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Gross Table of Contents
4.........................................................................................................THE STUDY OF THE HUMAN ANIMAL 7.................................................................................................................................THE THREE PAPERS 8 ...............................................................................................................Surgeons of the Mind 9 ............................................................................... Experts and 'Knowledge that Counts' 10 .................................................................................................The World of Brain Surgery 11..............................................................................THE MIND-BODY PROBLEM AND CARTESIAN DUALISM 11 .............................................................................................................. Descartes and After 13 ............................................................................................................The Cartesian Fallacy 15.......................................................................................................... INTRODUCING THE GNOSTIC SPLIT 15 ............................................................................................. 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 23.................................................................................................. INTRODUCING REPLICATED BOUNDARIES 23 ...............................................................The Gnostic Split and Replicated Boundaries 25 ......................................................Replicated Boundaries: The Professional Grounds 29.......................................................................................................................................INTRODUCTION 30......................................................................................................LOBOTOMY IN MIND: METHODOLOGY 30 ................................A Historical Approach to the Study of Replicated Boundaries 31 ....................................................................................................... Reading Psychosurgery 33.............................................................................................................................ON PSYCHOSURGERY 37..................................................................................................... CREATING ONTOGNOSTIC LEGITIMACY 37 ...........................................................................................................Prehistorical' Sources ' 39 .................................Replicated Boundaries: The Professional and the Legitimate 42 .................................................................................................... Building the Heroic Ethos 43 ..................................................................................................................The Founding Tale 45 ............................................................................................................Out of the Laboratory 47 .........................................................................................................................Men of Science 49 ...................................................................................................................Locating the Mind 52 ......................................Medicalising the Mind: Symbolic Correlates of Ontognosis 56.........................................................................................LOSING GROUNDS: AWAY FROM ONTOGNOSIS 56 ................................................................... The Traps of Rhetorics: Facing the Debate 58 .................................................The Traps of Science: Methods and Rationalisations 59 ....................................................The Traps of Symbolics: Freeman and the Ice Pick 61..........................................................................FROM THE MEDICAL INTO THE SOCIAL AND BACK AGAIN 62 ...............................................................................................Social Control and the State 64 ..................................................................... Dystopic Prospects: Psychiatry in Charge 65 .......................................................................................Back to Society: The Social Cure 67 ...................................................Illegitimate Interests: The Costs of Mental Asylums 69.............................................................................................................................. THE HOMO VADUM 71 .....................................................................................................The Homo Vadum's Brain 73 ....................................................................Corporeality, Pain and Phenognostic Truth 76 .....................................................................................................Madness and Ontognosis 77 ...........................................................................................The Homo Vadum and Society 79............................................................................................................................CONCLUDING WORDS 81.............................................................................................................. THE NEURO-ONCOLOGY CLINIC 82 .....................................................................................The Clinic: Spatial Characteristics 85 ...............................................................................Schedules and Organisation of Time 85 ..............................................................................................The Neuro-oncology Meeting 86 ..............................................................................................................................The Patients 87 .....................................................................................................................The Consultation 88 ......................................................................................................................Family Members
89......................................................................................................SOMETHING ABOUT BRAIN TUMOURS 89 ...................................................................................................................Types of Tumours 90 ....................................................Location of the Tumour and Functions Threatened 92 ..................................................................................................................................Treatment 95...................................................................................................................................... INTRODUCTION 96......................................................................................................................................METHODOLOGY 97............................................................................................AT THE CLINIC: THE DIAGNOSTIC PROCESS 99.................................................................................................................MEDICOSCIENTIFIC DIAGNOSIS 101......................................................................................................................THE WEB OF EXPERTISE 103.......................................................................ON THE ONTOGNOSTIC AUTHORITATIVENESS OF REPORTS 105 .............................................................................. The Sight of the Tumour: Radiology 110 ............................................................................... Sorting Things Out: Histopathology 112 ....................................................................................Figuring it out: Neuropsychology 113 ......................................................................................... Hands-on: The Clinical Report 116 ............................................................................................................................. The Patient 120 ......................................................................General Oncologists: Peripheral Experts 122 ..........................The Neurosurgeons and the Tumour Board: Peripheral Experts 123..............................................................................................................MECHANISMS OF INTEGRATION 124 ...................................................................................................................... Hierarchisation 125 ............................................................................................................................. Sequencing 126 ............................................................................................................................. Negotiation 128 .......................................................................................................................Peripheralising 129 ............................................................................................................................ Pragmatism 133..........................................................................................................................CONCLUDING WORDS PART V: THE BRAIN EXPOSED...............................................................136 ON NEUROSURGERY AND THE NATURE OF OBJECTIFICATION...................136 136.................................................................................................................................... INTRODUCTION 139....................................................................................................................METHODOLOGICAL NOTES 140................................................................... THE SACRED BRAIN: THE MATTER OF THE GNOSTIC SPLIT 142.........................................................................................................................................THE STORY 142 ....................................................................................................................................Prelude' ' 145 .................................................................................................................................The S-day 149 .......................................................................................................................Under the Skin 151 .............................................................................................................The Peak of Surgery 154 ............................................................................................... Closing up: The last stages 155 ..............................................................................................................................Just a Story 155...........................................................................................LIMINALITIES AND REPLICATED BOUNDARIES 155 ..................................................................The OR as a Space of Multiple Liminalities 158 ................................................................................The Temple of Ontognosis: The OR 158 ................................................................................ Keeping Phenognosis Out: Sterility 160 ............................................................................. Anaesthesia: Subduing Phenognosis 162 ...................................................................................................Space and Liminal States 163 ...........................................................................................................................Going Native 166...........................................................................................GNOSTIC SHIFTS AND 'THEORIES OF MIND' 169......................................................................................................................................CONCLUSIONS PART VI: CONLUDING WORDS...............................................................171 171 ...............................................................................................................The Bounded Brain 174 ........................................A Contemporary and Future Look onto the Gnostic Split
Sky E. Gross Macbeth: How does your patient doctor?
Doctor. Not so sick, my lord, As she is troubled with thick comi 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 th 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 3
Part I: Introducing the Work
The Study of the Human Animal
Sociology and anthroplogy have forever sought to
understand the ways in which the individual relates to the world, let it be 'society', 'nature', the 'other', or any category of entities or concepts. I believe, however, that one element should have been given a more respectable place in these endeavours: the understanding of what the human animal is in his own eyes1. That is, how does he conceive his experience in the world and how does he conceive his experience of the world. Can he regard himself as a thing among others, or can he only relate to himself as an experiencing subject, distinct from a world-out-there, from which would stem the things which he will perceive? The question which will follow us throughout this essay is not the question of how culture defines the 'self' – in that, this work would hardly be original. Rather the question here is how the self defines the self: Which can be said to serve as a basis to what is
The use of masculine pronouns and possessives was chosen arbitrarily – the text refers to both genders
Both relate to my choice to study the 'Western world'. religious 5 . Gross known in the world-out-there.Sky E. is a challenge in and on itself. there are some issues that I would like to address. or rather the 'they' ('society')? Thus. in the most plain-spoken way possible. In looking at the world and at the self. how much is this hierarchy contingent upon cultural settings – at both macro-level. The Western world is indeed a mosaic of different cultures. This may be a somewhat curious fact. Before entering the analysis itself. in it asking how do we know what we know. One may oppose the reference to Western culture as if it were one whole. and with its own historical development (each as defined by its own narratives). with its own dynamics. this essay is about epistemology. the issue of human understanding of the world and of himself within this world. which kind of knowledge 'counts'? and if one is considered more authoritative than another. the 'he' (the 'other'). and to try to understand Western culture in its own context. and I must join these expressions of discontentment. whether defined as based on national aspects. and micro-level? These are grand questions indeed. While acknowledging the value of these endeavours. considering it is itself the source of the initial interest in – and conceptualisation of . at any level. I have chosen to come back 'home'. It is this very achievement I sought in the years preceding the writing of this essay: tackling. and in the world of the self? The 'I' (myself).the issue. 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. and being able to attend to them.
mind or body. social stratification. Thus. in a world defined by a general (and scientific) consensus on which is True. Its 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. etc. There. looking at the world from my own private perspective. This has been acknowledged by endless works in the sociology and anthropology of medicine. in its modern and postmodern manifestations.Black Butterflies beliefs. There is. gender attributes. The power of biomedicine in the Western world can hardly be overrated: it may be one of the most dominant. many complexities began to arise: am I a subject. 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. or objectifying epistemology). These relations of power stood at the centre of my research in the 6 . Or should I rather adopt a vision of myself as an object among objects. felt. which can be said to hold greater homogeneity in respect to its epistemological and practical grounds: Biomedicine. and which is False? Once having ascertained biomedicine's tendency to reinforce the second way of defining Truth (adopting a body-centred. I shall look at the ways in which it is resisted by a sense of truth as held by the experiencing subject. I defined another vector of interest: the focal point within which the Western modern individual defines his identity – mind and body. thought of. and sources of many theoretical innovations in the social sciences in general. and highly regarded profession and body of knowledge. In my seeking the most promising field of study. by me. one important institution. now well-accepted subdisciplines. influential. defining Truth as it is sensed. as an conscious individual?. however.
Although referred to in the coming section more careful presentation of the methodology will be presented in each of the three chapters. 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. First. to the reflexive – a representation of the theory itself. as experienced by the field-worker. and clarify the claims above. And third. to the micro. The sequencing will go from the macro. to personal thought. exemplify. when based on more or less objective forms of knowledge. Accordingly. I will lay down an analytical first-person narrative on the processes of objectification associated with brain surgery. by which the mind-body split infiltrates (as 'replicated boundaries') all layers of sociocultural phenomena – from broad historical movements. to micro-interactions. I will use three different ways to substantiate. thereby avoiding 7 . Second. although remaining within the limits of qualitative analysis. The Three Papers In the course of this essay. material means for treating the mind. the use of surgical. methods will greatly vary. I will bring the analysis of an in-situ work where I observed the ways in which brain tumour diagnosis is reached. Gross last years and will be placed at the centre of this essay. I will propose a historical outlook on the ethical debate regarding psychosurgery.Sky E.
lacking the capacity for subjective experience. Drawing on philosophical and theoretical insights from recent works on discourse. as well as making the compatibility between the work and the methods explicitly evident. 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. Thus. and how these have increasingly become depicted as scandalous within a more recent post-modern bioethical debate.Black Butterflies redudancies and repetitions. and social studies of medicine. The study of the debate over psychosurgery will raise questions as to the ways in which mind-body epistemologies affect conceptualisations 8 . The analysis will then relate this transformation to the placing of human subjectivity above observable functioning as more relevant goals of medical and social practices. the body. I will suggest a conceptual framing whereby modern Western biomedical practice and research sees two forms of knowledge coexist and fight for authoritativeness: phenognosis (knowledge based on subjective experience) and ontognosis (knowledge based on the enquiry of a world-out-there). In this. this paper will propose an analysis raising cultural aspects of mindbody dualism in modern and postmodern Western society. its aim will be to build a framework for a social study of knowledge. 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. yet fully sentient individual into a complacent ‘object’. Surgeons of the Mind The first paper will serve as theoretical grounds for the overall analysis proposed in this work. although heavily drawing on philosophical insights.
this paper will provide a closer.g. Experts and 'Knowledge that Counts' Bringing these ideas to the realm of the clinical. Sequencing: relying upon the temporal dimension. These include Hierarchisation: ranking the relative validity and reliability of the different sources of information. The paper underlines the technological and epistemological grounds of 'expertise' in the medicoscientific practice of diagnosis. in situ.g. the degradation or amelioration of the disease). based on a sixmonth participant observation. leaving ambiguities unresolved.g. And pragmatism: using information only as far as it provides sufficient grounds for treatment decisions. and present these epistemological and practical complexities as they are uncovered in daily routine. Gross of humanhood and its association with self-consciousness (being a subject) and the ability to accept ‘objective truth’ (being ‘sane’). imaging reports would be considered more reliable than phenognostic patients’ accounts). several mechanisms of resolution are used.Sky E. eventually prioritising reports from more authoritative expertises (e. and their roles in the assertion of expert knowledge's authoritativeness. When questions of authoritativeness arise. Peripheralising: turning to other expertises to 'explain away' symptoms that do not fit with a well established initial diagnosis (e. It will point to the many challenges involved in the solidification of brain tumour diagnoses by different experts and forms of knowledge. These five 9 .g. Negotiation: adjusting diagnoses via a preliminary exchange between experts and a consequent 'fine tuning' of the reports (e. look into the life of a neuro-oncology (brain cancer) clinic of a large hospital in Israel. asserting that a symptom’s source was orthopaedic rather than neurological). radiologists being aware of clinical evaluations before finalising their reports). and defining the discrepancy itself as a diagnostic sign (e.
