Knowledge that Counts’(background) The World of Brain Cancer Diagnosis The Neuro-oncology Clinic During the first half of 2006. A total of 103 consultations were observed. according to the physician who happens to be using the room on that particular day. Wednesdays. nailed on the wall next to the door.Sky E. I spent some twenty hours a week at the clinic. 81 . patients. The secretariat is shared by both groups of physicians (the latter's forming a more substantial share of the staff). 2 with family members. Thus. and another with the neurosurgical team. one with the radiology experts. 4 with NROs. where I gathered extensive field notes (simultaneously translated and composed in English) along with both formal interviews and casual exchanges with staff members. The clinic includes about ten offices. although on the days in which the neuro-oncology clinic is active (Mondays. I followed members of a neurooncology outpatient clinic situated in a large hospital in Israel. Although forming but a small share of the data collected. and close-ones. there is no permanent office for any of the NROs. formal interviews –13 overall.

Black Butterflies and Thursdays). Each Sunday is spent around professional conferences. at the neurosurgery inpatient used for the weekly NROs' staff meeting. Her office has an interesting standing: it is both the heart of the clinic. none of which is actually secured for the NROs. their impressions and interpretations of the images they survey).on the days they do not receive patients). hinting to its more decision-oriented character) takes place in a conference room at the radiotherapy unit. at the hospital main building.. when the conference room is used for other purposes. the head of the Neuro-oncology team has a large. the whole team will go up to another conference room. ambulatory divisions. At times. in a small office. The Radiology conference takes place at the radiology (MRI) unit. The Neurosurgery conference (referred to as the 'tumour board'. luxurious office at the Moses Institute.e. Professor Lise. in writing. where nuclear medicine tests are conducted. The conference room at the "Moses Institute" -a building with mostly oncology-related inpatients units. The conferences take place at different locations. in terms of research mostly and administration 82 . The neuro-oncology clinic has thus no actual spatial presence: it is a virtual set of specialised knowledge held by 'visiting' professionals. was some other group needing this room. Her office is actually located at the one floor where the services provided are not targeted toward cancer patients – i. and out-patients clinics. albeit at some distance from the actual clinic. squeezing in into a room much too small. or the inpatient unit. the NROs will find a temporary office at the clinic. However. the working physicians tend to be placed in a habitual office (used by other physicians -or even nurses . where the experts usually sit and go through the MRIs (and reporting.

Floor B is where Lise's office is located – just near the corridor leading to the general hospital. easily accessible. alongside general oncology patients. 'spaceship'-like floor. this is the only floor where the activity has little to do with oncology. One will also find there the refurbished conference room serving the NROs on Sunday mornings' meetings. surrounded by glass walls from which the conferences may be seen but not heard). or the rest of the staff. interestingly enough. for that matter. Again. or as another patient called it: "the death wing". The outpatient clinic is located on -1. which serves the general public rather than patients (whose pathological state allows them some access to backstage areas). the reception area and the conference room (which is. i. some of which are underground: The -2 floor includes the radiotherapy (RT) facilities and completely lacks windows or direct access to the 'outer world'. leading almost directly to the hospital's mall. and a coffee shop is located in the general hall located on the East.Sky E. This unit is where most neuro-oncology patients are hospitalised. A small but lovely patio separates the Western and Eastern wings. with instruments and names on the doors that would not shame any science fiction movie. but it never serves as a meeting place for the different NROs.e. and where the general hospital is directly linked to the institute's building. Naturally. The Moses building has many floors. this is 83 . It is a dark. in fact. No one could guess he had entered the "cancer building". As expected from a frontstage area. Gross at times. the place is bright. The spatial arrangement may reflect that. while also contributing to this state of affairs. little cohesiveness or sense of 'team' between the NROs. There is. The first floor is where the oncology inpatient unit is located.

The third floor includes a large.hospitalised patients as opposed to the near-death. The reception hours tend to begin at around 8:00. although most physicians turn up only by 9:00. There. The onco-psychological unit is also located on the floor. Sundays are organised around conferences and rounds. in some cases) of the not-yet. perhaps much more than with hospitalised patients. The last appointments are set for around 12:00. As most of the staff members (Lise excluded) 84 . The team of psychologists usually works with ambulatory patients. and often unconscious. The second floor includes the haematology inpatient unit.Black Butterflies where most of the rounds take place. If the latter happens to be the case. The morning begins with a NROs' staff meeting. The rounds usually do not take more than forty minutes. with a consultation room of its own. after a short recovery and observation period. they will take the opportunity to finish the rounds before the radiology conference. condition of many inpatients. the day ends as far as the NROs are concerned. usually begins at 14:00. This is where patients are submitted to chemotherapy by perfusion and return home at the end of the day. This may last until 10:00. the group will go straight to the next meeting (which is invariantly scheduled for 10:00) with the radiologists. usually due to secondary complications of treatments. At any given moment one-to-two neuro-oncology patients are to be found hospitalised. quite modestly but recently refurbished ambulatory service. one or two physicians receive patients. although this may actually last until 15:00. Schedules and Organisation of Time On each of the days in which the clinic operates. If the former is the case. or end by 9:00. This might be explained by the longer life expectancy (and chances of recovery. The meeting with the neurosurgeons (the 'tumour board').

Gross also work as general neurologists. 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. This usually happens when the presenting NRO specifically says that "this is a difficult case" or "that is an interesting case". fifth year medical students are allowed in.Sky E. the head nurse. 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. and reviews of state-of-the-art literature. the meetings also include research presentations (such as dr. The meeting is organised around a briefing of each NRO on the cases he/she had seen over the week. Levitz' presentation of findings related to "chromosomal differences between infratentorial and supratentorial ependymomas"). 85 . None of the NROs consider him\herself as mere clinicians. The Neuro-oncology Meeting The first meeting includes the NROs. From time to time. the social worker and the neuropsychologist. however eager she may be to continue with her professional presentation. and at others by peripheral experts such as the histologist or the neuropsychologist. while the others listen and make suggestions as to treatment options or diagnosis. and all are involved in research at one level or another. at times by the NROs themselves. Thus. they will spend their 'free time' as 'plain' neurologists. Each NRO presents about ten cases. While the first is filled with technical terms and arise much interest.

and consider the progression of the tumour. The Consultation The patient arrives at the clinic. 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). gives his/her name to the reception clerk. There is no particular social characteristic which makes the patients' population remarkable. New patients almost invariably know about their condition beforehand. upon his arrival to the clinic. As the NROs tend to be late. or did they already have an attack which rushed them into neurosurgery – only then to understand they have a brain tumour. they will also find a pile of files – meaning that patients are already ready to be seen. The files of patients due to have an appointment are drawn from the clinic's archive the day before. Actually. Patients under active treatment will come up to once a week when under radiotherapy. The physician will find. the second scenario is much more common. Some would only come once a year (once every three months is more typical) to have their MRI done. a list of appointments for the coming day. as children are referred to a paediatric unit. His/her file is then placed on a pile which will be taken to the physician's office from time to time. They have either been referred to the NRO after a diagnosis has been given by another physician.Black Butterflies The Patients Patients –adults alone. Most of the patients I see come to the clinic for follow-ups. and once a month when on chemotherapy. The physician would not see 86 .are referred to this clinic from all over the country.

but allows to remain unseen. usually as is costumed to fill in the consultation report: the gender. I would then ask whether I could sit in the consultation. The NROs take great care in gathering information in an orderly manner. if not. 7 87 . the physician will then enter the patient's ID number onto the specialised software. The ways the NROs conduct the consultation is very similar: as the patient enters and take a sit. Using a At this point I would introduce myself as Sky Gross. to-the-point and assertive if he\she is determined to obtain clear responses. another will be given to the patient. or when complex treatment orders are given. and when the next appointment should be made. the NRO would utter a "how barcode reader. There is no formal room for questions. Then. comorbidities. Then come the orders: how to continue the treatment. doing research on brain cancer and brain cancer patients. the treatment currently undertaken. the patient may be hasted out of the room 8. and the patient is expected to quick. This entrance demands making a small detour. the physician will suffice himself with a general impression of the patient's condition). the current complaints. the report of the clinical examination (if there is one. are you doing?" without really hearing the answer 7. One copy will be filed. Even when diagnoses are communicated (often very bad news). he\she will stare at the computer for a few minutes. age and diagnosis.Sky E. Gross 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. if any test or consultation with another professional is needed. a researcher from the Hebrew University. All but one patient agreed.

forming in the brain itself. The types of cells involved and the form of its spreading give indication to whether the tumour is primary or secondary. 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. One cannot but be impressed with their efforts to keep pace with their extremely demanding schedule. Something About Brain Tumours Types of Tumours At the most elementary level.e. 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). They are clearly overwhelmed. Notwithstanding these comments. 8 88 . one may define two general types of brain tumours: Primary. Unlike many other forms of cancerous diseases. and etiology is little understood. there is little chance in effectively controlling the process. more members of the family tend to join in. i. it has to be noted that at no point do the physicians use their time for personal or leisure activities. Life expectancy differs dramatically. originating from another cancerous process elsewhere in the body. There is thus no known way to prevent the apparition of the disease. there are no known risk factors to primary brain cancer. and secondary (or 'metastatic'). i.e. that is.Black Butterflies Family Members The patients usually come with a family member. once a tumour has metastasised. Close to the time of diagnosis and often towards the patient's death. The family members are a critical part of the consultation.

I saw only a few of these patients. Gross The largest group of primary brain cancers is referred to as 'Gliomas'. based on the types of the underlying cellular formation and the location of the tumour: 'astrocytomas' (the most common). 'ependymomas'. Location of the Tumour and Functions Threatened The brain is divided into six primary regions. digestion. The following is a brief overview of each region and their correlating functions. often giving the patient a life expectancy of mere weeks. Grades astrocytomas' III-IV or tumours are referred to as 'anaplastic Anaplastic 'glioblastomas'. the presence of necrosis (dead tissue). a I-IV classification relating to the current speed of growth. each controlling specific functions. respectively. GBMs are deadly. and 'oligodendrogliomas'. The area where the brain connects to the spinal cord is called 'brainstem'. heart rate and blood 89 . All tumours are assigned a 'grade'.Sky E. and the level of differentiation (pathological deformation) of the cells . that is. may cause serious handicaps or even death. The Brain Stem. astrocytomas typically progress to become glioblastomas (GBM) at some point. Grade I-II tumours are considered benign. as they tend to come to the clinic for yearly follow-up only. although may become more aggressive at a later stage of growth. if damaged. the number of blood vessels providing nutrients to the tumour. They can also be located in or near a part of the brain which. 'medulloblastomas'. Gliomas involve abnormal growth of glial cells (the supporting cells of the brain) and include four main categories of tumours. It controls vital heart and lung functions such as breathing.

The Parietal Lobes. colours. or weakness on one side of the body (hemiplegia). pathologies associated with this area can cause almost any form of symptoms. which together. control our sense of touch. planning. However. posture. such as the control of behaviour and emotions and moral judgment. Patients suffering from tumours in or near the frontal lobes may not only have symptoms related to motor functions. Located at the back of the brain above the brain stem. size and texture. talking. abnormal functioning of facial muscles. It is also where higher functions. Presence of pathology in this lobe can cause partial blindness or the inability to recognise shapes. Located behind the frontal lobes. The neural network takes input from your eyes and turns it into the pictures that you see. sleepiness. The Occipital Lobes.Black Butterflies pressure. and at the top of the brain. as well as the ability to remain awake and alert. our feel and understanding of weight. but may also suffer from extreme personality changes. walking. or faces. the occipital lobes are 'in charge' of vision. problem solving and selective attention. since so many nerves go through the brainstem. The posterior parts of the frontal lobes also houses nerve cells that produce movement. Problems in the brainstem often cause symptoms such as double vision. and coordination. The Frontal Lobes. Located in the mid-back of brain. and eye movement. as well as much of our 90 . the cerebellum coordinates balance. nausea. The frontal part of the brain is responsible for organising thoughts. the parietal area comprises a right and left lobe. The Cerebellum. and affects activities such as eating. It is the pathway for all nerve function through the spinal cord to the highest part of the brain.

Treatment is thus meant to prolong life or to better the patient's quality of life. the two temporal lobes help us distinguish smells and sounds. Located on the right and left side of the brain (near ear level). Treatment The term 'treatment' is misleading. and may be involved in the experience fear. and may impact short-term memory. Surgery. Tumours affecting the left parietal lobe can cause difficulty speaking or difficulty understanding speech. Tumours affecting the right parietal lobe can cause a lack of spatial orientation and may hinder the ability to recognise one's own body. In most cases. The right lobe is primarily responsible for visual memory while the left controls verbal memory. provided usually in this order: Surgical resection. The NROs are unambiguous: there is no 'cure'. chemotherapy. and other sense-related symptoms.Sky E. although it may proceed over decades. Surgery is usually the first step. Surgical intervention is seldom able to remove the entirety of the mass' tissues – microscopic malignant cells almost always remain to begin the growth anew. The Temporal Lobes. 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. the progress of the mass is inevitable. Pathologies of the parietal lobes can cause numbness. Except for a number of first grade tumours. There are three types of treatment. and radiotherapy. the benefit of surgery must be weighted not only against the 91 . Almost invariably do they then report on their being rushed to surgery. tingling. Gross cognitive comprehension of the world.

burns on the scalp. oedema and more. at the end of which blood tests and imaging are given. in the course of which the patient is to meet the NRO weekly and give blood on a regular basis. and the patient will be referred to radiotherapy. but against the neurological deficits that may result from the assault on the brain. The radiotherapy causes many side-effects (which severity depends on the dosage and the areas being targeted). It also does not have remedial powers. Brain cancer has its own set of chemotherapeutic agents. The oedema tends to become more severe as a 92 . low platelets count or neutropaenia). it will create but little a sense of "Cancer self perception". at home. including hair loss. and has in fact little side-effects. Chemotherapy. does not cause hair loss. Themodal is self administered. if the treatment turns out to be ineffective. The treatment is given for one month at a time. However. The series of treatments is usually given once in the entire course of the disease. Radiotherapy is typically administered daily for a number of weeks. however. Symptoms Relief. or if two years have passed – it is terminated.Black Butterflies risk involved in any serious operation. this barrier is not penetrable by the chemotherapeutic agents known to be effective for tumours across the body. Unfortunately. able to reach brain tissue is in the form of tablets: Themodal©. extreme fatigue. The reason for that is that the brain keeps some of the body's material out. If the blood tests do not allow the continuation of the treatment (typically – anaemia. In all these. Radiotherapy. Epilepsy is one of the most troubling symptoms of the presence of the mass itself and the oedema forming around it. One agent is. through what is called the 'Blood Brain Barrier'. it usually does contribute to the shrinking of the tumour and does slow its growth.

but will eventually cause death). when more basic functions begin to deteriorate. some of which must be continuously accompanied with a monitoring of the active agent's level in the blood. usually in a hospice or at home. especially when given in high doses. thereby providing relief in epileptic seizures and intracranial pressure (a situation that may be uncomfortable at first. Epileptic seizures are also treated with anti-epileptic drugs.Sky E. perhaps besides steroids which would relieve some of the pressure on the part of the brain involved. It will also give the patient a typical bloated look. Steroids are provided for the relief of oedema. A major sign of brain cancer is the loss of strength (paresis) or paralysis of one or more limbs and/or enervated body part. 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. 93 . But. When the treatment panoply has been exhausted. unlike with most other types of tumours. especially breathing. making the surroundings accutely aware of their condition. These symptoms have usually no treatment available. There is relatively little pain involved in dying from a brain tumour. there is no role for the NRO but to follow from distance the palliative care provided to the patient. Gross result of radiotherapy and surgery. Palliative and Supporting Care. Steroids are eventually devastating for many body systems. The end may be uncomfortable.

to face consequences of brain pathologies (such as motor and cognitive losses. changes in personality). One instance in which the brain becomes a central focus of one's life is when it becomes the site of life threatening pathology. i. This will be the focus of this next study.Black Butterflies 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. Brain tumours brings about the neccessity to visualise the brain (through imaging tests not usually undertaken by healthy individuals).This. As is often the case in fieldwork. 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. to be of little concern in the everyday routine of most members of society. 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'). however. Yet. but perhaps most significantly.e. Questions of self and the brain tend. I unwittingly revealed other interesting phenomena. I would be soon taken aback: almost no patient sought an understanding of the mind/body conundrum as it applied for him\herself . however. those related to the creation of a web of knowledge hierarchised and utilised in high accordance with the gnostic split. amenable to 'discovery' through different ontognostically-based 94 . Introduction The majority of medical texts represent brain tumours as involving fairly clear-cut entities and categories of entities. even with the most philosophically-akin subjects.

1996). the physician's home ground. Finally.the potential frictions it may create. in a way. I was accorded access to the most inner 95 . seeking closer attention to the everyday practices of 'making science' (e. to underline the technological and epistemological grounds of 'expertise' in the medicoscientific practice of diagnosis. A closer look into the life of a neuro-oncology clinic proves. a lengthy and laborious work of negotiation and clarification. The aim of this paper is double: first. 2004. and the mechanisms of their resolution. Drawing on this now considerable body of research. however. 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. Latour and Woolgar. 2005). van der Geest and Finkler. In this case. in both epistemological and practical terms. Lynch.g. 1988. Pickering. and second. Shuval and Gross. the hospital constitutes a precious setting for understanding the world of medical experts (e. that the solidification of neuro-oncological objects is less than straightforward. a formal permission from the hospital's board of ethics (the 'Helsinki Committee') allowed me to begin my work.g. Anspach. to propose analytical tools to approach the complexity involved in the creation of knowledge. Methodology Over the last decades. By the end of this process. Mizrachi. Being.Sky E. a new approach to the study of medicoscientific work has arisen. Gross practices. 1986. namely with the head of the clinic led to the gradual gaining of the staff's confidence. 1992. this paper will present an ethnographic study which allowed for a sustained in situ look into the daily micropolitics of the diagnostic practice. and their roles in the assertion of expert authoritativeness. 1993. Rabinow.

in some cases. which may include epileptic seizures. these will reproduce.). In view of the intricate nature of the field of neuro-oncology and the complex terminology used in interactions. Still. wear the traditional white robe. I felt more comfortable using first names as pseudonyms. however critically. and eventually become numerous enough to apply pressure on adjacent nervous tissues. rather than on ad-hominem aspects of their work (i. this did not seem to eventually form any significant obstacle. to the request of the staff. create their own blood supply. X.e. for reasons little understood. That being said. Dr. naturally conditional on the informed consent of both the professional and the patients taking part in the research project. while referring to staff members in a manner that would reflect their professional roles. This was particularly salient as I did. loss of sensation in the limbs or. and as cooperation was ensured. The tumour presents itself through a neurological realm of signs and symptoms. 96 . undergoes molecular mutation. total or partial paralysis. which. provided that proper ethical directives were followed. Anonymity is ensured by the use of pseudonyms throughout. At the Clinic: The Diagnostic Process According to textbook medical knowledge. for both patients and staff. visual disturbances. At the histological level. a brain tumour arises out of the proliferation and multiplication of a single cell. Considering the level of intimacy I developed with the patients. In fact. personality changes. again. speech malformations. I had to repetitively make clear to patients that I retained neither medical nor counselling role in the clinic. to these schemes.Black Butterflies stages of the clinic. it seems one can hardly communicate the 'real life' work of the professionals without referring. I spent months prior to my insertion in the field studying related medical texts.

albeit only once options are discussed in conjunction with other experts. At the clinic. neurosurgeons. each physician is expected to present the files of the patients he/she has seen throughout the week. such as radiologists and neurosurgeons. radiotherapy. this process begins with the first encounter with the patient. First. There is a fairly ritualistic intake of new patients. and radiotherapists. clinical trials. In either case. tut tut tut”). the types of cells involved. where the NRO assesses previous findings. The second meeting proceeds at the MRI unit. If judged necessary. Its place within the diagnostic complex is limited. his/her colleagues offering their opinions and evaluations. the tumour is metastatic). along with clinical impressions allow NROs to determine the locality of the tumour. among typically a in this wide order: array neurosurgery. during the NROs’ staff meeting: there.Sky E. Routine assessments of cases are typically performed in the course of three weekly conferences. and later in writing (“a slight compression of midbrain structures was observed”). gathers clinical history. of biomedical chemotherapy. the 'tumour board' –which includes the NROs. treatment options (including. with the primary oncologist. its size. and palliative care) are deliberated relatively professionals.seeks a collective appraisal of the applicability of different surgical or radiotherapeutic protocols ('treatment algorithms'). and the approach is largely task97 . first orally to the staff (“things look bad. immediate intervention is considered. The third meeting. and performs a physical examination. and its degree of malignancy. where the radiologists go through recent imaging tests while the NROs provide clinical information on their patients. The formers then report their impressions. and. if applicable (viz. Gross Reporting diagnostic information such as biopsy and MRI studies.

diagnosis is literally a lifelong process. the practice of medicine has become increasingly dependent on expert 98 . remains in a certain state of fluidity. each diagnostic function defines a point on a temporal line which presumably depicts a logical evolution of the disease. The 'case'. The only common participants in these three sessions are the NROs. 1963: XV) With the proliferation of diagnostic technologies. we gather together in a file of his own all the information we have about him. as the integration of reports into a compiling diagnosis requires the adoption of a common way to ‘speak of' the disease. 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. thus placing the latter in a junction of significant power (Mol. we try to obtain a complete. For the NRO. Patients attend the clinic up to once a week while under a radiotherapeutic regime. for a brain cancer patient.e. 2002). (Foucault. In fact. We ‘observe’ him in the same way that we observe the stars or a laboratory experiment". thus. where each re-assessment demands further exchanges of reports through the web of expertise. the participants (i. The interaction between professionals is critical both before and after initial diagnosis. the reporting experts) are expected to conflate their way to 'speak of' the disease to the NROs’. objective idea of his case. Indeed. and once a month when under chemotherapy – typically referred to imaging tests every few weeks. usually towards a worsening in all diagnostic values. a fact that reinforces their centrality in the diagnostical process.Black Butterflies oriented.

1994. and alternating definitions of 'the Disease' as one epistemological object (e.g. 2004).g. assigned attributes and boundaries within its specific 'styles of reasoning' entrenched within formal and tacit knowledge (e. changing. 1993. Latour. 2003). this process involves a multiplicity of experts: within each expertise. what does this finding mean?) (Foucault. Berg and Mol. This ‘gaze’ then provides further interpretation of reality within these styles of reasoning (Latour and Woolgar. 2000).g.Sky E. 1988. Haraway. 2001. 1986. 2004). an object (e. Collins. and likelihood to respond to certain treatments (Foucault. the analysis of the spatial characteristics of a tumour) and a hermeneutic agent (i. a form of attention (e. 2001) have shown. Clark and Mishler. expert conceptualisation of pathologies is further mediated by technology (e.g. expected course. Mol. 1963. clinical examinations. and mediates the definition of the disease as a thing-out-there. an MRI machine). This quest aims at a reconciliation of accumulated diagnostic data (e. explained. 2002. most prominently in fields where diagnosis remains complex and critical (Reiser. 1988. 1998.g. Rabinow. Dew. 1996). Facing sets of signs and symptoms. Gross medicoscientific observation.g. Clarke et al. In many biomedical settings. This is accompanied by the need for a constant reshaping of the definition and conceptualisation of disease. Lynch. 2004). Casper and Koenig.. Koenig. 1963. This integration of pathology and nosology requires a ramified process of creating.g. adding to the intricacy of medical work (Howell. 1982. As Polanyi (1998) and others (e. communicating. 99 . Berg and Harterink. 1997). Hacking. 1992. Moreira. 1995.e. 1978. Moreira. blood test results) and the preconceived nosological scheme of knowledge regarding diseases’ characteristics. Bos. Good. physicians are expected to 'reveal' the one underlying ontognostically-reachable element: ‘the Disease’. diagnostic elements are observed.

1987. Bos. Reports may be as numerous as the number of expertises involved. 2002). 2004). Both the ontological status and communicable qualities of these mediated-objects are maintained by professional rhetoric in the form of reports. While mediated-reports may 'make sense' in the context of the single expertise. rhetorical. 1981. They will they be placed within a delineated. Hacking. Anspach. organised conceptual chart of identified pathologies (Lynch. epistemological inconsistencies may arise once these are juxtaposed. and create as many objects as the number of gazes laid upon it (Berg and Mol. they were seen to apply – often implicitly and always subtly – several mechanisms. where they can be 'spoken of' in a common language. 2004).e. Different expertises are sustained within their own technological. i. These will then be made comparable and manipulable within an established nosological order. Mol. each creating what shall be referred here as 'expert-mediated objects'. 100 . 2002. which will be discussed later in the text.tended to strive towards the assertion of the nosopathological uniqueness and integrity of the 'brain tumour' object.Black Butterflies 1996. and epistemic systems (Goodwin. 1992). As this work will seek to demonstrate. Beaulieu. With this aim. the artefactual products of processes of observation and translation (Young. 1998. often demanding an implicit evaluation of the forms of authoritativeness associated with each of its sources. 1985. Knorr-Cetina. and amenable to integration or alignment with other objects. 1996. 1994. Latour. 1999). NROs --being ultimately in charge of diagnosis making-. Boumans.

in itself. the NRO has to draw beyond his or her own field of expertise well into the neighbouring provinces of knowledge and technology. on a set of observable patterns ("a contra-lateral hemiparesis with frequent grand-mal seizures"). In general. neuro-oncological) sphere while being potentially involved in 101 positions: reporting. clinician. The clinical. normal results in the capacity to comprehend abstract notions"). and neuropsychologist. low tendencies towards anxiety. Reporting experts provide expert-mediated objects aimed at assisting in the overall assessment of each particular case. 2004).Sky E. Within the scheme proposed here. this involved exchanges between what I shall define as three relatively distinct diagnostic expertises. independent. And the neuropsychologist on a series of scores along different scales ("a normal IQ test. as shall be shown. However. Gross The Web of Expertise In order to create the neuro-oncological object as a coherent 'ontologically asserted' (or 'ontognostically-based') referent (Bos. and compiling . require translation and juxtaposition of these heterogeneous reports. 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"). for example. including the histopathologist. reaching a sensible overall diagnosis did. neither the ontological status. the fact that these expert-mediated objects are communicated in different forms seldom challenged. radiologist. on a qualitatively distinct object ("a mixed-cell oligodendroglioma with a necrotic centre"). In Marfa’s case.g. Independent experts remain external to the main expertise's (e. nor the pathological definition of 'the Disease'. these included several professionals. The histopathologist. At the clinic.

to an emphasis on 'profesionalism' based on accumulated agreed-upon scientific knowledge. these experts (such haematologists or general oncologists) served as autonomous physicians holding their own clinical complex and definitions of disease. transparency etc (Boumans and Beaulieu. medicine will seek to redefine itself from a focus on 'artisanship' based on personally-owned tacit knowledge. although chiefly in its margins. experts. accountability. Here. For instance. The compiling expert faces a multiplicity and disparity of objects presented in reports gathered from independent and reporting however. 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. This tension positions the compiling expert (here. in relation to the NROs. a separate file) were occasionally integrated into the patient’s neurooncological case. their diagnostic and record-keeping activities (including. Still. treatment. 2004). depending on his/her known co-morbidities and general health status. at the periphery of the diagnostic web. 102 . including dimensions such as accuracy. of an potentially threaten establishment integrated and congruent image of the disease as a relatively welldefined entity. and a quantification and standartisation of reports. the NRO) at a unique and most instructive junction which will be expanded upon throughout the paper.Black Butterflies the assessment of a patient's condition. 'Objectivity' is also sought through the development of well defined protocoles. typically. can Occasional disparity the of mediated-objects. This placed them. validity. and follow-up. a growing use of technology in both diagnosis. while conducted independently.