With this in mind. and associated with the theoretical thrust of this work.e. the presentation of three stand alone journal articles. space. Resisting a dichotomy between physician-objectifying and ethnographer-humanising. etc. in many ways. 10 . this account will provide a glance into the ways in which clinical or clinically-situated exchanges are not only observed but also experienced. rather than a necessary by-product of professional tendencies. the textual content is refined and condensed to create a succinct and to-the-point exploration of the issues at hand. This is. epistemological bases. practical necessities. I will first briefly portray my relationship with Ivan.Black Butterflies mechanisms will here be presented in the context of the daily work of the clinic. The World of Brain Surgery In this essay. with its own body of literature and methodological sections. and processes of socialisation. the relation of power between phenognosis and ontognosis. Considering the breadth of the methodological and empirical bases for this work. and then focus my attention on my observation of the brain surgery he had to undergo. and secondly.. 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. I will try to show how issues of objectification can be discussed from the viewpoint of the objectifying party. references are used only as far as they are directly relevant to the essays. First. As it is presented from a first-person perspective. symbols. a brain cancer patient whom I have followed over a period of eighteen months. each chapter will be structured as relatively independent unit. i. I will portray objectification as being of a fluctuating nature.
Matter has proper characteristics and attributes. René Descartes (1596-1650) offered his definition of the mind as an entity outside of the realm of matter. 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'.e. Part II: The Argument and its Theoretical Complex The Mind-Body Problem and Cartesian Dualism2 Descartes and After "Cogito ergo Sum" (I think therefore I am) In these few words. such 2 Note: some of the material presented here is borrowed from my own Master's Thesis 11 . he would define how mind and matter were distinct: Matter has a spatial extension. More specifically. Gross Nevertheless.. it has a place and a dimension.Sky E. i.
2001). 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 postCartesian Western philosophy (Leibowitz. in turn. but rather has different parts: some mechanical and some non-mechanical. 1982). an organ located deep within the brain). As Descartes saw mind and body as interacting entities (more specifically through the 'pineal gland'. The most prominent philosophers would argue for this or that view of the problem. 2001). Descartes will claim that a human being is not one entity. however. Matter is public and accessible to all. without having one affecting the other (non-causal dualism. including to scientific observation. in belonging to the latter form. in contrast. The mind. Dualist explanations. will speak of one dominant substance: this being either material (materialists) or spiritual (idealists) (Schimmel. 1992. 1967). and exists in the private world of the subject (Garber. Leibnitz (1646-1716). Kendler. Much like Descartes himself. can be subdivided into interactionist or non-interactionist ('parallelism'). in contrast. Koestler. no attributes. The mind. or non-interactionism).Black Butterflies as colour and shape. This 'identity theory' will have 12 . would see mind and body existing in parallel. 2001). will have no spatial extension. one could define him as an interactionalist (Schimmel. 1949. Monists. Along the same lines. Among the ways in which the problem was tackled one may find some that may be viewed as dualist and others as monist. will thus constitute a form of 'ghost in the machine' (Ryle. 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). giving birth to an immense body of works.
Mind and body interact. rather than one being a by-product of the other. there would be between the two a relation of function to matter (Ben Zeev. that is. 'Functionalism' will hold a somewhat related concept: the mind-brain relationship would be comparable to drive-car relationship. Trying. An additional important dualist theory is referred to as 'epiphenomenalism'. yet logically incompatible with the others: The human body is material. like monists and 'substance dualists' do. brings us four prepositions. have become ever more pervasive. 'Mind will appear when the question is approached from a subjective angle. along with clear-cut materialism. Gross mind and body as two manifestations of the same phenomenon – thereby not claiming for a duality of substances but for a duality of properties. a Hegelian 'foam on the wave' of brain activity. Spirit cannot affect matter and matter cannot affect spirit. 1996). 13 .Sky E. According to this view. these views. but rather two ways of looking at one phenomenon (Kendler. and 'matter' when approached objectively. to ask whether water is water or H2O. each considered 'true' prima facie. for instance. 2001). makes no sense to the 'property dualist': these are not two phenomena. The Cartesian Fallacy The mind-body conundrum can be defined around the logical fallacy arguably entailed by Cartesian dualism. The mind is spiritual. With the rising power of brain research. mental phenomena will be but a by-product of material substance. Benjamin (1988).
Black Butterflies In order to make these assertions 'make logical sense'. Mind and body would not interact (non-causal dualism: e. yet 14 . The accumulation of scientific knowledge leaves little doubt: there is to the very least some correlation between the mental and the cerebral. With it. This is. Spirit can affect matter and vice-versa (causal interactionism). one would have to give up at least one of these assertions. identity theory. the basis for the different philosophical approaches described earlier: The body would not be material (idealism). seem to have revitalised concepts regarding 'mind' as a powerful entity. 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. as a consequential actor in the 'world'. The mind would be material (materialism). This. This process will stand at the very centre of much of this current work. or ephiphenomenalism). positivism has gained much strength. With the evolution of experimentalism and the focus on pragmatism in the development of technologies. With the development of modern science. when modern physics (notably quantum theory) raised questions as to the ontological exclusivity of 'matter'. This until recently. idealism has lost most of its vigour.g. were it the world of 'nature' or the world of the 'social'. materialism – in its less or more extreme version – seemed to have led 20th century's Western thought. in the broadest terms. along with more general trends of New Age culture. or to the very least.
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. The 'hard' problem emphasises an epistemological gap between first-hand experience (‘felt’) and public. I will term the former ontognosis (gnosis – Greek for 'knowledge') and the latter. The answer must thus be found in the realm of the cultural. what are its fundamental essences). as expressed in one of its most powerful discourses: biomedicine. I will show it to be based on movements between two distinct forms of knowledge. For the sake of conciseness. This 'hard' problem 15 . affirming their relevance and consequentiality in the sphere of the sociocultural. and the hard problem. or between subjective and objective knowledge (Ornstein. and in order to avoid ambiguities with related terms. I will present some aspects of Western modern society's marked cultural character. Young. scientific knowledge (‘observed’). 1972. whether experienced or not). where conceptualisations on the nature of 'the world' originate and manifest themselves. of the social. and phenomenological (what is it like to BE. I will turn to picture the evolution and manifestations of these two epistemological forms within broader contexts.Sky E. Gross does not take us closer to resolving the problem of causation (Midgley. 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. After proposing an essential definition for each. With this in mind. phenognosis. 1996). how is the world experienced). each holding claims to the ultimate Truth: ontological (what IS in this world. 1990).
or 'This is' (ontological Truth). to the bat itself: Only a bat would know 'what it feels like' to see with sounds. 'I think'. Arguably. Heil. This first-person’s position is also the focal point where facts become meanings and where data become experience. i. and only a particular bat would know what it feels like to be this particular bat (Jackson. this again. of oneself) into which he/she will define and often declare to constitute the 'Truth'. this first-person standpoint is the site where one turns acquired knowledge (of the world. Searle et al. based on 'I know'. the sensation of an itching toe.Black Butterflies rightfully earned its appellation.. true knowledge of 'what it is like' is an epistemological privilege reserved to the sentient subject. Edelman. or a tooth ache which actuality could never be disputed by a dentist. a claim most often originating from the world of science and biomedicine. 1997). 2000. or aching in the place of another. 16 . 1988. regardless of whether the meaning assigned to a phenomenon seems ‘objectively’ acceptable or based on some sort of psychological distortion (Edelman and Tononi. no progress of science will ever allow being. Gertler. however elaborate. 1994. Metzinger. 1982. 2001). Facing an outside world.. As Nagel (1974). 2003). This locus of 'Truth'. 'I feel' (phenomenological Truth). 2001. and no map of the brain. feeling. will often be challenged and questioned by a claim for Truth based on 'There is'. in his famous article "What is it like to be a Bat?" eloquently notes. regardless of whether the source is the world-out-there agreed upon by several individuals or one’s own hallucinatory world. will be able to convey subjective experience (Damasio. 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.e.
Gross Thus. 1962) sought the resolution. one may find such a view in Bennett and Hacker's famous essay. With phenognosis. but also self-conscious – not a brain embedded in the skull of a body" (Bennett and Hacker. According to him and to many of his existentialist and phenomenologist predecessors.Sky E. 2003:3) [my emphasis. 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. on the other hand.g. One such important – and relatively recent – attempt can be found in French philosophy and human sciences (Lanigan. although the body could be seen as an mere object. For instance. The latter will only exist as far as it is embodied: the mind is not the 'ghost in the 17 . emphasising the irreducibility of the subjective into material elements. reason. "Philosophical Foundations of Neurosciences": "A human being is a psychophysical unity.G. act intentionally.] The Cartesian mind-body split has ever been the subject of philosophical attempts to either deny its existence or dissolve its problematic aspects. S. namely in the field of neurosciences. 'experience' or 'mind' cannot. an animal that can perceive. and feel emotion. a language-using animal that is not merely conscious. in the terms proposed here. I will adopt the notion of experience as addressed in the context of the hard problem. I will base ontognosis on a materialistic approach to the easy problem – portraying the world as essentially material. or rather. 1991): Maurice Merleau-Ponty (e. the conceptual annihilation of the Cartesian split.
While the body may be without mind. have taken up these leads and engendered considerable research on the existential and phenomenological groundings of the self and its relation to 'the body'. notably in the fields of the social studies of science. 1945 in Lanigan. These works generally sought to merge the body’s objective façade with the less tangible subjective experience of which it serves as the locus. it breathes life into it and sustains it inwardly. while the body may be regarded as a mere physiological and natural entity (an 'objective body'). This would lead to the understanding of culture and experience "insofar as these can be 18 . it will. The phenomenal body. Social Studies of Medicine and the Body Scholars.unified with (rather than distinct from) this physiological entity. perception. the 'experiencing flesh'). body) by external expert knowledge (most notably by medical practitioners. must be viewed as one with the objective body: experience is experience of the body. first-person. 1995a: 203).Black Butterflies machine' – it is the experiencing. turn into a 'phenomenal body'. cognition. mind cannot be without body: both empirically and philosophically. emotion are all 'embodied phenomena'. and with it forms a system" (Merleau-Ponty. rather than an entity IN the body. "[The body] is in the world as the heart is in the organism: it keeps the visible spectacle constantly alive. façade of the machine. a self problematised as dual (mind vs. This was associated with an ongoing effort to account for possible gaps between 'sentience' and 'science' at the level of the self. action. for phenomenologists such as Merleau-Ponty. dealing directly with the 'body in pain'. thus. once experienced. In other words.
1994). a fact that eventually only reinforces ideological and political dualisms. 1993. Turner. one of the leading scholars in the field. 1994. 1996) have shown how much 'we are our bodies' and how much of the mindbody split remains unchallenged by current sociological work (Nettleton. Crossley. 1996. In relation to the context of gender." (Csordas. scholars of 'embodiment' will claim that the sociology of the body does not take into account the lived-experience of the body. feminist literature took on the task of revealing conflicts between sentient knowledge on the one hand. that is. Along tangential lines. Gross understood from the standpoint of bodily being-in-the-world. represents the body in a way that is socially contingent (Martin. sociologies of embodiment (e. 1996. Williams. 1998). related to public realm. action 19 . and biomedically based knowledge on the other.g. 1994:143). Thomas Csordas. cognition. Lupton. According to these views (which were generally put under the umbrella of a 'sociology of the body'). Thus. these very works will be claimed to adopt a 'mentalist discourse' (seeing 'mind' as being superior to 'body') by which men are the 'mind'. Shilling. Webb. 1995.g. While agreeing with this basic premise. as a system of thought both external to the individual and concurrently present within the individual. 2006). often relating epistemology to constructions of gender (e. while women are the 'body' and belong to the private sphere (Williams and Bendelow. 2001). Root and Browner. 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. culture. prediscursive phenomenon that plays a central role in perception.Sky E.
Black Butterflies and nature to a way of living or inhabiting the world through one's acculturated body. using Foucault’s (1986) notion of discursive practices as entailing human desire for 'Truth' about the world and about the self. he uses it as to show the preciousness of the leib over the korper as a source and grounds for culture." (Csordas. Medical knowledge is essentially of a reductionist nature. in turn. For instance. In an attempt to do so. Still. while ascertaining the presence of epistemological conflicts in micro-settings where third-person and first-person views collide (IT vs. paying little or no attention to the subjective aspects of disease. 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 drawn from: the history of psychiatry. the establishment of an authoritative system of 20 . objectively accountable) as broad discursive forces. I). 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. Throughout this work. the clinic. while Turner (1992) brings up the distinction between leib (the lived body) and korper (the physiological body). the relationship between the two as 'Truths' is never analysed as such. This ontognostic epistemology is. even these 'embodiment'-oriented undertakings showed little concern for the changing hierarchies between the two forms of Truth (subjectively experienced vs. Overall. 1994: xiv). I will seek to provide such a complementary outlook. associated with the foundation of a powerful ethos. and the surgery room.
e.in a subordinate position (Foucault. This will ipso-facto place non-scientifically based knowledge – including phenognosis . however. 2005). the linking of subjectivity with power relations will reveal that it may indeed constitute a rising discursive force. Biomedicine has had indeed notable success in achieving this demarcation as highly respectable. and experience of self. In the 1979 Stanford Lectures. such as religion. Gross rhetorics. suffering. 'things' that are not based on discourse. and economics (Gieryn. Foucault stated that what troubled him since his first book was: "In what way are those fundamental experiences of madness. but that does not mean that we don't have to get the question". 1983. 1983). defining the forms of knowledge considered admissible while dismissing competing claims for Truth (Foucault. with knowledge and with power? I am sure I'll never get the answer..Sky E. politics. crime. and the drawing on highly evocative symbolic elements all of which serving to support its discursive supremacy. Phenognosis. I shall claim here that Foucault may have had the question misspelled: what if these 21 . and distinctive from other social spheres. individuality connected. and that have not been produced by the social. 1986. Mizrachi et al. Foucault's analyses distinguish between discursive events and prediscursive events – i. 1980. 1972. 1999. 1982).. This distinction persists within a particular power structure where a hegemonic regime of truth is established. These include pain. should not be seen as comprising mere 'leftovers' of this biomedical ontognosis. even if we are not aware of it. death. Armstrong. trustworthy. madness. When considering the development of post-modernism.
for power. Mizrachi et al. why not consider 'Man' as a discursive event based on the phenognostic authoritativeness of human experience? Thus. therefore.Black Butterflies experiences were not prediscursive. This postmodern era would see critiques of science joining existential. and relativist influences in the social sciences 22 . Traditionally then. 1994). as a consequent discursive formation in and on itself.. Harvey. through the challenges it may present to the material-ontological bases of biomedicine. both his writing and more recent literature has. Foucault’s own lifework can be defined as revolving around this issue of discursive subordination. omitted the option of a symmetrical opposite. 1989). Rosenberg and Golden. This lack of attention remains somewhat enigmatic considering recent historical developments. When at all acknowledging subjective forms of knowledge. 1984. This shift had both roots and repercussions within what social sciences have traditionally referred to as the rise of the postmodern (Lyotard. and modern Western social order (e. these works rather deal with them in oppositum to the hegemonic power/knowledge. that is. 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.g. Rosenberg. following his claim that 'Man' is but a discursive event. but rather discursive? After all. by and large. Eisenberg. 2005). 1972. rarely seems to be deserving particular interest. 1992. a "new wrinkle in our knowledge" (Foucault. phenognosis. science. although. according to Szakolczai (2000). 1977. Goldstein. 1999. again making the relationships of power between phenomenological and ontological forms of knowledge critically understudied. by which phenognosis itself would serve as grounds for legitimacy and. phenomenological.
to pave the way toward a destabilisation of the grounds upon which ontognosis drew its force. including – if ever considered. whereby stands the value of the proposed reconceptualisation. both at the macro-level and at the micro-level. negotiated. 1992. Gross (and in general culture. more radical postmodernism will reject the whole idea of Truth. most particularly in art and literature). Dickens and Fontana. although overwhelmingly rooted in phenomenological thought. while postmodernist thought may have notable affinities with ideas associated with the concept of phenognosis. Introducing Replicated Boundaries The reconceptualisation of the mind-body conundrum will serve to assert the sociocultural correlates of the philosophical problem.Sky E. 1994).phenognosis (Bourdieu. one cannot stress enough the distinctiveness of the two worlds of notions. Thus. and provisional forms of knowledge. This work has led to the formulation of a theoretical framework for the understanding of such processes: the definition of replicated boundaries. thereby allowing experience to ascend as a legitimate source of Truth. Still. both synchronically and diachronically. The Gnostic Split and Replicated Boundaries 23 . Grand ontological and metaphysical accounts lost grace to local. This issue shall be clarified as this analysis develops.
and will have powerful manifestations in several layers simultaneously: the splitting of brain and mind in the professional layer (e. in changes in the ways in which space is distributed (e. symbolic.g. and may encompass beliefs.g. spatial. and still keep structural similarities. detect. classifications. for instance. professional. and so on. one group of professionals losing their status). this will come about in the subordination of one professional sphere to another (e. These spheres may include both lay and professional epistemologies and practices. in the layer of the spatial organisation of biomedical 24 . and that this was followed by the creation of robust limits to forestall any 'leaking' of the phenognosis into ontognosis' terrains. replicated boundaries refer to the presence of epistemological groundings – here. interactional. or recognise its manifestations? How are phenognosis\ontognosis reflected in the institutional. how can one discern. The cases at hand will be used to illustrate this concept. as a relation between two forms of knowledge. one finds a process of subordination of one form of knowledge to another. forming a panoptical advantage in spaces where the more powerful form of knowledge is exercised).which will replicate themselves in several spheres concurrently. I shall further claim that these bounding limits will not remain in the layer of the abstract. In broad terms. neurology vs. actions. symbols.g. and assert that ontognosis' failure to conquer and subordinate phenognosis led to a rejection of the latter from the territories of the former. If. epistemological spheres? The systems of classification we hold ordinate the creation of boundaries at many layers of cultural phenomena (Abbott. etc.Black Butterflies If indeed the mind-body problem does stand at the basis of social phenomena. thus forming 'replicated boundaries'. 1995). psychiatry).
the apparatus used to keep each form of knowledge distinct in social settings). The rise of the professions is related to the processes of secularisation in Western society around the late eighteenth and nineteenth centuries (Parsons. the conceptual layer (e. Parsons (1971:145) sees the professionalisation as a "criteria of cultural legitimacy".g. and sees it as the "single most important component in the structure of modern societies". in the symbolic layer (e. The phenomenon of replicated boundaries will accompany us throughout the analysis. Goldstein. 1971. hierarchies of sources of information in the forming of diagnosis). neurology ('the profession of the brain') and psychiatry ('the profession of the mind').g. in the case of brain tumours .Sky E. Gross areas (e. As claimed by McDonald (1995: 160). Replicated Boundaries: The Professional Grounds Professions constitute social fields where particular organisations of knowledge are often manifested in a most palpable way.g. In the course of this study. I have thus chosen to lay special attention to the professional developments of the fields where the mind\body split would come about most noticeably. 1994). biomedicine. “professions are knowledge-based 25 . where the operation room becomes a well-bounded ontognostic shrine).the conceiving of oneself as either body or mind) and in the more general discursive layer.g. that is. in which I hope to be able to establish it as a valuable theoretical concept. where definitions of authoritativeness remain crucial (e. and most particularly. Associated with the interest in professions and the attempts to define the phenomenon has always been the study of knowledge and of epistemological subordination. Foucault (1982) joins him in pointing to the importance of the professions in Western modern societies.
it holds a body of abstract knowledge which must be mastered by its members. it holds a 'service ideal'. it holds a degree of exclusivity in the relevant field of practice and knowledge. for instance. 1964. most often present in discourses related to the practice and epistemological grounds of medicine (Goldstein. Second. rather than a mere occupation. There are several ways in which biomedicine. as an ideal type of profession may 'do' boundarywork (Gieryn. that is a disinterested practice that is based on altruistic rather than self-centred objectives (Wilensky. and 26 .Black Butterflies occupations and therefore the nature of their knowledge and the occupations strategies in handling their knowledge base are of central importance”. 1983. the unbreakable link between abstract knowledge and the profession would be based on the idea of the 'gaze'. Along related lines. Goldstein. 1977) that enable it to be referred to as a profession. And finally. 1999): First by expanding its authority or expertise into domains claimed by other professions or occupations. Medicine holds several ''core generating traits" (Larson. 2001). For Foucault. Thirdly. split jurisdiction. by monopolisation of professional authority and resources. 1994). The need for professions to bind themselves from other forms of culture and to gain power through knowledge involves processes of 'boundary-work'. Finally. it is autonomous in the definition of its practice. by labelling rivals as pseudo or amateurish and exclude them from its turf. Secondly. Halpern will claim 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. First. by creating a clearer contrast between itself and its rivals. Third.
This involves symbolic.as placed on 'a map of culture'. Gieryn (1999) defined 'science' –the basis for biomedicine's authoritativeness . This essay presents particular cases of professional boundary-work. I will try to propose that Cartesian boundaries are involved in the demarcation of two forms of 'truths' – the phenognostic and the ontognostic. These relations find themselves replicated on several layers. rhetorical and professional modes of boundary formation around and in parallel to these forms of knowledge. drawing a map of science is but replicating a map of a gnostic split. From a more recent perspective. as the interest of science is to remain the home of objectivity. these 'nonscience' territories can all be seen as belonging to the subjective realm. politics. Gross subordination (Halpern. I will show how specific demarcation principles of the scientific versus the non-scientific are related to a battle on the hierarchy of these two kinds of truths. and truth. in which notions of scientific truth were challenged and redefined. hence my proposed definition of replicated boundaries. Through the understanding of the enactment and then challenging of boundaries. 1992). reason. 27 . In my view.Sky E. In this case. or mysticism. bounded off from other territories such as common sense.
making this chasm remarkably explicit. it relates to the cultural significance of the brain in biomedical 28 . the case reflects a daring attempt to bridge Cartesian dualism –acting upon matter to alter the realm of the mind-. Its value as a basis for analysis is manifold: First. the story of psychosurgery. Furthermore. will serve as a case-study where the key concepts of 'ontognosis' and 'phenognosis' are taken to their extreme.Black Butterflies Part III: Surgeons of the Mind Frontal Lobotomy and the Mind-Body Problem The first section of this work.