In practice. who usually tried to keep informed. 2004. clinical. As the reports were characteristically composed in a cryptic language. Beaulieu. in MRS CHO/CR=4/3. CR/MI=0. it is through such translation processes that epistemologically distinct objects come to be linked together.. even for Alyosha. in the production of radiology. 2005). I will show it to my children".9". 1992. histopathology. The radiology reports were no more 'user-friendly'. whether asked for or not.e. the patient typically read and re-read it once having left the room.Sky E. This was obviously unapproachable. Indeed. often baffled by the swiftness of the consultation. the translation (i. Alyosha’s MRI report read the following: "CVB 3. Joyce. 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. Gross The report is both an artefact allowing communication among professionals. conceal 103 . the clinical report was handed over to the patient at the end of the consultation. For example. 2002). For example. and a channel through which independent and reporting experts translate the observed disease into expertmediated objects (Berg and Harterink. say Good (1994) and others (Bourdieu. As suggested by Callon and Latour (2006). She would remain unsure of whether she was "doing well" or not until having the report deciphered for her. tend to use jargon and rhetorics which make them appear more reliable. reports. As one perplexed patient said: "This is a summary of my disease. so I know whether I am better or not.

this may be more salient: as the visual medium may point to a lesser need of expertness in reading (it is "right there". This will have clear manifestation in the form of a relative indecipherability of the reports. "the tumour has not changed". Soren and Dr. Soren is a quiet but impressive man of about 60 year old. This can be said of reports produced by each and every reporting expertise at the clinic. with a beard that gives him the appearance of a wise oracle. The Sight of the Tumour: Radiology The radiology meeting takes place in the general hospital's building. The NROs then all offer their opinion. Martin is younger and his lack of experience is critical: in the field of radiology.Black Butterflies areas of uncertainty. "in black and white" some patients told me when asked whether they could recognise their tumour on the MRI). Martin. is it larger. on the underground floor. the need to assert the uniqueness and complexity of their expertise was obviously more critical. hoping to be approved by the MRI expert: "the tumour has grown". This is where patients are examined and results are processed and interpreted by the experts. Unlike his junior colleague. The questions to be answered are of two kinds: spatial and temporal. where the MRI machines are located. "wow. smaller. Where is the tumour? Between now and then. In the case of radiology. this is a big one". For each patient two MRIs are uploaded on the screen: the 'before' and 'after'. or unchanged? There are two radiology experts: Prof. The NROs and MRI experts stare at computer screens while patients’ ID numbers are called by one of the neuro-oncologists. tacit knowledge 104 . but rather with his full title: "Professor Soren". he is never turned to by his first name. however. and ultimately reify the experts' position as holding exclusive knowledge and thus epistemological authoritativeness.

thus not knowing what she was writing. Training the senses may be the only way of reaching accurate interpretations. she never expressed any interest beyond what was directly dictated to her.e. In fact.. nor shown emotions when news were particularly diffficult. albeit for the neuro-oncology team's use only. the meetings were tenser. Therefore. as well as the head nurse. each conceivably contributing to the diagnostic effort: the location of the tumour. Joining them was Lise's secretary. All four NROs were present at each of the weekly meetings. Gila. Clinical information was more often sought and drawn from when the picture seemed inconclusive (i. In this sense. She never made any comment on patients. whenever possible. Gila entered the evaluations she received from the group. in practice. usually as summarised by Lise. Soren worked with the team. if unsure of whether the tumour has grown or not. she served more like a mediating device than an actual 'professional'. Gila sat with Lise's laptop. It included several carefully operationalised components. while his colleague continued working on 'general patient's reports. When Martin did replace Soren. Gross acquired through experience is which allows the expert to 'see' phenomena which may pass unacknowledgded by others. 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). the 105 . and most of the final judgements on the meaning of the image on the screen were given by the neurooncologists rather than by the radiologist.Sky E. a worsening in the patient's symptoms was used to settle the interpretation – the tumour must have grown as well). She often did not understand the jargon. and equipped with the software especially designed for keeping and documenting patients' cases. plugged onto the hospital's intranet.

Jenks. etc. Draper. 1990. 2004). 1990. Boumans. and ruling out phenognostic interferrences and interpretations not intended by the reader (Bastide. 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. with 'seeing' being almost inseparable from 'knowing' (Lynch and Woolgar. As far as the team was concerned. Cartwright. 2007).Black Butterflies colouring of its centre and borders. 1995. Joyce. This. 1992. Dumit. enabled a grading of the tumour. 1990. 2004). and a characterisation of its cellular bases. that is: that the screen shows 106 . This materiality is what enables them to approach the thing. so much as to have patients sent home --without being examined-. non-interventional access to the truth (Foucault. This has grounds on several broader cultural stances. 2004. the regularity of its margins. 2002. It is easy for MRI technicians to forget that there is a 'body' there (Rohrer. and make the subject of this thing transparrent (Duden. Daston and Galison. Ala. 1995). along with the clinical and histopathology reports. 1993. including the medicoscientifical tendency to regard sight as evidence. 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 report played an important role in the continual examination and re-examination of the state of the disease. 1963.if their MRI had not been yet deciphered by the expert. the number of foci. Knorr-Cetina and Amann. 2006) and vision the as an unmediated perceptual source of an knowledge: images themselves purportedly allowing ontognostic.

In fact. unlikely to metastasise to other parts of the body. The diagnosis of a brain tumour. that is. and to the rate of its spreading. Frank. Once the visual is alleged to provide the most authoritative access to the object of disease. 1988. 1989): "Wow.e. 1992). its spatial characteristics. Joyce.Sky E. Gross an abstraction of something. radiology would undoubtedly represent the epitome of diagnostic science (Gunderman. it is indeed large. non-systemic disease. in the NROs' own terms 'a space occupying process'. indeed involved an emphasis on spatialisation: brain-cancer is a local. including phenognostic assessments by the object itself (i. more accurate than would any direct assessment of the 'object itself'. The site of the symptoms often directly reflects the location of the tumour. 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 symptoms tend to be in correlation with the surfaces of the brain affected by the disease. 2008). Burri. 107 . some will claim that radiology may make things 'more real than real' or 'hyperreal' (Baudrillard. a mediated 'something' rather than the 'real thing'. the patient). 2008. 2005. 'Space' is another crucial element in the assertion of the authoritativeness of radiological knowledge (Leigh Star.

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. "explains how she is". when speaking of a patient's pathology. Simone sat on a wheelchair. Yassar remained unsure of the thing he was supposed to 'look' at. and surgery is now impossible: the tumour takes on half of the brain". Albert. rather than where the (very visible) paralysis was. including in the clinic. only to go back and doze off again. however. has powerful epistemological affinity and mimetic relations with the disease as it is conceived: a spatial diagnostic technique. on the right side of the face. This is when Franz solemnly announced: "The radiotherapy had no effect. For instance. as a space-oriented measure. turned the screen towards Albert: "Look". 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. Her husband. keeping an empty smile when spoken to. she looked considerably worse. This is well examplified in the case of Simone. The spatial attributes of the tumour are strongly tied to every aspect of the physicians' work. now more clearly drawing around the edges of the tumour. Franz read the file: Simone had just completed a round of radiotherapy. "This". for a spatially defined pathology. but understood that something must be wrong. thus. Radiology. Franz pointed at the screen. and yet. he said. Albert: 108 .e. In fact. He looked at the MRI and without uttering a word. as if the visualisation of the tumour actually explained anything. the tumour has grown. i.Black Butterflies Often. with advanced cancer. completely lethargic. a 25 year old woman. accompanied her along with her mother to Franz' office.

it isn't supposed to grow. Albert proudly showed me how her hair had begun to grow again. now. This is when the mother burst into tears. in some cases. annoyed by the naïve question: "This is not a liquid! You would suck up all the brain out!!". like in a biopsy?". as it is the most accurate source of defining both the grade and the cellular basis of a tumour. right?" to which I answered with a smile. asking a rhetorical question: "she'll be alright. Gross "Couldn't you suck it up. After the consultation. 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. after 30 days of radiotherapy. He was by now completely deflated. 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). Thus. This assessment is extremely 109 . Franz bluntly answered. "You didn't think she looked tired?" "I thought it was the radiotherapy that made her tired". It was as if he finally 'got it'. Within days. I asked him whether he was surprised to see the MRI: "Yes. one of the first steps taken after the initial diagnosis is to have a portion (or.Sky E. I was interested as to whether actually seeing the tumour made any difference: Just a few minutes before. the entirety) of the mass removed and sent to the laboratory expert. I don't understand". now joined by Yassar.

Keating and Cambrosio. These sophisticated schemes of identification and classification are. central to the creation and preservation of the ontognostic medicoscientific ethos (Foucault. 1977. clear of the 'fuzziness of reality' (Foucault. astrocytomas. etc. 1999). 1964. or gemistocytic. Another characteristic appears to be involved in this assertion of authoritativeness. both within the realm of 110 . in a way. Histopathology’s evergrowing categories of mediated-objects. motionless. Patients. its high tech procedures. To mention only a few criteria of histopathological categorisation: one form of gliomas. Reiser. provides the laboratory a distinction drawn on a halo of pure science. one must note. Removing the personal particularities of the patient enables a more clear-cut alignment with existing nosological categories. especially in terms of correlating pathology with existing (and continuously growing) nosological schemes. out-of-site. Thompson. 1991a. 1995. in turn. with low or high degrees of cellularity. Bourdieu. 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. however. 2003). and welldefined areas where scientific work can proceed. and its position at the cutting edge of research contribute to its prestige as providing an exclusive corpus of knowledge. may be either well-differentiated or anaplastic. either fibrillary. 1963. isolated from subjective time and space (and thus from subjectivity itself) to create alternative sterile. low or high degrees of pleomorphism. 1963. Rosenberg.Black Butterflies complex. the removal of biological tissue and its analysis outside of its human context allows 'social distancing'. pilocytic. out-oftime. Cicourel. This. The living person becomes literally out-of-sight. or about their cancer being either malignant or benign. and. In sharp contrast to the 'hands-on' clinical evaluation.

That being said. but also guided psychology students who are obligated to practice giving these tests to patients. She administered psychological tests and interpreted them. If the neuropsychologist was so seldom consulted. neuropsychology played little or no part in the actual medical decision process. or to side-effects of the treatment provided for the tumour. 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. such knowledge – however justified and materialised in the form of standardised and empirically confirmed scales and numbers . 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. Arguably with the aim of establishing medicoscientific status. never to be read by the NROs. Yet. Still. the neuropsychologist (Keren) was regarded as a diagnostic source. whose task was to provide patients emotional support. it was probably based on the low authoritativeness and epistemological profile of psychological methods (and 'psy- 111 . Keren was assigned patients that seemed to suffer from cognitive or emotional deficiencies related to the organic effects of the tumour. and her reports were usually filed.Sky E. neuropsychological evaluations tended to be presented as highlydetailed statistical reports. Figuring it out: Neuropsychology Unlike the psycho-oncologists. Gross histopathology and within the broader neuro-oncological compiling diagnosis. Her contacts with the staff were very limited.remained illustrative rather than demonstrative.

numbers and standardisation allowed a rising of psy-knowledges to more towards the level of authoritativeness assigned conventional biomedical sources. as advertently or not. 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. Hands-on: The Clinical Report The first component of the clinical exchange. these include the tone of each muscle group. According to textbook directions. it was presented through a filter of 'epistemotechnics' that would 'truthicise' 9 it in the context of scientific medicine Indeed. and coordination by observing body 9 'make true' 112 . 1991b. usually non-instrumented. Relying greatly on statistics. it must relates to 'epistemotechnical' aspects of its work that put it in the same (or close) epistemological level as medical science. muscle power.Black Butterflies knowledges') in the medicoscientific complex (Rose. Hacking. 1985. 1995). although rarely meticulously followed in practice. The knowledge was allowed in. Porter.she refused to have neuropsychology remaining as peripheral to neurooncology as it was now. Reiser. 1992. 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. if psychology wants to take full part in a purely medical practice (here: neuro-oncology). the physical examination. assessment of a number of parametres. and reflexes. 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. comprises a direct. Changes in sensation will be identified by means of a probing of different parts of the body.

2006). duration.g. 1993. pain. whereby the physician would necessarily have epistemological supremacy as holding total and absolute knowledge of the phenomenon of disease. past medical interventions. while drawing on haptic skills and limited technological aids (Foucault. and preciseness attributed to this practice is critical in the evaluation of the validity – and thus authoritativeness – of knowledge portrayed in such reports. patients have a 'privileged access' to their own inner world of experience. and the method itself based on phenognosis and overall 'primitive' (Joyce. 1988. precipitating circumstances. severity. headaches. as well as should a more general background of co-morbidities. Arguably. 2001). nausea) which must be characterised by time of onset. motor or sensory dysfunctions. and associated complaints. 2005). demands a systematic gathering of information (e. Also central to the examination is the evaluation of gait. The clinician is expected to provide expert deduction and gather relevant information from the patient. visual disturbances.Sky E. and cases of severe illness in the family. Porter. The second component of clinical practice. location. objectivity. rather than to the patient's life-world: his/her belief system. progression or remission. seizures. the expert must bind his/her perspective to observable and accessible aspects of the 'reality' he/she faces. and are able to reach a phenognostic 'truth' that is beyond scientific exploration (Heil. In order to retain ontognostic authoritativeness. Gross movements. Moreira. Gertler. 1963. The lack of neutrality. frequency. 113 . history-taking. This impinges upon the ethos associated with ontognostic thought. 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. A history of administered treatments must also be sought. during which the patient will be asked to walk back and forth.

a clear form of power.. While the patients may influence the actual process of diagnosis (e.g. noting their relative unreliability.” or. The patients themselves cannot be assigned 'expertise'. both of which are –more or less-.was presented during meetings as if of higher authoritative status than the 'described'. they are denied any status of expertise: the expert is the 'reader' of the body. 1988. the deciphering agent of the narrative. 1983.than the 'complained of'. personality. particularities. written reports showed patients' accounts preceded by a sort of 'disclaimer'.. Gunderman. and panic feeling up to 10 times a day" or. patient. 1984. The second portrayed the 114 . the reports included clauses such as: “according to the "[The patient] describes events of abnormal smells. quoting from one clinical report: Typically. etc (Cicourel. The first was assigned some legitimacy as the reporting physician ipso facto provided a seal of approval to the actuality of the symptom. emotional issues.reliable givens At the clinic. A similar trend was found in oral exchanges: the 'had' – as in "the patient had headaches". tastes. Mishler.Black Butterflies background. "He complains of some difficulty getting his words out in conversations". Anspach.. 2005). 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. and –to a lesser degree-. overemphasise some minor symptoms in order to assure full attention and treatment).

and effectively communicate the nature of the symptom by offering a description. first-person information highly . thereby re-affirming the physician's skills in providing all relevant information. He does not have to be knowledgeable on the subject of his illness. 115 may provide. does not solely rest on the examination of the patient's body. asking the right questions and responding in an appropriate way to the the physician's inquiries. reflect on. This makes the definition of the authoritativeness of phenognostic. The Patient A clinical evaluation. Yet compliance does not merely involve following 'doctor's orders'. This classification has its basis on a range of characteristics. but also to the conceived credibility of different forms of clinical information: from the more phenognostic sources to the more ontognostic. The term. being too knowledgeable may be seen as an annoyance. These. also applies to the patient's ability or willingness to internalise the biomedical gaze and its ontognostic claims for epistemological authoritativeness (Gross. but also on the accounts he\she critical. In general terms. He still needs to be able to ask intelligent questions. Gross patient as able to observe. In general. and in fact. 2009a). Observations of the field suggest that a classification of patients into reliable ('good patients') and unreliable ('bad patients') is most sensible. I shall argue. however subtle. the patient is expected to be straight and to-the-point in reporting his complaints. rather than speak of a vague. or to refrain from asking questions at all. emotionally-laden complaint. as defined above.Sky E. the ideal patient is cooperative and compliant. variations provided clues not only as to the authoritativeness assigned to clinical knowledge.

were truthicised with ontognostic measures. i.e. at first not taken seriously by the oncologist. He\she would then quickly adjust his\her account accordingly. the authoritativeness of the 'observed' (ontognosis) over the 'felt' (phenognosis). when I had insane headaches. I never had such headaches – you know. yet: "After [I applied] very intense pressure. Was a patient to report on symptoms that were not compatible with the diagnosis. The reported symptoms' alignment with the determined diagnosis is a clear sign of the internalisation of the 'medical truth'.Black Butterflies For instance. you bow your head to brush your teeth or something… I felt my head will explode and drop to the floor". I'm not faking it!!!' " The 'good patient' reports symptoms that are compatible with the physical profile of the assigned pathology. Such a patient will tend to think some symptoms more relevant than others – or some symptoms being simply 'psychosomatic'. I've been living for thirty years. he would be expected to accept the superior epistemological status of the physical sources. The oncologist told her she was overmaking it.if they would not fit into the scheme proposed by the physician. I had several brain tumours. he sent me to do a head CT. Adi turned from 'a bad patient' to a 'good patient' when her reports. 116 . Shortly after the oncologist declared her "better": "There was one weekend – Thursday. Friday. and Saturday. They sent me for radiation right away and gave me steroids […] I felt like telling them: 'You see.