Finally. while over the years many medical procedures were eagerly embraced only to be consequently rejected. as it is of common usage to refer to the latter by the former. now broadly referred to as Cartesian.Sky E. and consciousness (Kleinman. 29 . at least partially. I will demonstrate. with the aid of an interpretative reading of texts related to the debate. This may account. 1942 Freeman. the body. Gross thought. few arose as lively debates and as much moral outrage as psychosurgery's. notions of humanhood. existence. 1997). I will use both terms alternately.individual into a self-content ‘object’ only partially able to sense subjective experiences. I will picture this chasm. Society can accommodate itself to the most humble laborer. one cannot overrate what is at stake here: i..e. 1984:766) Drawing on insights from a range of recent works on discourse. Introduction "It is better […] to have a simplified intellect capable of elementary acts than an intellect where there reigns disorder of subtle synthesis.yet fully sentient-. and how these have increasingly become depicted as 'outrageous' within a more 3 Lobotomy is but one psychosurgical technique – yet. (cited in Kucharski. through the study of the practice of frontal lobotomy3 (‘psychosurgery’): a modern endeavour using brain surgery to transform the mentally-ill -. experience. for the fact that. I will suggest here an integrative analysis of the cultural and philosophical aspects of mind-body dualism in modern and postmodern Western society. psychosurgeon. and social science of medicine. how certain epistemological assumptions led to the overwhelming acceptance of the technique within modern medicine of the 1940s-1960s. but it justifiably Walter distrusts the mad thinker". and as it was the most practiced form of psychosurgery.
This and more. at others weakened. sociocultural. or critical reconstruction of an event. Historical sociology is thus not some kind of sociology. rather it is the essence of the discipline" (Abrams. or epistemological entities. as well as a study of the set of changing relationships between two entities. I will then relate this transformation to the placing of human subjectivity above observable functioning as the ultimate goals of medical and social practices. 1982).Black Butterflies recent post-modern bioethical debate. 1982:2). Historical analysis is often most resourceful when tackling central interests of sociology (Abrams. this analysis will remain sociological in its nature: I will seek the theoretical drawing on a historical case. or the relationship with the 'other'. This is why a proper study of boundaries should involve a temporal vector. Psychosurgery is brought here as a "historical individual" in 30 . the two sides of the borders are ever changing. both defining and being defined by the boundary. were it professional. It enables a drawing of infinite changes and shifts in the relations of the subject matter with other contexts. and not a detailed description. Lobotomy in Mind: Methodology A Historical Approach to the Study of Replicated Boundaries "Sociological explanation is necessarily historical. Boundaries can be understood as a belonging to a process through time: their locations are drawn and redrawn. at times strengthened. Still.
This revealed 384 articles and 14 major book publications.provided a relatively continuous frame of analysis. I interpreted the texts along a chronological thread.  2001:47). as a rule. Gross Weber's sense. that was. the selection criterion being their referring to terms related to psychosurgery or to its main practitioners. 31 . the rhetorical devices employed. and four in Israel. 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. as a form of historical ideal type of the phenomenon at hand. (Weber. The focus on professional publications –mainly medical. as well as through several overarching themes: the criteria for the evaluation of the procedure. 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.Sky E. devoid of dramatisation tendencies often present in lay reports. I then defined the debate as rotating around a number of issues. or: "…a complex of elements associated in historical reality which we unite into a conceptual whole from the standpoint of their cultural significance". positive/negative stances. that is. I have included both French and English sources collected in two central libraries in Paris. and finally. Primary sources included books and journal articles published since the 1930's. the drawing on symbolic aspects of medical practice. but also from the social sciences-.
Third were issues of obtaining informed consent from mental patients. nosologically. Kucharski. cognitive. the patient giving his consent may not be the same person going through the postoperative phase. A fourth matter included questions of human experimentation. some going as far as claiming the latter to be infeasible in the case of such extreme mental transformation: in terms of personality.using a method of trial and error on groups of patients diagnosed with etiologically. Snaith. Berrios. Huynh-Dornier. including interventions on children as young as four year old (Valenstein. Browsing through the literature. often associated the procedure with contemporary Hitlerian concepts of euthanasia and eugenics. with practitioners having limited tools to predict the outcomes and calculate the risks of such an intervention. Sabbatini. 1980a. 1988. 1984. 1997). and symptomatically diverse mental pathologies. in fact. 1980b. 1992. Another issue was the immense power accorded to the psychosurgeon in social and political spheres: Critics. Bouckoms. 1994.Black Butterflies First was the inadequateness of theoretical and empirical bases. 1997. one typically finds depictions of the debate assuming an evolving movement from an inferior to 32 . Second were the procedure's mutilating aspects and the irreversibility of its effects as it inflicted great damage to both affective. and physical functioning by the severance of brain tissue not targeted by the procedure. And finally was the theme of abuses and aberrations observed through the implementation of the different procedures.
Here. Indeed. Gross a superior moral and ethical world (accepting and then rejecting the technique). and will insist that the procedure’s ascribed legitimacy is in line with other sociocultural developments. I will seek to portray psychosurgery as neither justifiable nor condemnable. I will propose a more contextualised. and scientific understanding (knowing more about the brain). This will eventually represent psychosurgery as a mere by-product of a darker era in medicine and psychiatry. True. On Psychosurgery 33 .g. lobotomy may have lost its place to psychoactive drugs.Sky E. The focus will be thus on transitions in the depiction – rather than usage-of the procedure. ethically. epistemologically – carry on. while historical accounts of the technological and scientific contingence of the abandonment of psychosurgery (e. yet debates over its legitimacy – morally.aspects of these developments. a fact which cannot be explained away by the pointing to scientific advances. which will describe not just past-proponents’ but also contemporary critics’ arguments as equally contingent upon the particular Zeitgeist within which they took form. reference to the introduction of drug therapy) may account for the decline in the use of the technique. I suggest the story must be told otherwise. namely specific epistemological shifts. they offer little to the understanding in the shift in the debate itself and the values it brings forth. and on broad epistemological --rather than mere technological-. less presentist view. from inferior to superior technology (the use of better instruments).
It is evident that. 1997.Black Butterflies In 1936. at the time. many 34 . and once experimented on a small group of patients. 1948:497) or. Moniz was granted the most prestigious scientific acknowledgement: the Nobel Prize (Berrios. Three years later. In the words of one of the practitioners: “[Prefrontal lobotomy is] the realization of a new stage in neurosurgery […]. Ligon. 1936b). reported preliminary success in the severance of brain tissue for the treatment of mental illness (Moniz. and Harold Solomon (president of the Association of Nervous and Mental Disease). In 1949. Egas Moniz. Soon. Edward Strecker (vice-president of the American Neurological Association and president of the American Psychiatric Association)." (Freeman. neurologists. "Psychiatrists. The introduction of surgery in the treatment of affective disorders is a momentous event. 1956:771). and cofounder of the American Board of Psychiatry and Neurology). and neurological surgeons may well look back upon the period before the discoveries of Egas Moniz as equivalent to the Dark Ages. 1998). the Pope himself accorded psychosurgery his blessing (Rouvroy. These included Adolf Meyer (past President of the American Psychiatric Association and the American Neurological Association. the most prominent neurologists and psychiatrists embraced the procedure. the practice was considered as one of medicine's greatest promises: In the US of the 1940s. a Portuguese neurologist.” (Wertheimer. 1954). Some promised a full recovery to a significant share of patients.
psychosurgery offered a source of hope for the deliverance of the mentally ill from the misery of their existence.365 were counted in the UK. 2% saw their symptoms aggravated and 4% would die as a result of the procedure.000 in 1949. This enthusiastic embrace. By 1960. however. to more than 5. Gross would consider it unethical not to propose lobotomy to some patients. Essentially. Indeed. since 1945 the number of lobotomies doubled each year: from 240 in 1945. Kucharski. 10. and although already in the 1930s most professional widely and openly acknowledged the ill effects of the operation. 1984). soon waned. or even cured.Sky E. both physicians and family members tended to consider the postoperative patient as better off. Still. Donnelly. according to Silverman (2001). In fact. 28% had little improvement. but also acquired a gruesome image as one of medicine's darkest episodes. both asylum psychiatrists and neurosurgeons viewed it as no less than a breakthrough in the scientific understanding of the mind. most particularly in the US. psychosurgery did not only lose grace. more than 18. and Japan (Hirose. 1995). 25% seemed not to be affected by the operation. By 1960. or the patient's condition has worsen). Until mid 1941. 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). Globally. the UK. but also in Continental Europe. Fewer 35 . tens of thousands of psychosurgical interventions were conducted worldwide. Between 1942 and 1954. a third of 'medium' results (where some improvement can be observed) and a third of failures (no change.600 operations were performed in the US (Swayze.000 lobotomies performed in the UK between 1942 and 1954 shows that 41% were fully cured or greatly improved. A meta-study of 10. 1972. 1978.
initiated in 1936. 1953. many texts. the press became progressively more critical. becoming increasingly detailed by 1941. 1999). the concept of frontal lobotomy has some grim connotations. with a typical depiction of the practice as a form of “menticide” or “mental euthanasia” (e. From a symbol of scientific progress. were brief medical reports. technology. that psychosurgery immediately joined the list of techniques thought to be in the arsenal of the opponent. changes in the attitude towards psychosurgery were evident (Diefenbach et al. research grew scarce.). Chorover. whether in the form of agents of secret services. diagnosis etc. the descriptions overstating the practice’s miraculous effects. began to associate psychosurgery with other forms of governmental excesses of power. 1979).g. the use of the technique has become extremely rare (and much more advanced in both target. including malicious brain-control techniques. with the introduction of antipsychotics. Baruk. With the rise of anti-institutional and antigovernmental movements in the late sixties and early seventies. psychosurgery came to be regarded as the craft of mad scientists with ill-defined intentions of mind-control at best. The first publications. an aversion towards the very concept of psychosurgery. or as radical communists seeking control over the American mind. 36 . It is only in the late fifties that a strong polarisation occurred. Today. Although by now. with a rising number of negative reports. mainly in the lay press. and its uses were to be confined to the darker rooms of mental asylums.. 1974. 1956. 1976. The tone was largely positive. In the popular press. and of pure sadism at worse. Umbach. 'Brainwashing' was so entrenched in the public imagination. Between 1945 and 1954.Black Butterflies and fewer neurologists showed interest in the technique.
'Prehistorical' Sources Although often ignored in historical accounts of the development of the practice. The practice has become particularly notorious for its effects on personality. thus forming a solid ground of legitimacy. Golz reported the effect of the ablation of the brain cortex in laboratory dogs. 1997) as Homi Vadum.Sky E. or empty. Here I shall refer to these "soulless" or "empty" patients (Valenstein. I shall claim. and suggested that this operation had a calming effect on the subjects. will place psychosurgery within the unquestioned ontognostic truth-basis of medical and scientific work. these Homi-Vadum were alternately seen as cured or simply damaged. the roots of psychosurgery can be said to go as early as 1890 with the experiments of the Dutch scientist Friedriech Golz. I will suggest that. selfcontent beings. 1980b. Creating Ontognostic Legitimacy In line with the scheme of this work. This. products of an ontognostic invasion of the 'mind'. When considered. 37 . I will argue that the embrace of the practice was based upon one critical component: the implicit and explicit use of rhetorical. symbolic. in contingence with the gnostic shift. Latin for flat. Sachdev and Sachdev. Gross invariably seen as destructive and abusive. ideas of brain control and psychiatric abuses of power are woven into a fearsome tale of the terrible consequences an unrestrained science may have. human beings. transforming disturbed patients into jolly. is still clearly present in a wide range of texts. and is said to produce individuals with no subjectivity or 'sense of self'. and institutional measures in the creation and maintenance of a scientific façade.
. she had to be assigned with two nurses around the clock. She was particularly difficult to maintain under control as she spent many of her days screaming in the halls of the asylum. Burckhardt (1890. 2001). This 51 year old woman. As Burckhardt himself put it: 38 . was considered to be "the most dangerous and difficult" patient of the asylum.Black Butterflies This report led to the more ambitious (and controversial) experiments of Gottlieb Burckhardt. behaviour that involved the patients’ lack of control over themselves (Stone. in the course of the next fourteen months. Each operation seemed to have had a calming effect on the patient. in Stone. the head of a large Swiss mental asylum. Four surgical operations were conducted on Frau B. diagnosed with schizophrenia. The first patient. Suffering from chronic diarrhoea and of a lack of proper hygienic manners. and did not seem to be responsive to any kind of treatment known at the time. Frau B. 2001:83) then began to wonder whether it would make any sense to: "…extract this impulsive emotional element from her brain mechanism. Almost 15 grams of her brain tissue were removed. mainly in isolation. was impulsive and violent. She once almost strangled to death one of the nurses. 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. She has been hospitalised for the last 16 years.
its origins in Burckhardt's work were. however. convince the psychiatric community of the beneficial potential of this avant-garde procedure. they will use my experiences and go the way of cortical extirpations and achieve continued better and improved results”.Sky E. (Burckhardt 1890. one will not survive the operation. Considered as utterly unscientific. forgotten. (in Stone. and another will commit suicide shortly after. Replicated Legitimate Boundaries: The Professional and the 39 . stating he could have turned asylum’s chronic population into calm and satisfied mental patients. 2001: 85) Burckhardt died convinced of the potential hiding behind this new technique. none of the more modern psychosurgeons wished to have their practice associated with it. in Stone. Burckhardt suffered from harsh criticism and was forced to bring his experiments to an end. 2001:83) Of the other patients to go under Burckhardt’s scalpel. It was not until the 1930’s that psychosurgery began to resurge. Gross “Though her intelligence seems to have been lost. although claiming: “I will not let myself be discouraged and I hope neither will my colleagues. she is now calmer and less dangerous”. perhaps most conveniently. The positive effects on the subjects' hallucinations and agitated behaviour did not. but rather. Yet.
They reassert an ethos. 1992). pure science: neurology as a mainstream biomedical and scientific endeavour on the one end. As knowledge on the anatomy and structure of the brain began to accumulate.Black Butterflies 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. and the fuzzy. it was passed over from psychiatry’s managing know-how. the emotional. Once the physical lesion of a disease was understood. and outside: chaos. Neurology of the mid-1930s was among the most prestigious and fast-growing academic fields (Abbott. the subjective psychiatry on the other. 1988. Lishman. nonmedical— disciplines. 2000). while 'pure' neurology pursued the incorporation of functional (or 'mental') diseases into the medical field.. neurology sought an alliance with psychiatry. 1995. Neurology. Gelfand. Eisenberg. 'neuropsychiatry' of the early 20th century became dominant in research on the cerebral basis for mental illness (Marti-Ibanez et al. such as psychoanalysis (Fadda. albeit less prestigious. Shorter. to the benefit of both professions. Pressman. could attain diagnoses 40 . a way of thinking the world.e. on the other hand. 1988. 1997. Psychiatry was to rely on subjective. a more commonly practiced. or symptoms. 1988. form of medicine (Abbott. Seli and Shapiro. 1997). Inside the category of pure reason reigns order and inner classification. a unification of the fields was undertaken. 1954. to neurology as an expertise founded on complex and abstract knowledge (Alexander and Selesnick. However. 1988). the soiled. Comprising a rather small group of physicians. Thus pure reason becomes pure objectivity. 1997). By the 1920s. introspective accounts. psychiatry remained associated with psychological – i.
2000). over the years. Indeed. The psychic nature of disease will be attributed to any mental syndrome for which no apparent 'physical' cause could be found. have found their physical basis in brain pathology. shaped the separation of psychiatry from neurology. 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. Gross through quantifiable. turning psychiatry into a mere nursing specialisation. while the latter will be left in the hands of psychiatrists. growing apart from the medical model that has excluded them and marginalised their practice.Sky E.. Price et al. 1968. diseases such as aphasia and epilepsy have been relocated from the blurry field of psychiatry to the more medical-like field of neurology. then conceived as mental asylum practitioners. Medical treatment for actual 'psyche-related' disease will be inconceivable. and physical – and therefore treatable within medicine – disease. as the epistemological bases of both of the fields were deeply affected by this psychophysic separation. since the basic definition of such a disease is related to the absence of known brain-pathology. and scientifically reliable signs (Audisio. One of the effects is the large group of psychiatrists leaning towards new psychoanalytical stances. The former group of diseases will belong to neurology as a medical expertise. The physical nature of disease will be attributed to any brain-related pathology which physical basis can be understood and clearly tagged. mainly directing day-to-day life conditions for mental patients (more 'technicians' than 'experts'). As more and more once believed to be mental disease. This process is not a simple labour separation process. the separation between mental – and therefore non-medical – disease. In other words. Early 20th 41 . communicable. neurology has grown to encompass an enlarging group of brain (and central nervous system) pathology.
leading to a severe identity crisis present to this day (Armor and Klerman. psychiatry remained in an awkward position: treating psyche-related illness. Psychosurgery stood at the very centre of this task. Merino. the areas of professional jurisdictions gradually aligned themselves around a distinct. This quest will be the main drive of psychiatric research into organic-based cures to mental illness. however. though implicit. Building the Heroic Ethos "Doctors are different in nature. 1968. the latter will strengthen its efforts to differentiate itself from the 'philosophical therapy' to resemble a more scientific model of medicine. Psychiatry suffered from a lack of clarity as to its basis of legitimacy. relentless efforts were made to medicalise (and thus 'truthicise' or 'make true') psychiatry. yet holding on to an organic epistemology. Light. 1980.Black Butterflies century saw two groups of psychiatrists beginning to emerge: while the more psychoanalytically-oriented would insist on a 'psychogenetic' (originating from psychological processes) explanation of mental illness. 2000). hanging in the midst between ontognostic and phenognostic grounds. While the former abandoned any aspirations regarding the integration into the more mainstream medical model. While neurology adhered to purely scientific ontognosis. Torrey. One kind adheres to the old principle: first do not 42 . cures that were believed to be able to form a bridge over the ever growing gulf between psychiatry and neurology. At the time. principle: the gnostic split. 1975. Thus. another substantial group will persist in its search for the organic and neurological bases of mental illness.
Witz. Gross harm. 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 others felt they 'had to do something'. Gieryn.Sky E. Was psychosurgery to be proven beneficial. 1976. I certainly belong to the second category". thus becoming a cure rather than a care specialisation (Sargant. 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. 1992. In practice. 1985. This 'something' took form in what was to become the psychosurgical intervention. 1983. (Gottlieb Burckhardt. and Burckhardt. 1999. 1999). 1997. The other one says: it is better to do something than nothing. the mere practicability and applicability of a scientific development may be of no lesser significance (Gieryn. Swayze. The Founding Tale "For the physical therapy of mental disorders they [the neuropsychiatrists] had the malaria treatment of neurosyphilis and 43 . 1995). This demarcation would then allow the practitioners to draw upon the legitimacy placed in core medical practice: the holding of measures that were both heroic and therapeutic. Moniz. While one can place some of science’s legitimacy within the ethos of a pure and disinterested search for Truth. Abbott and Meerabeau. The 'primum non nocere' principle cannot hold in the face of horrifying mental suffering. it would allow the discipline to become medicine-like. 1998). Shorter. 1983.
Electroencephalography was in its infancy. and of psychosurgery in 1936 brought about a revolution in diagnosis and treatment. to scream bars and urinate and defecate in the cage. one of its most powerful and diligent proponents. the eventual extension of which is not yet in sight". An examination quest of for the founding texts reveals that a psychosurgery's scientific legitimacy involved rhetorical portrayal of the practice's birth as a momentous breakthrough. Freeman (1956:771). if the animal it would the made with a few rage. mistakes. The introduction by Moniz of cerebral angiography in 1927. 44 . Throughout the years. After the operation [the excision of the frontal lobes]. Jacobsen and Fulton] noted a profound alteration in response to frustration in the chimpanzee with both frontal poles excised. the tale of its burgeoning was reiterated in the work of Walter Freeman. Within several important publications. feces.Black Butterflies prolonged sleep. during their presentation. and control of the autonomic system by pharmacological means was just beginning. roll in the shake refuse continue in the experiments. in London. radioactive unknown. by Egas Moniz: "[At the Neurological Congress of 1935. shock therapy by insulin and metrazol almost coincided isotopes with were leucotomy. Before the operation. Freeman persistently re-established the ethos of psychosurgery's 'discovery'.
would (and eventually did) provide a powerful stamp of legitimacy. The murmurs of disbelief in the crowd did not discourage Moniz. not incidentally did Freeman observe that Moniz' 'Eureka' was sounded in the course of a prized academic neuro-anatomical presentation. In a way. Thus. he is claimed to have returned to Portugal. according to Pressman (1988). He is said to have inquired as to whether the reproduction of such attempts on human would be conceivable. Out of the Laboratory Psychosurgery's initial association with neurology.Sky E. depicted Moniz as having stood up in admiration of Jacobsen and Fulton's presentation. stressing psychosurgery’s 45 . without the least indication of being upset emotionally. This founding tale is present in numerous reports. and to have soon begun his experiments. The drawing of the events seems to serve as a constitutive myth. Gross the same animal would continue in the experimental situation long beyond the patience of the examiner. having little grounds on reality. rather than psychiatry. while. James Watts (1947:417) begin their presentation of ten years retrospective on psychosurgeries by presenting the founding tale again. Walter Freeman and his associate. and in response to empirical data advanced by two of the world's most prominent neurologists: John Fulton and Carlyle Jacobsen. making mistake after mistake. much less than as a historical account. the portrayal of Moniz' deductive mind offered the endeavour a halo of insightful scientific thought. 1947:417) Freeman. among others in the field. In fact." (Freeman and Watts. his home country.
" (Marchand et al. 1970). 1956:769) 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. (Freeman.. Moniz himself sought to advance psychosurgery's position within his contemporary’s work on the localisation of cerebral functions. and clinical facts" (Moniz. we will enter domains that seem to us entirely unacceptable". If we wish to drift away from this organic orientation.Black Butterflies 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. Marchand and his colleagues reported that frontal lobotomy would allow to "enrich our anatomo-physiological knowledge of the human brain. thoroughly underlining his leaning on "anatomical. if only by asserting its position within an ontognostic 'normal science' (Kuhn. 1936a:40) "Psychic life is exteriorized in a different 46 . "In the brain there are regions that are particularly related to mental activity. […]". 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. 1949:515). physiological. (Moniz. 1936a:55). For instance. linking the practice to the body of accumulated knowledge on brain localisation.
Moniz will then take part in the quest for the Holy Grail of science: the mind. (Moniz. the mental functions. and to support the rhetoric placing the procedure on an ontognostic-based legitimacy. the underlining of this empirical basis served to reinforce the founding myth. science could replace explanation by classification. 1936a:55) In sum. but also in terms of the potential accumulation of knowledge on the brain and its functions. and in a definitive manner.Sky E. (Moniz. the 'factory of Truth'. It would be a great progress as a primordial fact in the study of the organic bases of the mental functions". This presented psychosurgery as a symbol of a genuine scientific quest for 'Truth' through objective observation and methods of trial and error. by being able to spatially define the mind. Gross manner. Men of Science 47 . and the parts of the brain that take part in their production. the texts of the period defined the benefits of the practice not only in terms of the relief it could allow the mentally ill. There. as a bold empirically-oriented endeavour: "[if our experiments prove to be successful] we would have put in relation. as out of the laboratory. 1936a:41) Indeed. but completely comparable to other functions of the organism".