Sky E. A good patient will provide just the right amount of reporting. He must also not be "overly anxious" (this being a typical term used). although. She is retarded. but in the ears". one may wonder whether there is such a thing as being 'overly' anxious. In fact. This has two major reasons: one. it is considered most credible when the patient seems to 'incidentally' report symptoms that. The good patient also never argues with neither the diagnosis nor the advised course of treatment. where brain cancer is involved. Gross The 'good patient' must also report symptoms that 'make sense': problematic accounts may include "feeling as if crossedeyes. I think". the person may simply be not truthful (lie). such as feelings of numbness or pain. one may distrust these first-person mediated. the person may not be aware of his own condition. 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. Lise's account of an exchange she had with a patient: "His wife doesn't understand the drug thing. would be compatible with the textbook account of the disease. [In my view. being succint but informative. and second. without him holding true knowledge of it. phenognostic accounts. She argues with me and won't agree with me. The field teaches us that the patient must provide specific forms of accounts that eliminate. the woman did not show any sign of mental retardation] Although some information may only be sough from the patient's account. or diminish these two considerations: he must speak of symptoms in a credible way talking about witnesses. There is also a right timing when the symptoms must be mentioned: an eagerness to report symptoms may have 117 .

Black Butterflies one lose credibility. he may seem 'hypochondriac' or as more often used – 'suffering from anxiety'. Riba. 'Bad patients' will get raised eyebrows in exasperation when leaving the room. marrying the wrong partners. and will at time refer to it with some sense of humor. The staff members are well aware of the suggestibility of patients. also because they are seen as making choices that give rise to clear indignation: having too many children. too early. They may arrive to consultations with too many family members ("they must think it's a party!" said the headnurse about one such family). if you don't feel well [as if trying to catch her bluff]: go to radiotherapy. 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". again reifying the epistemological inferiority of patients' accounts over MRI results. so I told her. 118 . The team was amused. When we looked at the MRI." She refused. and often from lower socio-economic status. the headnurse. Riba has the morale of the story: "A month later she said she felt much better and stopped telling these overly dramatic stories. turning to a Rabbi for advices and so on (Gross and Shuval. Ultra-orthodox are quickly assigned to this group. told the team a story about one of the female (deemed 'hysterical') patients: "She won't admit it but she's getting better. there was no real improvement". 'Bad patients' tend to come from less educated backgrounds. 2008).

position. and not unlike other specialists. passive. Little did she know the sister soon approached me with the exact same request. however. Lise. he arrived (from the provincial area of Tiberiade. passing snacks and water from one to another. 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.Sky E. two sisters. Benjamin was recently diagnosed with a brain tumour. 119 . 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. and sent to more elaborate testing. General Oncologists: Peripheral Experts The oncologist that worked most closely with the NROs is Doctor Sari. Invited to receive the results of his biopsy (and the qualification of the tumour's grade). in charge of breaking the news of Benjamin's impending death. more than 100 miles away from Jerusalem) accompanied with no less than five family members. although she would often have consultations with three or more persons present. and a sister-inlaw. She would later scornfully describe the incident to her colleagues: "These people" were "impossible to work with" and "didn't know how to behave". speaking outloud. she tends to take on a subordinate. a middle aged woman. Lise responded with a dry "no" and went on ("Does she think it's like giving out candies?" she would later say). this. a brother. 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. The group was quite assertive with their presence. including his wife. He himself seemed embarrased to be followed by what the staff will disdainfully refer to his 'Tiberiade' family. Gross One memorable case of such 'bad patienthood' is Benjamin Abitbul's. just so to make him [Benjamin] less upset".

The rooms do not hold any specific characteristics that would point to any particular specialty (such as drug posters.Black Butterflies The physical basis of the clinic is in a general oncology clinic. anatomical illustrations and so on). besides the head of the clinic. Levitz. This is in line with the general trend of regarding brain-related disciplines as most distinguished. Thus. which facilities the NROs use three days a week. they are general neurologists (who. The clinic is an environment which accepts specific nosological categories but also 120 . The brain responds to only a few chemotherapeutic interventions. which also points top the importance of the nosological difference between brain cancer and body-cancer. with some on-the-job experience in neuro-oncology. Rather. since neuro-oncologists are not trained as oncology specialists. in many ways. It's an intelligent field". 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. the neuro-oncological clinic and its related interdisciplinary web is organised along a nosological concept. Knowledge in general oncology is rarely required where brain cancer is concerned. 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. Lise. This is particularly interesting. all work as neurologists either in the hospital or in the community). 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. Indeed. and seldom does the tumour spread to other organs. the diagnostic tools are well defined.

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. 'the tumour board' is somewhat enigmatic: as if this was when the tumour would be defined. and will never suggest surgery 121 . This aside. Although the NROs are the ultimate decision-makers. identified. clinical evaluations are brought up along with radiology reports. and characterised. Each meeting focuses on no more than three to four patients where surgery might be considered. and treatment options are deliberated. it alters in its very nature the way in which the disease is manifested. Then. but that of its truth" (Foucault. the neuro-oncology staff (the four physicians and the head-nurse) meets with the neurosurgeons. This perhaps defines best the importance of the nosological complex that would define or be defined by the institutionalepistemological separation of neuro-oncology from oncology. This has in fact little relevance to what actually ocurred in these meetings. and the relationship between what is present is the disease itself. assertive and at times even aggressive in their manners. in the body that is appropriate to it. but rather centres on decision making: 'can and should this patient be operated on?'.Sky E. The neurosurgery staff comprises three middle-aged men. perhaps as a by-product of the nosologically-based criteria of inclusion: "By operating a process of selection. The Neurosurgeons and the Tumour Board: Peripheral Experts Once a week. The name of the weekly meeting. Gross finds the chosen cases most instructive. the meeting is not diagnosisoriented. 1975: 26). which is not that of the patient.

In terms of the web of experts. as described at length in an earlier chapter. but also served to support the general notion of brain cancer as a cellular based. 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. and are therefore somewhat outside of the scope of this scheme. one for which a specialised compiling expert should be ascribed. however. These boundaries are further replicated in the spatial organisation of the clinic.Black Butterflies when deemed impossible or not beneficial by the surgeons. 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. the ontological. spatially spread. One must remember. and scientifically detectible form of disease. that the neurosurgeons play no role in actually diagnosing the patient. pathological differences between 'body cancers' and 'brain cancers' are replicated in the field of relations between professions and profesionals: between oncologists and neurooncologists. well-defined. Mechanisms of Integration The raison d'être of neuro-oncological expertise lies in the contention that brain cancer is a distinct. but also via the establishment of disease categories and diagnoses pointing to 122 . the latter remain highly authoritative. 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. and conceptually unified disease entity. In other words.

rather than oncological. As claimed above. and the affirmation of the diagnosis as requiring neuro-oncological. Latour and Woolgar. settling for a diagnosis based on narrower -albeit more solid-. In this sense. to provide reliable prognosis. 1996). Gross the particularities of brain cancer over other oncological diseases. Latour. 1983. hierarchical position. or excluded from the sphere of legitimacy (Foucault. sequencing. as well as the objects produced by this knowledge. and then preserve the areas of jurisdiction and epistemological boundaries of the compiling expertise (Abbott. expertise.Sky E. When faced with a collection of disparate reports. and pragmatism. 1986. negotiation. 1988.foundations. consequently. This secured the NRO's prerogative to elect and determine treatment options. 1980. Gieryn. this endeavour involved five relatively distinct mechanisms: hierarchisation. the NROs thus sought to establish the case as of a well-asserted neuro-oncological nature. the metadiagnosis also served to delineate. 123 . could (and often did) choose to constrict the range of available knowledge by discarding information from less authoritative sources. peripheralising. and to centralise documentation and records for future research: to be the compiling expert. but also in terms of their perceived authoritativeness. confronted with the task of incorporating the disparate reports. Hierarchisation Forms of knowledge. 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. are created and sustained by having its different forms become authoritative. and others subjugated. As shown throughout the text. 1999). The NRO. and. marginalised.

Sequencing Brain tumours are conceived as having a dynamic constitution. but is completely asymptomatic…". thus the 'anomaly' had to be located at the clinical level. First. his latest MRI took Lise by surprise: "this looks bad…". The pictures were unquestionably there. Tal’s chemotherapeutic treatment was discontinued. "It’s amazing. symptoms tend to accumulate and aggravate. while the clinical picture pointed to a more stable and benign condition. rendering the patient’s experience subordinate to the images on the monitor. he has no symptoms! This guy walks around with a ticking bomb in his head. it is granted that the tumour may progress from one grade to another.Black Butterflies This was the case with Ilya.or may simply remain unchanged. At the radiology meeting. substituting ontological fluidity for temporal fluidity: the object may not be stable as an entity. the MRI suggested a progression. the less authoritative of the two forms of knowledge. may respond to therapy --at times long after the treatment itself has been interrupted or concluded-. Moreover. 124 ." Lise declared a worsening in Ilya’s state: now judged ineffective. As well put by Gunderman (2005:342): "We radiologists sometimes find ourselves giving more credence to the images than to the patient. she told her colleagues. In other words. Sequencing uses this set of temporal factors to account for diagnostic changes without challenging the unity of 'the Disease'. but still retains a continual consistency as a neuro-oncology-mediated object. and their response to medication may decrease over time.

Yet. she answered that the disease had probably worsened since. suggested a shrinking of the tumour. while sensible. for example. Karl’s wife called Franz to report that her husband had a new symptom: he felt 'tingling' in his left arm. There. well before the written report was issued. this was an assertion that. In general. taken two weeks earlier.Sky E. as it allowed the initial diagnosis to remain valid. to the very least until other evidence came along (the next MRI suggested that the tumour was indeed growing). Negotiation It is during the weekly radiology meeting that 'negotiated processes' (Moreira. 2006) could be observed. Rather. in case presentations. On some occurrences. Gross On one occasion. he focused on particular sites. and thus also impossible to challenge. She was surprised as the MRI. The clinical and the radiological were often – again. it was accepted. never deliberately . paid attention to specific patterns. As MRI images were never compared unless taken at least one to two months apart. that is. These. all the while well aware of 'what it is we are looking for'. the sequencing of the events is very much put at the centre. compared to reports resulting from the 125 . was impossible to be put to the test. Led by the NROs' instructions. Franz did not readily discard the imaging report as unreliable. the NROs were provided with nonnegotiated reports. Considering the authoritativeness assigned to medical images. the four NROs would sit behind a radiologist who gave 'live' interpretations of the images. Only with little exceptions does it not make complete narrative 'sense' as the development of one (or several concomitant) diseases. and the temporal dimension is central to the characterisation of the disease.adjusted 'on the spot'.

According to Lise. One such report was Friedrich’s. The NRO. thus having little to add to the histopathologists’ interpretations. The use of this mechanism was also evident where clinical reports were concerned. Negotiation was less apposite where histopathology reports were concerned. the NROs tended to regard themselves as more competent in reading MRI pictures than in the deciphering of cellular formations. The NRO. while the MRI report remained 'incomprehensible'. interpretation. tended to be vague and obscure. performed a dual role in the web of expertise: once as a compiling expert and once as a clinical reporting expert. the importance of the histopathology report was often only tangential to decisions on 126 . one may recall. and thereby as being more rigid to processes of negotiation. She advised Friedrich to phone her the subsequent Monday for a more definite answer. Thirdly. the clinical picture suggested a slowing down of the tumour's progression. which were delivered also orally. when clinically evaluating one particular patient. the histopathology as involving a report lesser was degree customarily of human communicated solely in writing. unlike MRI reports. The highly negotiable nature of the imaging report permitted the team to agree that the MRI showed some decrease in the tumour's size. Secondly. emphasising the fact that he had recently received treatment. could thus favour interpretations that were most consistent with his/her overall preconceived impression. Hence. First. In the course of Sunday's meeting. Lise briefed the radiologist on Friedrich's clinical improvement. Finally. histopathology was conceived.Black Butterflies MRI-NRO meeting. overall. some degree of compatibility could already have been incorporated into the reports. by the time the file reached the NRO as the compiling expert. facilitating the reaching of the meta-diagnosis.

holding her face in her two hands. mumbling: "OK…right. he referred her to a dermatologist: "it could be a different problem". he concluded. Franz interrupted her short monologue: "That. Looking carefully at the MRI.. Gross treatment. 127 . he was almost literally told what he 'should' be feeling..Sky E. was told by Franz that "the latest MRI shows [she is] doing better". Lise: "It's… I don't think it's really something". 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!". Misha. Lise asserted: "I don't believe you should feel any change" Misha: "Well. Negotiation was also present in clinical exchanges with the patients. I do have some headaches…". As she attempted to persuade him that her pain was real. Now almost completely blind. and conseqently abided to this normative statement. a 52 year old woman with a highly malignant cancer. I can’t explain". a symptom now completely discredited. Peripheralising Sofya. and was conducted significantly less frequently than radiology tests." The headaches. For instance. when Misha came to hear about his latest MRI and discuss his condition. were never brought up again. The MRI showed that the tumour had slightly grown over the last two months.