1937. (Freeman. including attempted piracy and murderous assault. the antagonism was based on three purely "subjective" grounds: political antagonism.Black Butterflies Freeman (1956:770) speaks of the basis of the resistance to the 'discovery' by the medico-psychological society in Paris. indicates true genius". 1956:771) 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". Thus. professional jealousy. hampered by physical handicaps. 1956:771) or. "…He was also able to present to the scientific world the results of his meditations and experiments. rather he lectured or presided with courtesy and dignity. and "philosophical tenets". His was an inner life of thought rather than an outer one of action" (Freeman. Moniz himself is presented as being "extraordinarily modest": "He was never flamboyant in his speech. He explains: "Here was a brilliant discovery belittled through political antagonism and possible professional jealousy. often in the face of considerable opposition. and gave expression to his thought in measured terms. The intellectual vigor of the man.
Gross 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. we will enter other domains that seem to us entirely unacceptable". however harsh. 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. Interestingly enough. in 1956.Sky E. 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. 1936a:42) 49 . the year this article was published. "Psychic life is exteriorized in a different manner. Locating the Mind Moniz. (Moniz. The physical is the ontological basis of the explicit phenomena of the mind: "In the brain there are regions that are particularly related to mental activity. If we wish to drift away from this organic orientation. Freeman himself will be facing powerful antagonism. Reifying his own status as a 'true' man of science. was but a misunderstood genius. Freeman. like Moniz. but completely comparable to other functions of the organism".
Freud's work. Kraeplin. such as Broca’s and Wernicke’s in 1861 and 1874 respectively. which.Black Butterflies These claims did not grow in a vacuum. he is unambiguous: one needs to apply strict 50 . Kolb and Whishaw. Liepmann. Charcot. 1955). 1970. Barker. 1996. 1995). not unlike phrenology. The ontognostic foundations of biological psychiatry (or 'neuropsychiatry') can be traced back to Franz Joseph Gall’s phrenological theory. 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. 2003). Indeed. was itself based on a view of the brain as the physical seat of psychic activity.that the brain was indeed the seat of both mental functions and mental pathology (Young. although developed along different lanes. Freud and Alzheimer . persuaded many central figures -such as Meynert. 1995. In fact. which manifests itself through its action. at the beginning of the 19th century. 1968) Gall (1808:5) himself will claim to seek to: "…grasp the material conditions of the immaterial principle. Later studies of brain localisation. 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. in his well known "Beyond the Pleasure Principle" (Freud. and seems to undermine our research". MacMillan. linked brain and skull structure to personality traits (Barker.
even in the context of mental disease. World War I further produced clinical evidence on the various effects of head traumas. one would find the key to understand the workings of the brain. Although the understanding of 'higher' brain functions (such as thought. and assert its fundamental form as purely material. Studies used more and more elaborate methods. imagination. thus contributing to already the dominant trend of cerebral localisation. All would suggest some important correlations between function and location. Psychosurgery took on this lane of scientific studies by asserting. de facto.Sky E. By progressing from observation to theory. The films are put against the trepan holes”. reducing it to mere products of brain function. X-rays are performed in order to precisely localize the plan of the section. Porot (1947:126). including electrical stimulation. Gross empiricism. reject speculated metaphysical explanations. localisation was still able to replace a nebulous notion of the mind as a vague spiritual essence. This provided psychiatry a clear epistemological primacy over claims based on phenognosis. for instance. different imaging techniques. and later. describes the surgical proceedings of Freeman and Watts: “The surgery is usually conducted with local anesthesia. the spatial grounding of the mind as well as its material ontology. 51 . emotion) still lingered. This is precisely how psychosurgery's early proponents sought to portray their undertakings. After the surgery. thus justifying a denigration of subjectivity. post-mortem investigations. experiments on animals. and keep in line with scientific methods.
psychoactive drugs). A more thorough study of the literature supports this assertion. 1977). The idea of physical intervention into the realm of the mental began to lose its association with a momentum of scientific advances. The cutting of brain tissues. by endeavouring a mapping -however primitive and restricted. the idea of gross intervention into the brain to alter mental status began to seem unreasonable (Koupernik. Baruk (1956). considered then as the epitome of the scientific ethos. 72% of the cases operated on had a "macroscopically pathological brain". This predisposition involves a 52 . once the localisation of mental illness was largely discredited as a scientific endeavour. a few practitioners going as far as to weight the brain tissue excised in the course of surgery. Much of the work on psychosurgery involved notions of gross anatomy. 1977. This anatomical knowledge. Dew. Medicalising Ontognosis the Mind: Symbolic Correlates of This trend soon moved from the field of research to the field of practice. in the second half of the century. as general and imprecise as it may have been. now served as a rebuttal to the practice. may have well served as a source of authoritativeness grounded on materialist ontological concepts. undoubtedly more than any other non-localised attempts to treat psychopathologies (such as shock therapy from the early 1930s. for instance. According to Puech (1949:117). for example.Black Butterflies Thus. However. 2001).of the mental. and. the technique drew significant attention. will claim that psychosurgery should be morally forbidden since it would transform a functional disorder into an irreducible disease. ontognosis lies within an overwhelmingly materialistic episteme where the primal focus of attention is the body (Eisenberg. As noted.
literally. Gross form of objectification by which the human body is stripped of its subjectivity and transformed into a plain object (Babbie. it was not only reductive. demands a suppression of the subjective. however. An ideal form of these processes occurs in the operating room. and the reduction of the human body from a sentient whole into a seemingly lifeless object. 1991). depersonalised. but also substantiated it by providing it direct and unequivocal evidence. it also reduced: It brought the mind onto the surgical table based on it being deemed operable. 1997). accessible to dissection and rearrangement. the scrubbing rituals preceding the entry into the operating room and the elaborate draping of the patient which absorbs him/her into a small.to the realm of matter. McNay. seldom do they constitute. Surgery. such powerful proclamations on the very nature of mind-matter relations. Csordas. in and on themselves. a surgical blade was employed. As practiced. 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. did not only comply with ontognosis. by definition. 1981. to subordinate it --by means of a simple sway of a knife-. 1992. to excise sentient experience. Again. Psychosurgery. In the case of psychosurgery. but ipso facto. 53 . 1991. altering the spirit through the severing of a physical essence provided clear evidence to the spatial subsistence of the mind.Sky E. This 'symbolic theatre' thus creates a demarcated space within which ontognosis prevails4. These include. 1994). Fox. 1999. for instance. objectified body-part upon which the surgeon holds complete visibility (Hirschauer. as well as to its materiality. Although most biomedical practices do hold implicit reductionist bases. 1970. it also 4 This point will be further developed at a later chapter.
involving the body as a whole.Black Butterflies created and recreated this 'operable mind'. This brought about psychosurgery’s transition from a state-of-the-art endeavour to a second-line treatment at best. Clearly. some of its characteristics were more compatible with phenognostic views than its therapeutic predecessor’s. such as psychopharmacology. allowing the 'mind' to retain its mystique as being too complex for science to grasp. psychopharmacology offered a less costly. and artificial object: the lobotomist's knife. technical. Second was the fact that the mechanisms by which the psychoactive substances actually affect the brain are still little understood. at least in appearance. with more readily visible and immediate results. would be more than just therapeutic: its characteristics would be more in line with epistemological assumptions on the nature of the mind. did not raise nearly as much outrage as psychosurgery. The introduction of anti-psychotics in the mid1950s did have direct effects on the practice of lobotomy. 1994). spatially defined area where 'the mind' would be seated. thus. While this may not be enough to explain the replacement of 54 . First were the symbolic aspects of its administration. as well as less serious and permanent side-effects. a more subtle paradigm of mindbrain activity. Psychopharmacology’s superiority over psychosurgery. rather than a small. Although equally based on ontognostic views and although equally establishing a domination of brain over mind. this ontognosticallyapproachable mind. psychopharmacology proposed what was. More significantly. however. This may explain why other measures. and the former almost instantly substituted the latter as the treatment of choice in cases of severe agitation and hallucinations (Snaith. safer alternative. This stood in clear contrast to the protruding intervention and intrusion of an external.
1986). it would satisfy an unconscious need to be punished. but readopted with the disenchantment from psychopharmacology. although two main sets of explanations were brought forward: psychological and physiological. Gross one treatment by another. reducing side effects such as memory losses.Sky E. the shocks would be so unpleasant to the patient to have him cease his 'bad behaviour'. it may well account for the lesser magnitude of the debate surrounding drug therapy. the procedure has greatly improved. This technique. In contrast. however. the usage of the technique will become less common with the apparition of psychoactive drugs. Weiner. introduced in the 1930s and still of widespread use in treatment centres around the globe. Another form of physical therapy for mental illness should perhaps be mentioned in this context: Electroconvulsive therapy (ECT). On a more psychoanalytic note. and general anguish to the ECT patient. 1997). The latter. Not surprisingly. 55 . remains in use to this day and is still given a 5 The first attempts to incur states of shock for psychotherapeutic ends involved insulin injections. 1984). This would be highly effective in cases of severe depression. limb fracturing. involves the induction of electric stimulation5 causing the patient transient seizures. According to the former. from the 1970s onwards (Friedberg. Since. followed The debates over both its psychosurgery and psychiatry throughout development as a legitimate 'cure' expertise (Valenstein. the physical explanation is regarded as more sensible. better known as 'shock therapy'. according to the physiological thesis ECT will have the brain respond to the electrical charge by altering its own electrical activity and restore it to its functionally optimal level. The technique was relatively short lived. 1977. in some cases where psychotic symptoms became unmanageable (Braslow. The mechanisms of ECT's action are still poorly understood. and to a lesser extent. by now. As with psychosurgery.
non-localised. Science. these effects would not include actual personality changes. is ideally amoral: its role is to judge on questions of truth and falsehood. Babbie (1970:14) tells us. More 56 . the effects are believed to be (at least in the public eyes) less irreversible than psychosurgery. Indeed. 1997). but rather temporary losses of memory or transient states of sedation or psychocognitive 'numbness'. First of all. not on questions of right and wrong (or what would be moral or immoral). as in the case of psychopharmacology. the 'organ of the mind'. Secondly. As with psychopharmacology. it was evident that psychosurgery held a strong ontognostic position of legitimacy. rather than on gross anatomical processes (as claimed by proponents of psychosurgery). Furthermore. Another factor may be the general acceptance of the idea of brain function as based on electrical exchanges. there are several symbolic characteristics which may serve as a complementary explanation for ECT's more lasting state of legitimacy. Finally. and less ontognostically ritualised procedures seem to find a more accepting attitude in the laps of a publicly scrutinised psychiatry. there is no actual opening of the skull.Black Butterflies place of honour in the panoply of psychiatric treatments (Alexander and Selesnick. nor direct contact with the brain. less direct. Losing Grounds: Away from Ontognosis The Traps of Rhetorics: Facing the Debate Throughout the first stage of the debate. and not of ethics: Opponents insisted that the practice of psychosurgery was justified by poor research methods. initial disapproval of the practice belonged to the realm of science.