2004). The patient will then be offered supportive and palliative care. explain away the 'hair ache' without openly dismissing the patient’s complaints on the one hand. This 128 . Such objects could then serve either as contextualisations of the meta-diagnosis or as evidence of its accuracy. This being the case. in some cases. Phillips and Reid. As these objects belonged to a sphere of expertise defined as 'independent'.Black Butterflies Here.e. providing the NROs a certain degree of slack in their meta-diagnostic work. alternatively. This dermatology-mediated object could then be incorporated into the view of the neuro-oncological disease. the independent expert was sought once a diagnostic element could not be accounted for within the neurooncological sphere: the dermatologist could. Only one fifth will be expected to survive for more than five years (Coldman. seem somewhat less crucial.i. They include a few forms of chemotherapy. extrinsic rather than intrinsic – the NRO held considerable leisure in their re-interpretation or. Pragmatism In neuro-oncology. and relatively little room for intense radiotherapy. was to a the place of independent-expert-mediated objects large extent assigned by the compiling expert. as in other cases. Overall. 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. typically in a hospice or among his/her relatives. In practice. their thrusting aside. however. a limited array of surgical interventions. treatment options are comparatively scarce. the NRO usually ceases to be involved.. or challenge the already wellestablished diagnosis on the other. once treatment options run out. albeit in its periphery. elaborate and minute diagnosis may.

more often than not.this after five years of follow-up. spent months visiting the clinic without showing any interest as to whether his tumour was graded III or IV. for example. Recently diagnosed patients tended to use the more hesitant "I was diagnosed with…" than the definite "I have…". however. In effect. a 84 year old woman. a large dose of the most common steroid used in brain cancer: dexamethazole©. Treatment prospects seemed more salient: "Will I have to go through chemo?" "Will I lose my hair?". formal diagnosis remained futile. or 'the lump'. At this point. "Am I doing better?"). Although undoubtedly aware of the grading system. to rather refer to hazy notions such as 'my condition'. Gross was the case with Grushka. we are still unsure of its exact nature" was a classical opening. Indeed. i. beyond general notions of improvement or degradation ("Has it grown?". she will be given something for her symptoms. As a rule. Oren. Simon. In line with the 129 .e. was surprised to hear me refer to the 'oncology clinic' when we set a location for an interview. and. for example. avoided using the term 'cancer'. rather. The group was unanymous: she will not have her tumour biopsied. patients themselves were little interested in precise diagnosis. Both patients and physicians entered a sort of unspoken pact. Patients rarely demanded much more details. for many patients. he "never thought of asking".Sky E. He said he never noticed it was a clinic that "also deals with cancer". the neuro-oncology clinic saw patients only once a brain-tumour diagnosis was reasonably established. whose precise type and grade of tumour were unknown. where the precise diagnosis was regarded by both as merely tentative. the diagnosis remained vague: "There is a finding in your brain.

In the course of more than one hundred such consultations observed. under any variation. 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. only a few patients inquired into expected consequences of their diagnoses: the "how long do I have. but we have to do what needs to be done". one of the younger patients. In the case of Alexey. told me he read "a lot" about his condition. Physicians themselves never went beyond a general: "it’s all just statistics". as far as patient-physician interaction was concerned. or I must have missed this line [where life expectancy was mentioned]…". doc?" question was never raised. prognostic information was only vaguely sought. In fact. "We’re never sure of anything. precise diagnosis did not serve any prognostic aim.Black Butterflies "pact". rather than "will I live?". While family members did occasionally sought online information on the expected lifespan of their loved-ones ("for practical reasons". When at all. or "each case its own". an 18 year old boy. a computer programmer well acquainted with the web. As to his life expectancy: "Really?! Do they [the websites] say anything about that?! It must be in small letters. Although aware of many aspects of 130 . he would go on and on about becoming a physician. they would typically claim). with a "can this be treated?".

as far as the NRO was concerned. Patients were then less concerned about the precise nature of the neuro-oncological aspect of their disease. These were referred to the clinic after the treating oncologist (being. As far as I'm concerned. Gabriel. like many other patients. The disease may itself be loosely defined as belonging to a more general diagnostical category. This trend was also evident among another significant group of patients. during which he will probably be increasingly handicapped. NROs often favoured the use of as little information as needed for the determination of the most 131 . In these cases. I don't need to know anything beyond the tip of my nose [places his finger on his nose]". here. However. he seemed completely oblivious to the fact that his life expectancy was of a year or so. as the presence of metastases remained an almost definite death sentence. 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. the compiling expert) suspected the presence of cerebral metastases. Gross his condition. focusing on treatment options and palliative care rather than on elaborate diagnostic undertakings. active or stable. The prospect of medical school was poor. 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. the neuro-oncologist (here. a 66 year old man. as was his life prospects in general. he would simply deny this reality.Sky E. a more pragmatic approach was be adopted. At this point. Also.

and involve highly heterogeneous epistemological forms. this stance of pragmatism typically involved tacit avoidance of definite and elaborate diagnosis. stating. this study demonstrated the significance of the web of expertise in the production of diagnosis. being little aware of the looseness of its epistemological grounds. The ability to witness the processes of diagnosis from various angles. little research was based on thick descriptions of expert exchanges in the backstages of a hospital setting. the undertaking of diagnosis. Still. for example. whether the tumour was defined as a grade-IV or –III. In practice. This was in many cases. whether a glioblastoma multiforme or an anaplastic astrocytoma. most particularly where the latter tends to be ubiquitous. an official diagnosis invariably appeared on the reports.e. the NROs accepted the fluidity of this definition and proceeded to consider treatment options. While widely acknowledged in past literature. This process of alignment usually involved reporting and independent experts: these would typically treat this diagnosis as ascertained. pragmatic considerations could eventually have some bearing on the overall diagnostic process: once a tentative object of disease was defined.Black Butterflies advantageous course of therapy. while unspoken. including different actors and different settings. which the NROs regarded as of weak empirical validity. i. however. 132 . In these cases. Concluding Words As part of a larger attempt to consider issues of dynamics of knowledge and their relation to social phenomena. Perhaps most interestingly. allowed for a thorough and detailed presentation and schematisation of the microdynamics of a central aspect of medical work. other forms of diagnosis could align. little more than a bureaucratic formality.

phenognostic forms of knowledge). Participant observation of the insitu workings of the clinic suggested that this reification involved. yet mesmerising way. this work was narrated in a way that suggests the presence of a similar bias.Sky E. expert gaze incorporates sets of epistemologies and technologies. One cannot. both of which mediate diagnosis and reduce a multileveled phenomenon into one single manageable object. and pragmatism. and concepts. and with different sets of expert relations. to give them more time with their family and loved ones. All being said about the ontognostic 'reality' of these 'objects of disease'. sequencing. by reflecting biomedicine’s utopian vision of diagnosis as sterile from non-scientific spheres (e. 133 . some more in comfort than others. or less painfully ended. through mechanisms of diagnosis and decision-making. prolonged. role in The replicated both flows of artefacts. the use of five mechanisms of consolidation: hierarchisation. that actual. Many of the patients discussed here died before this manuscript was finalised. it is through exchanges between experts. It is through dynamics of knowledge exchange. experienced lives are altered.g. it eventually comes down to the effort to save patients’ lives. emphasising the complexity of diagnostic work. negotiation. peripheralising. Yet. The analysis presented here may seem abstract. I propose concluding with an afterthought. Gross As defined above. In an ironic. These mechanisms were shown to involve different cases at different conjunctures. to make their last moments more bearable. Others will soon die. and expert interpretations among experts were shown to have an important asserting reporting independent authoritativeness. of human exchange that the enterprise sustains itself. on the part of the compiling experts. but also in reifying the legitimacy of neurooncology as a compiling expertise.

technology. brain is both the assigned locus of phenognostic knowledge. 134 . epistemology. This section will be based on a notion of the brain as an intermediary between matter and consciousness.Black Butterflies and indeed should not. or objective insularity. in the suffering. A discussion of these very issues will stand at the centre of a later section of this work. They are encroached in the flesh. and an ontognostically observable 'thing'. when the individuality and subjective depth of one particular patient will be brought to the fore. in the existence of actual men and women. symbols. and eventually the experts themselves. lose sight of the fact that ethos. do not live in an abstract world of theory. it thus only makes sense to place the brain at a most significant juncture of this work.

g. are challenged as to their objectivity by the reductive discourse of the doctor. as a dominant discourse of modernity. 1981. Lanigan. discarding the latter (e. (Foucault. with its tensions and its burnings. Scheper-Hughes and Lock.Sky E. ontognostic entity (e. 1995a. this tendency toward objectification will have biomedicine centre its attention upon the body as a material.thus the articulation of medical language and its object will appear as a single figure".g. 1994. the silent world of the entrails. Indeed. associating biomedicine’s practices and epistemological bases with stances of depersonalisation and objectification of the patient (e. Scambler and Higgs. a significant range of research has accumulated. Merleau-Ponty. as well as established as multiple objects meeting his positive gaze…. observable through expanding scientific 135 . 1998). 1962. Lock. Eisenberg 1977. Gross Part V: The Brain Exposed On Neurosurgery and the Nature of Objectification Introduction "The presence of disease in the body. over the last decades. 1997). Cartwright. modern Western culture has always held an intricate view of the body: while still being considered as an object among others. 1975: XI) As described earlier in this work. 1987. Mishler et al. 1956. where it would be treated as a machine. 1995. 1995b). Thornquist. the body will keep its singular phenognostic status as the locus of a subjective consciousness (Sartre. Dew 2001). tends to refer to the body in terms of the former. the whole dark underside of the body lined with endless unseeing dreams. Martin.g. Focusing upon this dualist epistemology. Arguably. 1997. social studies have repeatedly shown how biomedicine.

1999). 1994). the observable and ontognostically-graspable body will take precedence over which remains beyond biomedical epistemological reach. Barry et al.Black Butterflies technologies and knowledge (e. 1984. as if a necessary 136 . Good. lived aspect of the body. Turner. Arney and Bergen 1984. The split between experience and the body is perhaps most salient in studies of patient-physician interactions (Murphy. Wiltshire. 1994. Young. As the former will relate to the body in abstract decontextualising terms. subjective experience (Babbie 1970. According to this claim. 1992. 1997. Indeed. Walters. subjective. 1990. personal aspects of human existence. in important works studying the body as a site of conjunction between the two spheres (e. 1992. 2004). and the portrayal of biomedical epistemology as reductionist and materialistic is by now little questioned. 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. the researcher is typically portrayed as more aware to the phenognostic. Synott. and thus favouring the ontognostic over the phenognostic. Armstrong. 1990. 1990.. Csordas. An overbearing claim – albeit often implicit – in these texts is that since medicine seems to disregard this life-world. or by applying more sensitivity toward the complex. 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. Toombs. 1984. i. Csordas. These lines of argument have become the dominant voice in broad areas of social study of biomedicine.e. 1994). 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). 2001).g. 1993. 1983.g.

however is not a mere pre-discusive form. It is a discursive power in and on itself.power. I will argue that one cannot. Any participant observation in the social studies of medicine will have to address this issue prior to the actual insertion into the field. If the body is imbedded in contexts within which it appears. necessarily applied unless 'disciplined' by ontognosis. It is. Rather. Haraway. and if dependent on its characteristics and positions. it is neither a constant position. The researcher. exclude the researcher from these microdynamics. Phenognosis. This means that a phenognostic-based attitude toward the 'other' is not a mere default position. alternating subject and object positions. nor is it a necessary by-product of epistemological. Although biomedicine might indeed use a dualist. Taking this a step forward. and definitions as either patient or person (Berg and Akrich. the patient is defined and redefined in interactions. historical. as I have argued before. Berg and Akrich. 2004). which requires fit contexts upon which to attach itself in order to gather – and retain. 137 . technological.. held in nonmedicalised settings by not medically-socialised individuals. 1991. both ethnographer and biomedical practitioner will find themselves in transition between stances of objectification and empathy. however reflexive and empathetic. or even political characteristics of the profession. passive and active stances.Sky E. Gross consequence of his/her position (e. Featherstone et al. 2004). a consequential discursive force. 1991. and must not. or materialistic view of the person. is hardly immune to objectification tendencies.g.

I gradually took on the role of a confident and provided some of the mental and emotional support he desperately sought. 1988). while becoming increasingly intimate with both him and his close ones. In an attempt to understand this fluctuation in my stance toward him. it seems the complexities of our relationship would be taken to their extreme. Tied with the development of his illness trajectory. where a last attempt to prolong his life was undertaken. as an illness (Kleinman. Six months of intensive participant observation pursued by a year-long follow-up allowed a close rapport to develop. I also had continual access to the purely biomedical aspects of his condition this by attending staff meetings where his case. As I accompanied this 32 year old man throughout his battle with brain cancer. Along parallel. was discussed. as a lay (i. to some extent. among others. There. 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. a friend.e. non-medical) researcher with strong personal relationships with the subject. and eventually accompanied him into the surgery room where I would witness his brain exposed. I attended the many clinical exchanges he had along the way. Ivan became a principal research subject and. An interesting feature of this case is that. I use this essay to reveal my internalisation of different roles. at others.Black Butterflies Methodological Notes my own relationship with Ivan 10. I depict the ways in which my own experience 10 As with all names mentioned throughout this work. an informant encountered in the I will present this movement using a first-person narrative of course of my fieldwork at the neuro-oncology clinic. this is a pseudonym 138 . at times as part of the clinical team.

Turner. It is the site in which all bodily activities. brain-dead individuals The idea of replication of boundaries is discussed in the introductory chapter and will be developed here at later stages of the analysis. but also more promising: The Brain. It is where subjectivity and objectivity ultimately link: a conceptual pineal gland. the social is imbedded in the body (e. The Sacred Brain: The Matter of the Gnostic Split The brain is not just another body part. 1962) the brain is where 'the world'. Social science literature has brought us several illustrations for the centrality of the brain in biomedicine. cognitive and emotional processing take place. I shall claim that one organ holds particular features. sensual perceptions. Its ontognostic components are further based on the concept of efficient causation – of biological processes being linked together as sequences of cause and effect. 11 139 . 'the self' all meet. However. These elements may be discerned in many arenas where the body prevails. Frank. It is the source of action and the endpoint of both internal and external sensory input. according to some theories. features which make the analysis around it more complex.Sky E.g. and as made ever more evident in this work. 'the other'. and the point which every bodily process eventually affects. The brain plays a central part in this anatomical-causal complex. 1990. Gross was altered by replicated 11 ritualistic and symbolic elements. often said to serve as facilitating medical objectification. Western medical thought is largely based on an organoriented view. 1992) and the body is what is situated in the world (Merleau-Ponty. If. First may be the conviction that. in being both the causal source of every bodily process (from blood circulation to muscle coordination). although biologically viable.