Kolb and Whishaw. the practice proved to be in discordance with a valid scientific model by which results could lead to a falsification of the theory (Popper. the disapproval of psychosurgery focused on the delicate process involving the choice of lesion as well as on the intricate selection of candidates. the group of patients operated on was nosologically heterogeneous: there was no common pathology that could be given to proper experimentation (Malizia. Practitioners.. White. 1975. 1936b). The discussion remained almost entirely restricted to the 'science' of the practice. who reported his attempts as representing but a first success. 2001). keeping relatively 57 . 1998. 1997. 1950). Ballantine. and more than a dozen different sites targeted (Huyn-Dornier. 1965). still needing refinement (Moniz. 1950. 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. In these respects. Gross specifically. which made the attribution of success or failure less than certain (Bockoven. Pressman. Feldman et al.Sky E. Thirdly. empiricallybased assessment of outcomes was unattainable. continued to urge the development of better and more precise surgical techniques. Secondly. This portrayed the procedure as correctable and dynamic. 1998). Egas Moniz.. 1992. and for a more effective choice of candidates. While initially. The responses to some of these claims involved a drawing on the words of psychosurgery's mythical father. staying in touch with empirical facts and ongoing observations. none the least because more than twenty different techniques developed over the years. rather than addressing ethical and moral questions. 1994. Lopez-Ibor and Lopez-Ibor. 1977. a similar number of theoretical rationales proposed. Bockoven et al. it would be claimed that a systematic. 1980). the patients were typically under several therapeutic courses.
Hitchcock et al. and with the choice of medical apparatus. both with the dosage of alcohol he injected into the brain. this would be performed under local or general anaesthesia).. psychosurgery surrendered itself to public scrutiny. Based on Moniz’s reports. The Traps of Science: Methods and Rationalisations Moniz conducted the first operations with a methodical approach. the initial questioning of the practice will result in an abrasion in its status as a pure scientific endeavour. Beginning with the use of a Berthelemy's syringe. thereby diminishing both frequency 1975). and dissociate 'pathological' neuronal connections. and the device would be inserted into the frontal lobes of the brain. 1972. 1953. Greenblatt and Solomon. 1950. a device used as a way to pit (as one would do an apple) selected sections of the brain (Moniz.Black Butterflies insulate from the spheres of public debate. The procedure was such that a hole would be drilled into the patient’s skull (depending on the patient. Then. and severity of its side-effects (Fairman. Gildenberg. 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. Although these responses did allow for some justification for psychosurgery’s shortcomings. 58 . the steel thread attached to the leucotome would be manipulated to cut through the white matter (where neuron cells are linked). The procedure indeed grew more precise and less hazardous. De facto. 1936a). he went on to design a specialised instrument: the leucotome.
the lack of flexibility leading to pathological "idées fixes". To alter one’s pathological fixed ideas. he went as far as to suggest psychiatrists employ the procedure within the setting of their own private practices. although we are still unable to precisely locate and differentiate the different functions. psychosurgery's most fervent supporter. An ablation of the frontal lobes will not result in irreversible psychological damage.contemplated on transferring psychosurgery from the sacrosanct operative room into the mundane world of the asylum. according to him. and cut through pathological nervous connections. This brought Freeman to propose. Gross Mental disease is due to a malfunctioning of these sets of connections. in 1947. Walter Freeman -himself not qualified as a surgeon. Rather faulty or not. The psychosurgeon would then manipulate the instrument 59 . Psychological activity is mainly located in the frontal lobes of the brain. 'Transorbital Lobotomy'. and into the frontal lobes of the brain. which are. the basis of pathological ideation.Sky E. Moniz presented an elaborate theoretical basis for his work. In fact. Moniz decided to concentrate his efforts on the frontal lobes of the brain. Based on those assumptions. a basis which he would carefully associate with neuroanatomical advances of the time. 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. The Traps of Symbolics: Freeman and the Ice Pick Some years later. it is necessary to disconnect the underlying nervous ties.
1986).theatrical sideshow. further in the back of the skull. James Watts. from 'primitive' areas. Freeman ignored much of the developing models of neuroanatomical functioning. By so doing. at the time. most particularly with the introduction of a 'psychiatrist-friendly anaesthesia'. Freeman chose to perform some of the surgeries in his own consultation office (Bernstein. unlike Moniz. and taking no time to 60 . Freeman's co-author in major psychosurgery publications. and. 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. making the pathology less significant for the mentally disturbed patient. This was. affective lower parts of the brain. claiming it unbearable to witness this: "…. 1975. This and more. nonmedical object. decried transorbital-lobotomy. Freeman's instrument was a mundane. Transorbital-Lobotomy turned the practice into a form of 'non-surgical surgery'..Black Butterflies in swift vertical movements and sever groups of nervous connections. with Freeman administering electroconvulsive shock for anaesthesia. The operation barely lasted a few minutes and allowed Freeman to perform dozens of lobotomies a day. In fact. a certain measure of affectivity would be lost. Neurosurgeons soon objected this trend. Valenstein. who conveyed his patients from mental asylums into his well-equipped operative room. an explanation that was considered weak to the very least and improbable at best. holding an ice pick for a surgical instrument. et al. as well as rational and imaginative thought) from the more irrational. based on electroconvulsive shocks.
and reflected upon the loosening of medicine's epistemological demarcation from the spheres of 61 . 1947:127) The drifting away from the rituals involved in surgery. as we have recently reported. Its introduction into the asylum and away from the control of specialised neurosurgeons denuded it of its biomedical aura and demoted it to the mundane universe of daily-life. Ironically. and up through his brain. as he is completely unaware of his condition and may. From the Medical into the Social and Back Again By the 1970's. (Porot.Sky E. ethical issues began to surface. The lack of medical caution in the care of the postsurgical patients was also apparent in many of the reports: "…In the first hours. Freeman contributed to the vulgarisation of the practice and to its consequent decline (Pressman. tear away his bandages and put his fingers into the surgical wound. while supporting psychosurgery until his very last day. as well as its detachment from the powerful ethos and symbolic aspects of medical practice and science. one has to watch the patient very carefully. 1988. The role of conquering the realm of the mind could not be left in the hands of mere 'technicians'. 1986:257). A powerful public scrutinising both created. which can lead to unfortunate consequences". undoubtedly contributed to psychosurgery's declining legitimacy as an endeavour based on scientific. Gross wear gloves" (quoted in Valenstein. 1998). ontognostic demarcation. and this is precisely what Freeman portrayed himself to be.
Mark and Ervin. in sharp contrast to the formerly 62 . was an erosion of the autonomy usually attributed to scientific practice. Snaith. 1978.In fact. the authors proposed a surgical intervention that would solve the social problem of violence: psychosurgery. Parallel to the development of the critical debate on psychosurgery. A suggestion within the same range appeared a year earlier. 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. power and prestige (Rudin and Zimmerman. and its association with issues of science and the social (Gieryn. 1983). the very involvement of social interests in the provision of medical treatment became increasingly objectionable. 1997). Goldbeck-Wood. 1983). and professional interests. where individuals would be controlled through electrical brain stimulation (Delgado. and reflected the changes in the assigned power of medicine. In this text. and more particularly. encompassing a vision of a utopian 'psycho-civilised society'. 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". 1969. however effective. and professional interests. ideological. constituted now but a malice intrusion into an illegitimate area (Chorover.Black Butterflies political. 1996. 1980). The outrage was immense. of a medicine of the mind: its intervention into the social. placing it on pedestal. ideological. away from political. Public scrutiny will lead to the practice's loss of absolute authority and a decrease in its scientific autonomy. 1970). hence the rise of the larger field of 'bioethics'. and thus. Equally.
Freeman himself would declare that the best candidate to undergo lobotomy would be "women. Kaimovitz. 63 . This led to a perception of psychiatric treatment as a means of social normalisation. Those were described as having a lesser degree of initiative. 1980). 1975. 2008: ix) Another troubling element was amplified by the air-du-temps of a post WWII Western world: The association of the technique with attempts to apply 'Brain Control' over the general population. as Howard Dully. Gross accepted vision of a 'psychosocial' medicine (Breggin. This would remain an issue of concern to this day. Dr. and further reinforced the view of an omnipotence of the institutionalised power over the individual. 1949). such as in instances of criminal deviance. brought a certain sensibility regarding issues of mind control.Sky E. with the eugenic notions of sterilisation and euthanasia of deviant population. The period of World War II. the psychosurgical treatment of certain cases seems to have been more controversial than others. My father agreed to it. 1978. Scheflin and Opton. where homosexuals and children were chosen to undergo the operation. That being said. to a perhaps even larger extent. and. a lobotomy 'survivor'. It took ten minutes and cost two hundred dollars" (Dully and Fleming. and questions of social control over individual differences. black and Jews". I was given a transorbital or 'ice pick' lobotomy. Walter Freeman. the father of the American lobotomy. when I was twelve years old. told me he was going to do some 'tests'. will open his 2008 biography with: "In 1960. and therefore as expected to have lesser difficulties in adapting to their new post-operatory personality (Brisset. My stepmother arranged it.
Black Butterflies The relation with localisation.different constructed image of him\herself. after all. associated psychosurgery with what was seen as a perhaps equally dangerous trend: control through omniscience. especially considering that the effect of 'pacification' and the general agreeableness of post-operative patients may have been. A second problem is based on the assumption that psychosurgery brings about basic changes in the patient’s self: does it not mean that the patient agreeing to go through the operation is not the same person coming out of it. 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. at the head of which would stand neuroscientists accompanied by 'surgeons of the mind'. an association not totally unfounded. it seems to be even more complex in the context of psychosurgery. this powerful enterprise of revealing the mind through a science of the brain. The fact is that informed consent is difficult to assert in the case of mental patients. 64 . The ability to see through the mental would create a dangerous panopticon. Yet. especially those locked behind the closed doors of the world of the asylum. the very target of the procedure. 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. Psychosurgery found itself connotating with such controversial ideas. in him\her having an – at times radically. his\her values and preferences.
had little to do with the decision as to whether or not proceed with the operation. she walks around the apartment. eats on a table. She has become capable of living in society. Gross This claim is also likely to be based on the fact that the first patients to undergo psychosurgery suffered from severe psychiatric symptoms. then. Moreover. or would bit her hands and knees and scream for hours. the aggressiveness and agitation of the institutionalised patients still formed the main criteria for the decision to operate. we can see a large heterogeneity in the nosological categories of the different patients. 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. The diagnosis as such. Since indeed. the intensity and duration of those symptoms were the main criteria for selection. After the surgery. This idea of a 'psychosocial medicine' was evident in the context of 65 . Her parents were forced to attach her hands and legs to her bed as well as her head and chest. Such a result aids in legitimizing lobotomy…”. who was going through episodes of violent rage during which she would rhythmically hit her head on the ground or on the wall. this girl could be left alone with her toys. (Klein and Tardieu. 1949: 113) The patient could be back to 'society'. Back to Society: The Social Cure “…[Interesting is] the case of a 15 year old young girl.
will to think more brain relief at of his the in constructively whether of depression and its conversion into euphoria permit adequate adaptation society. where the position of medicine vis-à-vis the social sphere formed a central issue. Proponents acknowledged this loss from the very beginning. compromising the sense of self-determination of the psyche and the agency assigned to the individual. according to the concept of post-operative re-education. and whether the individual so treated stands a better chance of survival in the highly competitive society of today 66 . For instance. In one such 'lobotomised school'. established by Joseph Farmer in 1948.all central elements of a phenognostic discourse. lobotomy would allow patients to become candidates for active 'pedagogic intervention'. This reframed the intervention as a cynical brain erasing and rewriting. exterior 1949:491). behavior. and progressive adaptation to circumstances" (Brisset. Practitioners were clearly unapologetic when stressing the social aspects of the 'cure'. therapeutic progress included three elements: "Lowering the tone gradual in delirium modification and of hallucinations. whether the individual disposal. 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 will or be able with less the accentuate the disharmony already present.Black Butterflies psychosurgery.