Black Butterflies have lost their personhood or humanhood. having nothing to do with his/her perceived 'self' (i. Feinberg. 2002). Webb. 2000.g. patients may go as far as calling this limb by a name. pain. such as in cases of phantom limb syndrome. of the self" into the latter. rather than the body as a whole. again providing a vivid instance of brain's domination over the body. 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.. such as 'Joe' or 'Mary' (Sacks. 1985. 1994. Tsementzis. the brain can have primacy over the body. 2006). when cerebrally activated. Greenberg et al. holds paramount significance in the definition of selfhood and subjectivity. This phenomenon may be explained by the presence of neuronal representation of the arm or leg at the level of the brain. Another example can be found in Popper and Eccles' work (1977:177). 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. when the brain creates a seeming perception of one's body.. A related (and. 140 . which.e. This phenomenon has its source on disorders of brain activity. This takes place when a person's limb 'feels' like an external object 'glued' onto one's body. for instance. In these cases. 1998:1). tingling) as having their source in the limb removed. 2002). can 'feel' as the 'real thing'. and can be referred to as beating heart cadavers or neomorts (Youngner. Kaufman. Then. 1989. OkhuniTierny et al. 2000. reverse) condition is of 'asomatognosia'. 1998). in a way. This leads amputees to experience sensations (e. At a different level. the brain. and "the paramount cultural and material importance of the mind" (Webb. The central position of the brain in Western society can also be seen in its cultural emphasis on reflexivity. Lock. external to the brain.

asked me whether I knew a 'Ivan 141 . mostly nurses and other hospital employees. The day of our first interview.Sky E. 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. I shall turn to the analysis of these dimensions. Gross This idea of the brain as the apex of subjective/objective liminality. calling out my name and describing me to the security man. ten minutes into the interview he left the table to freshen up in the bathroom. he immediately asked for me. was incidentally the day when Ivan experienced the first epileptic seizure he had in the last two years. however. 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". he collapsed. replicating the liminality and the boundaries created as a result of this liminality. will have clear ritualistic expressions in the surgery room. As I was later told. He was diagnosed in 1999. It will create multiple dimensions within which the subjective will be dealt with. On his way back. he regained consciousness surrounded by strangers. We were now at the end of 2006. set at a coffee house near the hospital. Based on the following ethnographic description. a type of brain cancer with a life expectancy of seven to ten years. The latter reached the coffee house and almost out of breath. he was probably emotionally drained from having to recall his seven years experience with brain cancer and. As far as I could gather from the situation. The Story 'Prelude' I had barely begun my fieldwork when I met Ivan. Lying on the floor of the staircases.

while I remained indecisive. we were to spend the next seven hours together. although continuously troubled by the question: was this a purely bodily phenomenon – with its own causes and effects . a fact which explained the seizure. as The Truth? In medical terms. however.or was I to take Ivan's account as a fact. There was little need for professional deciphering: the tumour grew considerably. 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 was the tumour "having its will when it had its will".at the centre. there was little doubt that Ivan's condition was deteriorating.Black Butterflies Katz'. On the day of this dramatic interview. I would be the first to see the image. It 142 . 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. I knew that the seizure was a clear sign of relapse. There. "He doesn't feel well" was all he said as he was leading me to the staircases. I was well aware of that. The following year would be his last. As to my question on the specific episode and its timing. as I regularly participated in staff meetings. usually reserved for staff members. Ivan had an MRI taken. Later this week. backstage observer. 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. As a behind-the-scene. as my research placed Ivan –rather than the medical team. However. I was told a few days later that the chemotherapy ceased to be efficient and that his tumour was growing. We were able to use – unquestioned – the back entrance. Ivan would continue to see this as a direct reaction to his emotional experience.

subject and body. he became hemiparetic 12 and suffered an almost his body. now in Tel Aviv. his hair fell out. and very much dualistic. now up to a five times a day. which spoke of the disease. more aggressive treatment became inescapable: Ivan went through radiotherapy. and the personal. and an embodied subject. refused to give up without what he considered as a fair fight. sending cues in the forms of signs and symptoms. aware of his condition). the team offered one additional surgical intervention in order to remove a part of the tumour. Toward the end of the year. They had nothing else to offer. the Jerusalem team gave up on treatment. typically leaving the other completely functioning 143 . complete loss of sensory and motor capacities on the right side of 12 A neural weakness on one side of the body. seeking advice. he gradually lost his ability to communicate properly. they thought.Sky E. After the last chemotherapy round turned out to be almost lethal. As the months went by. The disjunction became ever clearer: Ivan was both a talking corpse. might possibly allow for the chemotherapy to be more effective. at least consciously. Gross would have merged which has become the two spheres within which I operated: the professional. perspective became omnipresent in all exchanges related to him: Ivan was both person and patient. to remember phone numbers. eventually mediating the knowledge of his disease via his conscious self. Ivan. it was the clinical (his seizure) and pathological (the MRI). That. His seizures grew both in intensity and frequency. experience-focused (thus perhaps more phenognosis-inclined). even while Ivan still did not (as he was not. biomedical (and thus ontognosis-oriented). This double. He and his family turned to another hospital. to focus his sight. The surgery was to take place a month later. At another level. Palliative care was all that remained. however. There.

In 144 . I could only speak figuratively. His brain said nothing. and as to whether he would have had the same request was another organ the target of surgery. the size of his brain had more to do with the space-occupying presence of the tumour. On the top of his head were scattered a few chick hairs. a bit detached. I myself could now hardly recall the way he looked 'before'. as if it reflected his intelligence. I looked curiously. and a long purplish scar at the centre of which stood a bulging bump of fatty tissue– both remainders of his first surgery. when his body did not declare that it was a cancer patient's.Black Butterflies Ivan was amused when I first asked him whether I could join in on the operation. The S-day The morning of the surgery. The increasing doses of steroids had his face so puffed-up that he looked like a giant squirrel. at this grotesque figure being wheeled to the OR. 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. or to my understanding of him. Sadly. I wondered whether knowing what his brain looked like would add anything to his understanding of himself. huge bold blemishes. As far as I was concerned. and swore me to talk to him afterwards about "what [he] looks like inside". eight years ago. the baring of the 'organ of the self' bared nothing of his 'self'. He dared me to go through this. he responded that "it wouldn't have been that cool". 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. on how large his brain was. his hands nervously petting his skull. and right after Ivan’s brain surgery. When I inquired about it. and tong in cheek.

As if suddenly awakening us all. I kept asking myself who this body was. even now. We reminded ourselves of the evening Ivan. He now did not only feel like a cancer patient. Not able to make genuine eye contact with him. and whether it was at all somebody's. Reaching the door to the surgical area symbolised the breaking of our serene silence and sense of 'normality'. Gross fact. So little snow ever falls in Israel. that we were all three captivated by the scene. the nurse abruptly halted. at others immersed in his experience. I had to remember to hold Ivan's left hand rather than his right. as we were chatting about this and that. in these moments. He looked at me and made a slight attempt to smile from time to time. where patients were kept and monitored right before and after surgery. as I was about to cross into the biomedical realm. and I spent at the hospital inn (where he was staying for the course of his radiotherapy). I followed the wheeled bed down the elevator along with his parents and sister. in tears. firmly instructing us to be careful not to cross this boundary and to say our goodbyes now. as Ivan bought his first hat. 145 . he looked like a cancer patient. There. after having lost most of his hair. his mother. all clinical details of his case seemed to evade my mind – I was with him. rather than as a patient. I followed the nurse to the Intensive Care Unit (ICU). he proudly told me how he "gave the man [the salesperson] a heart attack" when telling him he was buying it "for the radiations". here. Throughout. at times detached. but raising his heavy eyelids seemed extremely painful. Ivan ran to the window: Jerusalem was covered with a white blanket of snow. The family kissed Ivan. as if reminding me to treat him as a friend. and asked me.Sky E. where he was completely insensitive to touch. to take care of him. but somehow.

I quietly arranged his pillow – this familiar (albeit futile). I answered that I was a doctoral student conducting anthropological research at the neuro-oncology clinic in Jerusalem. 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. He smiled and replied "of course. his gaze pierced my eyes: "and who are you?". the surgeon then arrived. a fact compatible with the analysis of his position in relation to the the replicated boundaries as provided later in this text. As he approached the bed. gesture of concern. short. Treating me as courteously as 146 . impressive man wearing his 'scrubs'. a young. I used the medical jargon I knew so well by now. only at this point. the anaesthesiologist approached his bed and began asking questions. As I rubbed his good arm. The scarce attention he gave to my response seemed to reflect his lack of interest in 'gatekeeping'. efficiently phrased information. Ivan’s bed was positioned between two other patients’. My answers surprised the anaesthesiologist who. and provided clear. I explained my position as an anthropologist. I immediately stressed that I was given permission by Professor Zosima (the head surgeon) to attend to surgery. Since Ivan found it difficult to answer -his speech being highly hindered at this point – I intervened and answered myself. asked me who I was. His eyes still painfully shut. Much more careful as a gatekeeper. he announced Ivan that he will shortly be brought to surgery.Black Butterflies 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). no problem at all". Shortly after Ivan had signed the consent forms (which he could obviously not see at all). and my affiliation to the Jerusalem neuro-oncology team.

I must take off my casual clothing and wear it directly on my bare skin. As I passed through the ICU. 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). I was told by one of the surgeons not to forget to put the hair cap and mask on before entering the OR. my identity in Dantean limbo until I wore the uniform.. Once I have reminded him of my name.. he turned to the nurse again: ". These were available only very near the entrance to the OR. Entering the changing room dressed as a lay person. 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. now my uniform. he called on who turned out to be the OR head nurse: "This is – what is your name again?. I remained there virtually naked for a few moments. and consist of the last piece of garment promising me a place in this in-group.Sky E. 147 . [This is] Sky Gross. were dispensed.". she is from neuro-oncology in [the name of the clinic in Jerusalem]. My position as an outsider would be hidden behind these clothes: fully camouflaged. 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. carefully bagged in plastic.. I could then identify myself and be identified as a member of the biomedical team. she will be joining us. Can you show her where she can get ready?" The nurse reluctantly showed me to the changing area.. Gross one would a guest in his own home. an even more restricted area.

the room gradually turned silent. but Ivan was nonetheless completely absent. The room was relatively free of tension. a head-nurse. a practical nurse. allowing the opening of a fist-wide cavity at the centre of the wound. The cutting revealed 148 . a surgical intern. When the first stage of the actual operation began. draped from head to toe. organising their gear in relative leisure. The skin was pinned to the sides. I found him unconscious. an anaesthesiologist. The staff (which at this point included a junior surgeon. and a neurophysiologist accompanied by his assistant) moved freely around the room. unaware his brain was being picked and probed. his large blue eyes shut with tape. All I could see was an idle body. I applied myself as I followed the knife going over the long crescent-shaped scar and two centimetres further down. His body was at the centre of attention. his body scrapped clean and sterilised. Was he to open his eyes at this moment. anaesthetised. his puffy face concealed. Ivan's bed was wheeled up into the OR and 'prepped' for surgery. an assistant nurse. the material. he would not have seen me. his open skull and his brain. talking. Ivan lost all awareness as the staff completed his transformation into a living corpse.but was rather directed by an acute sense of curiosity. I could see the back of his head.Black Butterflies Under the Skin As I was struggling with the hair cap – reminding me how little I 'really' belonged there. I remained standing over the orifice. from accompanying him to accompanying the surgeons. feeling surprisingly little awe or disgust -as one would perhaps expect from an 'outsider'. graspable loci of his subjectivity. Deep into the realm of idle objects. From where I was now standing. nor would he have recognised me behind my mask. as both were insensitive. I could not pet neither of his arms now. As Ivan increasingly waned as a subject I shifted roles. Upon joining the staff.

Although I never questioned the subjective truth he communicated. still. For me. kept the majestic organ in. I could empathise with his pain as he moaned and groaned.Sky E. the visible seemed to provide me more 'evidence'. the brain herniated and literally broke out into the open air. The staff showed interest in the unusual extent of the phenomenon. yet something about the sight of this bulging lump of flesh made it more 'real'. albeit at a less central position. only a thin layer of tissue. he sat on a high chair. When I heard his mother tell me. and seemed thus more authoritative. only once objectification reached its peak did the head surgeon make his appearance. material phenomena over patients' reports. Swollen and eager to escape its captivity. He sat on a similar chair. carefully prepared in advance. I found this portrayal curious. literally. the physical. In the surgery room. The junior surgeon also took a sitting position at this time. a remainder of the previous intervention. I held on to a model that is classically claimed to pertain to the world of physicians: valuing visible. For instance. 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. the ritualistic aspects of surgery became more dominant. covered with a sterilised sheet. As the two junior surgeons removed the white eggshell pieces and dropped them into the stainless steel bowl. the ontognostic. beside (rather than directly behind) 149 . the dura. Gross five pieces of bone stapled as to form a sort of jigsaw puzzle. The Peak of Surgery As the team was getting closer to the handling of the actual brain – and entering deeper into the body. After intensive and extensive scrubbing. and she was afraid his brain will 'leak out'. curiously resembling a king's throne. a year before that her son's head was a closed box.

except for a beam of pale light illuminating Ivan's Skull. I felt I had developed a relationship with Ivan's brain. the 'it' and the 'he' are interchangeable 13 150 . I knew how the brain looked like. but I did not know how Ivan's brain would look like. like Ivan. The LCD screens. still. the head surgeon could observe a live MRI picture of Ivan's brain as he inserted his instruments. Time went by as the surgeons were methodically vacuuming tumour tissue and were carefully closing blood vessels. From one of the screens. Other members of the team remained standing. At this point. Seeing the brain without seeing the mind. This was perhaps most striking when the surgeon showed the latest MRI image on the screen: its shape.Black Butterflies Ivan's head. It did not. I remember the remark. its shades of grey were all-too familiar as I recalled the many staff meetings it had appeared in. the mind is nowhere to be found. which made the team giggle: Impressed by the tumour's current size. Ivan the person. I had almost as many direct encounters with Ivan's brain as with Ivan himself. were turned on. Was I taking lightly the sight of In Hebrew. He then set 'coordinates' which will serve him in the spatial handling of this complex organ. observing its actuality. its fleshiness. a relationship that was in many ways independent of its carrier. At some level. one has to admit: in the OR. I found myself disenchanted. with some level of freedom of movement which was only rarely taken advantage of. from which the site of the operation was 'broadcasted' to the OR audience. and tensed. and I became increasingly focused on the physical biological presentation of the tumour. in the course of the last eighteen months. the OR became silent. I expected it to look like him. As I was to realise later on. as if I had been speaking of a child. The lights were turned off. After all. I said I knew it 13 "since it was this little!".

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. including the detrimental health impact receiving bad prognosis can have. and thus localise functions in the areas neighbouring the site of intervention.Sky E. however. as the surgeon moved an electrode on the surface of Ivan's brain. prognosis is a form of knowledge which is habitually held away from patients. was decisively too deteriorated and the idea was abandoned hours before the intervention. and manage his condition without burdening him with details he is not able to deal with (such as one's impending death). Ivan had to be treated as an ontognostic source: a more 'objective' – and objectifying—measure was used. prognostic information (and at times. His condition. In cases of life-threatening brain cancer. unwelcomed by the patient. and this for various reasons. Ivan's surgery was planned to be performed thus. Gross this immense lump slowly killing a beloved person? Was I talking about Ivan at all? As discussed earlier in this work. although often not explicitly. 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. since his tumour layed in the midst of critical senso-motor function areas. As his phenognostic account became of little value. and. and a neurophysiologist was asked to join the team. the neurophysiologist reported on movements detected .meaning essential motor tissue was stimulated. Ivan's body was 151 . Wires were attached to Ivan's legs. even diagnosis) is clearly. The latter expects his physician to act as a 'responsible adult'.

the 152 . volumes. 1975:8). (Foucault. The clinical gaze involves the creation of a spatial dimension which will create the disease as an entity.e. and movement became freer. lights were turned on again. source of knowledge into his own wellbeing. making the mediation of a subject redundant. surfaces. As the pieces of bone were placed back and the skin stapled. my mediation was little needed. 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. the head surgeon told the juniors to "close him up" and left the room. and routes are laid down. While perhaps not unusual in the field of medical diagnosis. the body as an ontognostic-based 'thing': "… a space whose lines. in accordance with a now familiar geometry. the younger surgeons included me in their small talk. Closing up: The last stages Once the thrust of the surgical intervention (i. reporting to the family whether Ivan was awake. palpable. and supervision was loosen. Overall. that the functions observed were speech and movement (both typically associated with purposeful volition). the fact that the organ involved in this latitude-longitude definition was the brain. Once alll would have access to Ivan as a tangible. and that the process took place in 'real-time' made this event particularly intriguing. the removal of tumour tissue) over. by the anatomical atlas". since only once he regained consciousness were family members (one at a time) allowed in. As if now having gone through an initiation ritual.Black Butterflies electronically probed and mapped.

it was only a few hours later. Only when directly questioned did he admit that. Gross tension was released. focusing on concerns that are particularly meaningful to the teller. during which I remained standing – directly looking into Ivan's skull. Gross. 2009b). i. The despair with the intractability of his condition and "the impossible mess the tumour made in his brain" was reserved to backstage discussions. once having taken off 'my scrubs'. Again. cables and electronic devices were removed.Sky E. they will not be able to offer him any more chemotherapy. one important aspect of narratives is that they are typically told in hindsight. However. It was as if I now returned to myself as a lay person. the surgeon gave a relatively reassuring impression: Ivan survived and the surgery did buy him some more time. Thus. not only mentally but also in terms of how my body felt to me. The operation lasted more than five hours. Not entering into details. which he will spend in nursing and palliative care.e. leaving the hospital. Just a Story The account of the past is almost inevitably tainted with current interpretative schemes. Williams. 2008. I knew what my informants did not: the surgery was in vain – this serious and dangerous intervention only gave Ivan a few more weeks. 2008. which makes past events appear as if naturally leading to the 'now' as it is understood (Mattingly. The 153 . considering what they observed in surgery. and Ivan's face and body were again visible. masks were taken off. I followed the head surgeon as he went over to discuss the operation with Ivan's parents. 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.

1966. 1960. that these contexts all involved some extent of boundary definition (replicated in the conceptual.e. The OR is also a space where states of liminalities are omnipresent. 1990.Black Butterflies 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. professional. 1985. 2004). Second. Foucault. and to thereby justify current claims: First. 1975. Moreira. This is where the invisible becomes visible. a state of simultaneous presence (as a body) and absence (as a person). It also allowed me to create a common thread of meaning around a series of noteworthy moments or 'events' (Polanyi. and between forms of 'presence': i. Goffman. Liminalities and Replicated Boundaries The OR as a Space of Multiple Liminalities The OR might be regarded as the epitome of biomedical practice. I shall now like to unfold some of these points as they arose in the field. 154 . And finally. 1995). Mattingly. Turner. 1969). 1998). the inaccessible accessible. as restricted both physically and symbolically from everyday life. and most particularly liminalities where scientific thinking ceases to exert its conceptual control (Van-Gennep. spatial. that my experiencing and perceiving of Ivan as a subject and object was of a fluctuating nature.g. that this reflected on and was reflected by contextual elements within which our interactions took place. symbolic layers) between two seemingly opposite sources of Truth: phenognosis and ontognosis. 1954. Douglas. This includes the patient oscillating between life and death. 1961b. Becker and Kaufman. and as they relate to recent and contemporary work in adjacent subjects. and secluded from the less distinct areas of the hospital (e. Wilson.

They may also convert mundane objects into entities that belong to the 'sacred' and are thus less likely to form objects of liminality. more particularly the distinction between things that belong and things that do not belong in the OR. 1992). been directly attempted. and 155 .Sky E. to my own knowledge. 1983. 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. Katz and Kirkland. Here. Gross This liminality and confusion of categories demand a clear ordering of things through elaborate rituals. Katz. Hirschauer. I shall advance the idea according to which the gnostic split is symbolically. Rituals. Hahn and Gaines. and while the issues of purity and danger (and their relations to social practices and categories) constitute one of the pillars of cultural anthropology. As has been well shown in previous studies (e. van der Geest. 1981. 1985. 1991). Felker. when transformed from a sentient whole into an operable body. While the discussion of objectification in medical contexts is omnipresent in the social sciences of medicine. the wedding of the two subject of interest has never. 1979. the sacrosanct of biomedicine. OR rituals are associated with the need to facilitate the transition between categories of things by clarifying their distinction.g. can do more than create boundaries. Along with specific rules and practices. 2005). 1981. 1988). however. 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'. Fox. 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. 1982. For instance. practically. the patient can be allowed into the OR (Katz.

In this shrine of objectivity. boundaries cannot and will not remain blurred: surgical intervention is the pure manipulation of matter. In all three cases. dominate. of inside and outside which boundaries must be reinforced and safeguarded. e. however. between an 'ontognostic neurology' and a 'phenognostic psychiatry'. the subject must be either subdued (anaesthetised). between an ontognostic biomedicine and a holistic. First.Black Butterflies epistemologically replicated as comprising a 'dirty' element (phenognosis) and which can be regarded as its mirror reflection: the 'pure' element of biomedical ontognosis. or subordinated. which 156 . which transforms the sentient self into a passive body. with sterilising practices. The Temple of Ontognosis: The OR Questions of objectification arose in the field around several elements. in settings such as the OR. Whichever is not clearly assigned to this sphere must be either eradicated. as its epistemological resistance contests ontognostic authoritativeness. In the case of surgery. Shuval and Gross (2005). These worked in unison to replicate a movement from the subjective to the objective and from the personal to the biomedical. or made sterile (disinfected). it is not only categories of life and death. 1966). at times 'spiritual'. or restrain phenognostic presence. with anaesthesia. ontognosis will be seen to annihilate. and as shown by Mizrachi.g. hidden (draped). This is in fact much similar to the type of boundaries shown to be drawn and replicated in other layers of the gnostic split. If phenognosis is the matter out of place (Douglas. constrained. approach to the patient. In other words. but also categories of subjectivity and objectivity: of sentient person vs. present body. Second. the subjective will need to be conquered.

1991:91) involves transformative practices in regard to the experience of surgery (Landzelius. with spatial definitions. The "precise and beautifully choreographed ritual" of scrubbing (Cassel. S. sterile. A person is either scrubbed. or gloved. gowned. which create clear boundaries between areas of objectification. 2003). I shall now discuss each of these.] According to Katz (1981) and others (e. More specifically. whether germs are involved or 157 . 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. and gloved. at different stages) and the demand for elaborate scrubbing.g. Keeping Phenognosis Out: Sterility "Rituals exaggerate operating room the discontinuity they proclaim in the and definite categories. with components such as clothing. An instrument is either sterile or nonsterile." (Katz 1981:345-346)[my emphasis.Sky E. not sterile. or he is not scrubbed. Along these lines of arguments. namely in keeping a view of the body as belonging to the world of matter. I will claim for an association between levels of objectification (by different professionals. Third. therefore. it is never almost sterile or mostly sterile. gowned. suggest that these rituals cannot be explained away by simply turning to this 'germ theory'. language and technology associated with this stance. Gross 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).G. Finally. however. and. My observations. 1987). Cassel. therefore. and. Listerism and sterility would play no role other than promoting practical aims of preventing infections.

This was especially curious as I was. stable. occasionally joining me and offering me trivial information on this or that procedure. the more one would be required to be sterile. Interestingly. i. Throughout securely the course and of his Ivan's vital operation. the the anaesthesiologist kept holding his mask rather loosely. Although I did wear a sterilised surgical robe and did put on a mask and cap. he would take on a more religious attitude towards his scrubbing attire. his active presence was required only at the temporal edges of surgery. asked (by the looser gatekeeper: the anaesthesiologist) to touch Ivan by holding a cotton ball over his perfusion wound.e. 158 .Black Butterflies not. repetitive. between dying or viable would be most challenged. 1981:349). I was not asked to wash my hands ("that's OK. that is. Ivan anaesthetised signs anaesthesiologist sat at one corner of the room and engaged in online crossword puzzles. This again suggests that sterility guidelines are not followed in a mere attempt to physically keep things clean of germs. to abide to this "stylisied. arbitrary. you don't have to" the junior surgeon declared). the entering of Ivan into the anaesthetised condition and his gradual emergence into full consciousness: Then. 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 a rule. but it is also then that the boundaries between conscious and unconscious. In more concrete terms: the more one would treat the patient as an object. as well as an insider's. at one point. I was the least sterile. It is then that he would have most contact with Ivan's body. and exaggerated" behaviour (Katz. They are intimately associated with patterns of observance of the place of subjectivity in the OR.

when the critical spectator turns absent. 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. the summary the surgeon14 may give the patient. This is in fact precisely at this point. In submitting him/herself to sedation. as in Ivan's case. and did not offer an analysis based on the observer’s position. 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. By eliminating the patient's subjective presence. they focused rather on the team than on the patient. 2005). Hindmarsch and Pilnick.Sky E. anaesthesia creates a lifeless body to be manipulated. which could not have been enacted in the presence of an 14 Or. as if in the absence of its owner. but to a basin of knowledge and an embodiment of skills: to the praxis as well as to the epistemological soundness of biomedicine. 1961a. When sedated.). The patient often willingly accepts but always ceases to resist the overpowering of his/her own subjective experience (Mizrachi Shuval and Gross. the anaesthesiologist 159 .e. Gross Anaesthesia: Subduing Phenognosis The effect of anaesthesia on objectification is undoubtedly powerful.e. 1994a). The consent forms are typically signed to never be read. a person's state of wellness becomes defined in terms of pulse rates or levels of oxigenisation as shown on a computer screen (Collins. 2002).. In the surgery room. Pilnick and Hindmarsh. never to be really seriously considered. i. 1999. when one is unconscious. Still. the patient surrenders any claims for epistemological supremacy: phenognostic claims cannot be made if subjective knowledge is not generated. that the team is able to make the transition to a backstage form of interaction (Goffman. this faith is not granted ad hominem – i. trust is not bestowed upon a particular person or persons.

160 . It was thus little surprising to see myself perplexed when confronted with instances where my own knowledge regarding Ivan's diagnosis greatly surpassed his. Ivan himself was absent (i. As discussed earlier in this work. 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. including the detrimental health impact receiving bad prognosis can have. I was not impressed that this was merely due to my presence. prognostic information (and at times.e. Backstage. 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. This is a statement that could hardly be made in the presence of a patient or his/her loved ones. alarming news on the patient's surgeon called me over and showed me. anaesthetised) as his death sentence was declared. the head 15 This is also when the team's sense of humor was more readily exercised. that never in reference to Ivan. and manage his condition without burdening him with details he is not able to deal with (such as one's impending death). 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. as in this case. For instance.Black Butterflies outsider: the patient. and this for various reasons. The latter expects his physician to act as a 'responsible adult'. Not certain if the patienttechnical and inside information is more freely communicated 15 – prognosis. However. unwelcomed by the patient. while Ivan was deeply sedated. even diagnosis) is clearly. I must admit. In cases of life-threatening brain cancer. Perhaps most strikingly. prognosis is a form of knowledge which is habitually held away from patients. although often not explicitly. the language becomes more including.

'stable' and 'out of danger'. the ICU. Turner and Turner. I was again to wonder as to the nature of our relationship: As I knowingly withdrew information from him. This backstage stance was increasingly difficult from my position as an ethnographer. Intersubjectivity is present only when two subjects experience a common situation. I could not create an intersubjective relation with what seemed as a 'thing'. Landzelius. If one of the parties become absent. when re-becoming a 'normal body' 161 . as Ivan's subjectivity has been made to disappear. The ICU was where a taxonomic order that has been loosen and endangered in the OR could be reconstructed (Turner. my attitude becomes simply phenomenological – that is. Gross physician 'pact' regarding prognosis applied to me. for example. This stood in contrast to what Alfred Shutz (1970:31) termed the 'we-experience': experiencing the other experiencing. the spatial organisation of the hospital reflects conceptual elements central to biomedicine's epistemological bases. Space and Liminal States As Young (1999) asserted in her work. or made irrelevant. In my study. Still in a state of limbo between life and death. Another issue arose when. 2001). clearly served as a space of transition between the outside and the inside. I found myself in the role of the 'I know.e. and most vulnerable to unforeseeable and rapid deterioration. i. the patient is there followed with elaborate rituals and monitoring. it refused to enter the stream of my own.Sky E.. 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'. based on my own experience of a world of matter. until fully awake. and as described above. 1978. between the sacred and the mundane. 1969.

reporting to the family whether Ivan was awake. 2001). or go native. I 162 . this lack of understanding of the physician’s lifeworld (or verstehen) leads to significant biases in ethnographies of medical settings. the patient may be released to the outer circle of the 'sacred' space: into the ward. 1994b). ontognostic monitoring becomes less essential. it seems little attended to in mainstream social studies of biomedicine. 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. One way to attain a deep understanding of the native’s perspective is to find oneself within this perspective. my mediation was little needed. At the point where there is less danger to the ordering of the orthodox state-of-being (Van Gennep. Whereas this argument seems well developed in other fields of anthropology and ethnography. to the best extent possible. palpable. Landzelius. 1995). and supervision was loosen. intensive surveillance is relieved. and biomedical. Going Native There are other elements affecting my own stance of objectification. and the keeping of an outsider's ('etic') distanced position. elements belonging to one of the oldest concerns of anthropology: the adoption of the research subjects' ('emic') viewpoint.Black Butterflies (Kaufman. 1960. Achieving. Once alll would have access to Ivan as a tangible. According to Collins (1994a. 2000). In an attempt to achieve such an understanding and become an expert observer (Bolton. an emic look into the surgeon's world would then allow a more elaborate and accurate depiction of the field. since only once he regained consciousness were family members (one at a time) allowed in. As life-world modes of interactions become available (the patient regains consciousness and is able to report on his/her subjective experience). source of knowledge into his own wellbeing.

Walters. 1989. In biomedical settings the expert observer will perform as a nativeethnographer. Good. at least partially. and will provide valid contributions. to underrate instrumental aspects of medical practice. Medical education includes the teaching of the ability to keep role distancing. Smith and Kleinman. 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. which might not be available unless abandoning this lay naïveté which is often overbearing in anthropological accounts of medical practice (Collin. this enculturation has also affected my view of Ivan as a subject. I acquainted myself with the different aspects of neuroanatomy and clinical neurology and was able. what Bolton (1995) defined as the inherent bias of non-medically informed anthropologists: The incapability to really understand medicine. 1961. non-physician anthropologists tend to romanticise the physician. Fox. 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. through the internet. 1994b). or hold clinical detachment from patients as human beings (Goffman. It allows physicians not only to treat 163 . This knowledge allowed me to avoid. to watch sequences of both general brain surgery and tumour resection operations.Sky E. For instance. 1979. Considering the methodological advantages of expert observation. Gross undertook an elaborate preparation which included the study of the technical and more theoretical aspects of the profession. thus to really enter the physician’s state of mind. 2004). and overrate the reductionism of medical texts. 1994.

2006). distancing was a fluid state-of-being highly contingent upon the setting. in experience a tension between his 16 position in his disciplinary field the social studies of medicine. 2003. Leder.. When undertaking the task of surgical intervention. 2006) on the positioning in the field of a researcher. the researcher might and his position in the ethnographic setting. Thus. It worked not only upon the 'medically taught' participants. distancing is not only a skill taught in medical school.. Still.Black Butterflies the case more objectively or to be less sensitive to awkward and at time repelling tasks. an attachment that is often emotionally straining (Hafferty. Without having gone through clear medical socialisation to distancing. Here. For me. however. Frank. but not only that. 1980. Most particularly. but upon the lay observer as well. Goodwin et al. so as not to impair the readability of the text 164 . 1992. 1995. as this case shows. It also showed that relating to phenognostic forms of knowledge is 16 I again use the masculine stance here. the specific rituals and symbolic elements work to suppress feelings of identification and compassion. I have focused on the setting itself. one may find oneself holding incompatible ethical imperatives. 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. Good. 1988. There is little doubt as to the effects of professionalisation and disciplinary field (Anspach and Mizrachi. 1994. but also to refrain from developing emotional attachment to patients. as elaborated in Anspach and Mizrachi's work (2006). nor is it simply a form of tacit knowledge acquired through practice. Francis and Lewis 2001). and as seen in this particular field. rather than on the disciplinary or professional background of the different actors. I was still able to sustain the surgery observation without extreme emotional response. Dickson-Swift et al. depending upon the field he regards himself as being a part of (Dingwall.

as well may be one's own body (Gallagher. whether experienced first-hand or scientifically ascertained. the human being learns to regard himself as distinct from the surrounding world. perhaps unavoidable. According to Western tradition. The first relates to the fact that one can only be confident of his own subjective presence: as far as can be ascertained. based on considerations of style and readability. a ground upon which to assert its power and act to apply itself in the field. or the ontognostic third-person perspective which has been made secure by scientific method. the other will seem as an object. While the former view relates to the more detrimental effects of referring to another as an object. there would be two ways of 'knowing the world': the phenognostic first-person perspective which provides subjective certainty. 1934). including his own body (Mead. experienced. This is when he realises himself as a subject facing objects. as it binds attempt to understand the 'other' as a subject. others can 17 Here again. 2000).Sky E. part of one's exchanges with the world. This type of objectification is an inevitable consequence of the gnostic split. understood as a subject? From his 17 very own birth and throughout his infancy. the latter returns to the philosophical fundamentals: can 'the other' really be seen. This problem has been addressed by philosophers. In either way. in terms of daily interactions. Gnostic Shifts and 'Theories of Mind' Objectification can be seen as either 'medicine's biggest fault or. like any other discursive formation. as a natural. namely around notions of solipsism and the presence of a 'theory of mind'. Gross not a 'natural' unquestionable given: it requires. I will use the masculine form 165 .

I will have to treat objectification. including comatose patients (or 'vegetables' accordingly). and perhaps to a larger extent in the OR. these can almost be used interchangeably. However. blending in the crowd) the more he would be objectified (treated like one piece of a faceless whole). and as. I find the 'objectification' preferable 'dehumanisation' outlook. human deemed subjective beings tend to be referred to as 'persons'. According to many philosophers. accordingly). Some will have broader theories of mind to include animals (which may squeak in pain when tortured. being insensitive and nonreactive to pain). dehumanisation as strongly linked notions. Considering the inclusion of non-human categories – such as animals. in the modern Western World.g. ethnic minorities. thereby seeming to have a subjective presence). the aged. having masks over one's face. the more he would be dehumanised. Others will have more limited theories of mind. thus. depersonification.Black Butterflies be automatons claiming to 'feel' and experience an inner world of their own. In the setting of the clinic. foetuses (or 'unborn babies'. opponents in conflicts. The less 'person'-looking one is (e. The less human one 166 . as in the modern Western World 'things' considered as holding subjectivity tend to be anthropomorphised. 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.e. women. 'things' others may consider as objects (i. 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. The idea of a 'theory of mind' turns to the understanding of the mechanisms by which human beings DO ascribe 'minds' to others. wearing uniforms.g. objectify) – in to theories the of mind. etc. 'Others' can alternatively be characters in a dream one would be the protagonist of. and in some religions. More than that: as more 'object'-looking one is (e. being still.

and so on: e. both the biomedical team and myself. The instances where Ivan most resisted objectification were when he looked. and this had deep effects on stances of objectification. and his draped inertness in the OR. disregarding basic taboos. and was treated like a person. his hemiparetic state outside the OR and the effects of anaesthesia inside the OR. 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. acted. and replicated over different layers: This was true on this first day. Conclusions In the case presented here. as well as his cognitive and language processive deteriorating skills. as he was attached to non-biological electronic. as a researcher. words. Again. he acted and appeared as less than a full ideal-type person.g. the boundaries between absolute objectifying distancing and complete personal identification seemed to be in a continual flux. acting 'like an animal'). and mechanical devices (creating a sort of cyborg as the mechanical extended to his own body). Gross acts (being cruel. Not only was his ability to perceive affected by this. With Ivan. It also included the sense in which he was 'reachable'. 167 . sounds. yet basically dualistic attitude. such as touch. digital. eventually found ourselves within a complex. This included his increasingly grotesque appearance as his disease advanced. This had to do with the level of pain he was suffering from. or respondent to communicative stimulations.Sky E. but his ability to respond was as well. as if in a dynamic flip-flop between the patient as object and patient as subject. on both my part and the biomedical staff's. the more he will be depersonalised (and can thus become a target to violent acts of indignation).

The ethnographer is not immune to these influences and might find herself involved in the objectification of her research subjects. Neither is objectification a process limited to biomedical settings. and symbolic elements. This interpretation of exchanges in biomedical spheres points to the inherent tension between these two tendencies (objectification-empathy). 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. often sway from objectification to empathising positions (Fabian. The OR has its own rituals and is in many ways an extension and intensification of biomedical epistemologies. and two phenomenological 168 . 1986. Often defined in terms of a loss of human concern over another. nor is it exclusive to physicians: anyone can objectify anyone. Indeed. objectified body-part (Hirschauer. 1999). and unavoidable part of biomedical work. McNay. undeniable. 1991). Clifford and Marcus. I raised the need for a multi-faceted approach to questions of objectification. depersonalised. objectification is overwhelmingly used in a pejorative tense. and remained no less salient as our relationship developed. taking on the concept of epistemological fluctuation in ethnographic studies of biomedical exchanges. This involves the transformation of a life-world into an object which can be manipulated. In fact. Using insights from my own ethnographic work in a neuro-oncological clinic and a neurosurgical unit. 1986. contingent upon the setting and my own role-taking. Pratt. the tendency toward objectification is affected by ritualistic practices and symbolic elements. Ethnographers. in particular. The patient is then absorbed into a small. Here. I sought to show how it might be a necessary.Black Butterflies when I only knew him as a medical case. 1983. two roles (physician-ethnographer). 1991. two perspectives (biomedical-personal). practices. perhaps no less than biomedical practitioners are claimed to. however. Wiltshire.

necessarily The adopt not a medically-disciplined phenognostic discourse as default: It iself needs to be encroached in a form of knowledge\power in order to sustain itself. The ethnographer does not merely observe. on occasion. nor does she merely participate in transformative rituals.she also experiences them. and forms of rapport. 169 . yet so can be said about the adoption of phenognostically-based actor does not attitudes.Sky E. and is phenomenologically affected by them. Gross states. 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. I claimed that. and highly dependent upon the symbolic and ritualistic setting. the most empathetic actor may take on a position oscillating between these two attitudes. experiences.

reason and emotion. at both ontological and phenomenological levels. both object and site of meaning. I have claimed. I hope. and the inner world of experience. and replicated. This makes it both organ and concept. objective and subjective. the site of the clashing of two ultimate realms: the world-out-there. and the world of academics seeking the understanding of Western society. and theoretical work on the issue has too seldom been undertaken. I suggest. allowed a refinement and elaboration of concepts of scientific vs. and is the ultimate locus of our selves. that a deep and attentive study of the notion of 'brain' is likely to offer unique. the brain can be regarded as an interim. meaningful insight into the fundamental questions troubling the sociocultural world of modern Western society. and the role these forms of knowledge may take in 170 . science. challenged. This work presents instances where these boundaries are encountered. Hence. This clash. or fundamentally 'true'. is not nearly as problematised as one would hope. My contribution wishes to stand precisely within these nascent fields of studies. a colossal pineal gland. knowledge about the brain can never be universal. The understanding of these processes. would be reconceptualised in a way to assert clearly bounded categories: science and non-science. bioethics. thus. discourse. both biological and hermeneutical. history.Black Butterflies Part VI: Conluding Words The Bounded Brain The brain is the apparatus through which we experience the world and relate to it. As shown here. but only interpretational and culturally contingent. Still. the association of the mind-body split with broader social terms such as professions. subjective forms of convictions.

I believe that this served not only to portray research in advanced scholarly language. and to most thoroughly consider their actual contribution to selected bodies of literature and areas of concern. This also demanded an intense focusing on which I considered as the most essential aspects of the phenomena at hand.Sky E. while still holding a substantial empirical range. each with its own empirical foundations. This was shown to represent a case of 'replicated boundaries': an occurrence in which boundaries are drawn and concurrently replicated at several levels.each with its own body of literature and theory. as required in professional academic publishing. In this. Finally. Indeed. The significance of the association of the papers stands at their similarities rather no less than at their diversity. I offered here a first 171 . Somewhat unorthodoxly. Gross both diachronic and synchronic perspectives on the sociocultural world of biomedicine. 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. I proposed a detailed picturing of the adoption and then relegation of psychosurgery as a decreasingly 'purely scientific' ontognostic medical procedure. First. I chose to present this analysis in the form of three relatively independent essays . three fields were chosen as epitomising the theoretical suggestions made throughout this text. 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. to carefully extract the most powerful points I chose to advance. but also to distil my ideas.

1994). phenognosis was sought-after as a site of knowledge to be tamed and conquered by science and biomedicine. In all three cases. Martin. epistemological. where both macro-levels and micro-levels. 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. it was to be kept strictly outside of the practical. Cartesian boundaries were presented not as a philosophical but as a cultural phenomenon: a phenomenon where both professions and rituals. 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. in and around the debate on psychosurgery and in and around complex processes of diagnosis. As mentioned. my aim here 172 .Black Butterflies 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. As it remained still beyond the reach and control of the ontognostic endeavour. Phenognostic resistance to this reduction to the realm of matter created a clear threat to the discourse of objectivism as potentially omniscient. where both institutions and personal thoughts were looked upon to identify the replicated boundaries of 'Truth' around an obstinate gnostic split. as was the case in and around Ivan's brain surgery. rhetorical and symbolical of the ontognostic realm. hence the great attention given to the creation and sustainment of these boundaries. rather than a mere pre-discursive default.

that a number of recent developments have created a more urging need to attend to this conundrum.Sky E. 1998). one thing seems to be clear: Western culture has not yet overcome the gnostic split. 1986. 2000). 1999). after all. 1992. 1996. These include the exponential growth of neurosciences and the rising power of post-modern and New Age epistemologies. I shall claim. 1996. unstable. and despite some exceptions (e.g. Crick and Koch. define. 1990. In terms of its social revelation. and has been overwhelmingly portrayed as the most perplexing epistemological chasm of post-enlightenment society (e. Martin. Williams. Rosenberg. Levine. and still holds on to the two forms of 'truth'. Searle. a clear disparity hangs between philosophical advances on the matter and efforts made by social sciences to recognise. the brain indeed holds peculiar attributes which makes it such a fascinating object of study: It is. Nagel. Dennett. the mind-body problem has indeed enticed endless contemplations. Over the years. however. Gross was to refer to the mind-body problem as one such conceptual complex. 2000). not-commonly shared. 1983. long before the neuroscientific revolution of the 1960s.g. idea of 'what the world is'. Long before the 1990's 'decade of the brain'. Chalmers. As has been well addressed throughout this essay. Withstanding all efforts of reconciliation – notably in the field of neurosciences. 1995. Still. and is still of critical consequence in broad domains of research (e. 173 .g. and study its sociocultural grounds and implications. This dualism continues to create areas of contest where symbolic actions as well as rhetorics are used to reassert an uncertain. the cerebral organ has raised considerable interest from both medical and scientific endeavours (Hyman. and functional imaging studies this explanatory gap remains insoluble. artificial intelligence.

'what it feels like' to be. and the most important threat to its ultimate authoritativeness. to remain in the private world of inner sensation and beyond the reach of objective query. chemical. it would seem almost as nonsensical to claim that our sense of existence can be utterly reduced to the brain. and is the ultimate locus of our selves. is doomed. to see the sunshine. biological. and sensomotor activity. As well put by Horgan (1999:4): "Inner space may be science's final – and eternal -frontier". Today. Subjectivity and our sense of 'being-in-the-world'. Most significantly perhaps would be the rise of the post-modern. cultural biases. if only by definition. personality. phenognosis. emotions. Other sociocultural developments raise a need to deal more substantively with the mind-body problem.Black Butterflies the apparatus through which we experience the world and relate to it. and relations of power. as well as an exponential growth in neuroscientific technological developments. 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. 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. 174 . Over the years. and electrical bases of mental activity. research has gain tremendous successes in identifying the physical correlates of thought. to experience pain.e. This calls for a more accepting stance towards claims to truth based on subjective impressions and inner experience. it would be nonsensical to deny the presence of some form of correlation between mind and brain. Science finds there its ultimate boundary. In other words. i. The last decades saw a growing interest in the physiological. Yet.

i. This social and cultural phenomenon should stand among other areas of concern in which contemporary social scientists are engaged. In many cases. for example. The believer. as it felt true to an experiencing individual – it IS true. and now both will share a common battle ground: Modern Western epistemological culture. It also presented a theoretical framework on which to ground future studies in the field. this study sought to assert a claim by which the mind-body problem deserves to be seen as more than a philosophical problem. may be able to alter an ontognostically-known 'reality' and work beyond the forces of the world-out-there (in ways considered 'supernatural'. Science. 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. will claim that. Here again. when scientific evidence will not support a claim based on subjective experience. These may go as far as to portray 'experience' as not only a legitimate source of Truth and as holding strong authoritativeness. may have a strong case against the probability of the divination of the dead.e. Phenognostic sources may have predictive elements. the latter will be considered superior. two sources of truth will interact and fight for authoritativeness. beyond ontognostical metaphysics).Sky E. 175 . Gross Many New Age movements will take this stance even farther. In sight of a possible contribution to these works. however.

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