1997). according to Porot (1947:130): "Their [the post-surgery patients’] behaviour is as a rule impeccable since. In is in that context that Fulton. they also know with much precision the sanctions that are involved in the transgression of moral codes"." (Freeman et al. 75% of patients would die in the five years following their first hospitalisation (Duffy et al. 1942:214) Or. Illegitimate Interests: The Costs of Mental Asylums In the beginnings of the 20th century. Gross than he would with intact frontal lobes and a potentially recoverable psychosis.. even more so than normal person. they are sensitive to the demands their education impose on them.Sky E. might they be conceived as mentally ill or as responsible criminals. for instance. will declare that psychosurgery 67 . which turned 20th century asylums into crowded 'human warehouses'. 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. The two World Wars brought a growing rate of institutionalised mental patients. with no efficient treatment available. a patient entering a mental asylum had lean chances of ever coming out alive. In Warren Hospital in Pensylvannia. at the time optimistic about the treatment..
1995). was but a conspirative means for social control not only at the state level where it is embedded within political and ideological interests: This 'surgical strait jacket' also served ill-intended asylum psychiatrists. (Klein and Tardieu. these procedures would only serve to relieve some unmanageable symptoms. 1949:116) 68 .Black Butterflies 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. both in the asylums and in the home – thereby benefiting the patient’s caretakers as well. For Baruk (1956). 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. Even patients not be able to be released after a lobotomy will at least be more manageable. as an important constituent of psychiatry’s therapeutic arsenal. not requiring as much staff and facility costs as the pre-lobotomised patient (Swayze. An intervention holding but a modest intent to cease this agitation is received as a deliverance by the family". and will have no effect on the patient’s well-being as such. Other proponents will talk of 40% of mental patients being able to be released after psychosurgical treatment (Sargant. 1976). seeking to make their patients more manageable. Anti-psychiatry advocates could easily use these types of texts to establish their claims: psychosurgery. for example.
the loss of a phenognostic compass. and orderliness of the physical. By destructing their prison of material flesh and bone. and fore vision: 69 .Sky E. became intolerable that this surgery of the mind became a practice with victims and perpetrators. such as creativity. under the skull. It is only when the price of these 'emptied' brains. Szasz (1977). and represent the releasing of madness from its captivity. i. order could be restored. Gross In effect. The Homo Vadum Black butterflies appear on Walter Freeman's 1942 book 'Psychosurgery'. these creatures of the mind will be freed back into their own universe. of the unobservable phenomena of subjective experience will all be cast out from a medicine of the mind: either tamed or overthrown. control re-established. inside the brain. madness will cease to operate its threat on ontognostic reason.e. efficient causality. including a so-called 'loss in human's superior mental capacities'. While the outcomes of psychosurgery were of a wide range. Ideas of free will. of an immaterial and unreachable mind. According to these accounts. By doing away with these uncanny creatures. but regarded it as yet another instrument at the hands of a coercive institution seeking to eliminate individual autonomy of thought.. The brain would be but a bodily organ. arguably the most important figure in this anti-psychiatry movement. was himself not opposed to psychosurgery per se. the brain. the 'flattening' of human subjectivity is by far the most discussed in both professional and lay literature. Black butterflies endanger the materiality. rather than patients and healers. and action: turn individuals into 'Homi Vadum'. experience. reflexivity. the personality of the lobotomised patient hold fairly consistent traits.
[…] Life is enormously simplified by the relatively complete 1947:416).Black Butterflies "The lobotomized patient achieves his normalization at the price of the vertical component in his being-in-the world. (Vidor. “The outstanding feature [of the emotional set that characterizes people who have been operated upon] is a lack of selfconsciousness […]. desires. A disconnection between the two areas will pacify the emotional tone. the frontal lobes inhabit the functions of foresight. 1965:654). or. imagination. They laugh easily and flare up in anger on slight nagging or frustration. but seldom weep. They cannot be insulted. according to Freeman. of any higher-level functions. The rationale Freeman (1951) provided for the workings of prefrontal lobotomy seems to reflect this notion. 1963. in Freeman. As discussed earlier. 70 .” (Freeman and Watts. obliteration of the need for introspection. no matter what one says to them. while their emotional tonality is provided by the limbic system located deeper within the brain. at the price of a loss of horizon and perspective […] Neither hopes nor fears. and the consciousness of oneself. or associated phenognostic experience. nor regrets can present themselves in his greatly reduced temporal horizon…". they do not take offense.
controlling 'lower' needs of the organism. This is which places them at the centre of Moniz' book: "Two categories of clinical facts can be used in this study: the different types of lesions of the frontal lobes and the results of mutilating surgical operation on these lobes" (Moniz. but will not necessarily be experienced as 'true' to the individual. Porteus. Bouchard. doing purposeful acts. such as hunger or sexual drive. Moniz (1936a) linked the frontal lobes to the higher human functions of planning. The Homo Vadum's Brain According to many contemporary psychosurgeons and neuroanatomists (e. Gross Hallucinations may still be present. 1955.g. 1936a:30). He reports: 6 These assertions are generally believed to be correct to this day 71 . 1968). the effects of psychosurgery on patients' personalities would be related to the damage incurred to the frontal lobes. acts that are beyond reflexes and automatic responses6. The frontal lobes were further claimed to be related to the ability of learning from experience.Sky E. 'the seat of higher functions'. that is.
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. […] in sum. 1946:457: 72 . 1936a:31) "It is […] certain that the frontal lobes tumors present. The gains of psychosurgery. (Moniz. although later research will refute the presence of the first effect. and a centre of 'reason' will remain central to the description of psychopathologies related to lobotomies. They are in fact incapable of the most simple of intellectual tasks. 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. (Moniz. the greatest frequency of mental disorders". they are unable to group and orient the different elements of a given problem. Interestingly.Black Butterflies "We have noted with those who have injuries of the frontal lobe disorders of voluntary attention skills and of mental synthesis. lesser control over emotional responses. Frank. above tumors of other lobes. the image of the frontal lobes as a form of super-ego. intellectual disorders and second. the highest manifestations of psychic life are altered". melancholic and other forms of delirium: occult forces that lead patients at times to acts of despair". of hypochondriac.
or its importance. more plain. Existential ideals of self-fulfilment became ever more dominant. the patient could not have reorganised his psychic scheme (Mayer-Gross. They become. without which. 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. or disappearance of dereistic experience-they cannot daydream about their wishes. did seem to intensify over the last decades. Corporeality. the fear of loss of the human. With the gradual rise in the authoritativeness of phenognosis. Gross “None of the patients regained full insight in the full sense of the word. or entire lack of dreams. and a thinning. Normative functioning could no longer compensate for the damage inflicted upon the Homo-Vadum's phenognostic sense of truth.Sky E. or is able really to appreciate what the operation was for. or be abstractly angry in a sustained fashion. this formerly amoral scientific endeavour turned immoral. Pain and Phenognostic Truth 73 . of the turning into a HomoVadum. 1949). As sentience prevailed as a discursive force. due to this emotional asymbolia. matter-of-fact like”. […] The specific [personality] change was a poverty. Let it be noticed that Frank added in the same paper that "no cases were considered worse". Indeed. the position towards the Homo-Vadum began to change. Yet. some will claim that the beneficial effects of the procedure derive precisely from those personality transformations.
passive and dependant. childish. 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). over the years. this would often be counterbalanced by certain personality changes. both as to his body and as to his relationship with his environment. lacking motivation and spontaneity. the his associates”. no longer caring whether his heart beats or his stomach churns. (Porot. 74 . as termed here. Some will add the notion of "post-operatory personality"(or "moria") to describe the combination of symptoms observed after psychosurgery has been performed. It seems that the patient’s initial complaint of having to deal with overwhelming emotions was substituted by a total loss of the ability to feel any emotion at all. or whether his remarks embarrass 1947:129) The Homo-Vadum. yet incapable of sentience.Black Butterflies Perhaps not unsurprisingly. was thus to a certain extent aware and conscious. a growing body of literature referred to the patient's inability not only to reflect upon his/her own condition and behaviour. Indeed. […] he loses interest in himself. Reports describe the post-lobotomy patients (as many as 91% according to one source) as being apathetic. 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 lobotomy inactivated presents a by prefrontal of number peculiarities that distinguish him from his pre-operative self.
S. 1946:445). but no other significant changes. These patients had a tendency to be unconcerned by subjective aspects of their being: while acknowledging drives and feelings. the experience can be borne with equanimity” (Freeman and Watts. “[after a prefrontal lobotomy] pain may be present.Sky E. rather than internal (experience-based Truth – phenognostic knowledge). There was moderate lipping of the vertebrae. Gross quality that translates mere stimuli into full-fledged qualia and by which experiences feel pleasurable or painful. 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. After being lobotomised: “Within three days the patient permitted manipulation of the limbs. and internalising sensory information. Or: “L. However. She winced and cried out when the knees were 75 . they reacted as if these cues were external (based on out-there sources of Truth –ontognostic knowledge). the patient complained so bitterly and was so apprehensive that it was impossible to make any headway in treatment”. at which time she had spent two years in bed because of “arthritis”. A 44 year old woman was first seen in November. 1936.
resistant to the reasoning of ontognosis. she showed interest and willingness to help in the efforts that were made to aid her. and/or perception. affect. but instead of shrieking with apprehension and refusing to cooperate. and thus expressing an incapacity – or unwillingness. "More difficult to influence satisfactorily are those persons who have drifted away from the world of reality. (Freeman and Watts.to recognise what is collectively considered as True. 1947:427) Madness and Ontognosis The concept of 'madness' is intriguing in this regard.Black Butterflies straightened. 1943 in Fleming. hence its characterisation as deviant in thought. by definition." (Freeman. is he to be considered too emotionally deteriorated to be aided by psychosurgery. and the crepitus was very considerable. in fact.[…] [Only when] the individual lapses completely into a dream world of psychosis with no struggle against the manifestations of disease. justify the use of techniques intended to secure willing or coerced subordination of what is seen to be a faulty or muddled phenognostic experience. 'madness' remains. in turn. but nevertheless kept on walking”. When intractable. comply with an ontognostic agreed-upon Truth as to a world-out-there. This phenognostic experience cannot. 1944:490). […] She fell and sprained her ankle. 76 . This will.
all mental deduction operations and that accomplish 1948:497). psychosurgeons who did refer to the personality dimension argued that the creation of the Homo-Vadum was a moral act par excellence. and respond to the world more 'rationally': "After a prefrontal lobotomy.Sky E. The Homo Vadum and Society Still. Some proponents went on to claim that the inflicted personality changes allowed patients' intelligence to actually become more effective. Gross As psychosurgery did not seem to have negative effects on one's intelligence. Here. based on an ontognostic conception of humanity. proponents of the technique used the descriptions of the Homo-Vadum as a validation of the beneficial results of psychosurgery.side effect. concern productive activities" (Wertheimer. Rather than referring to the patient’s acquired condition as a regrettable – albeit perhaps unavoidable . for it enabled the return of the insane into the laps of a normative society. At the peak of its popularity. practitioners depicted psychosurgery's effects as pointing out to the success of the procedure. remains capable of calculation. in line with the idea of the 'social cure'. a person who was previously trained for the practice of law. 77 . at least as far as studies of the time could show. analyse. while typical patients' sensitivity to ontognosis grew. their phenognostic consciousness deteriorated: the patient would know but not experience. engineering or scientific work. One must consider that. providing them with the ability to perceive. turning a socially incompetent individual into a Homo-Vadum was a valuable accomplishment.
notably in fictional literature. As an act of mercy. above the ability to accept an agreed-upon ontognostic Truth. he was now both literally and symbolically at the hands of the more authoritative power: Ontognosis. Surgery left him barely conscious: a mannequin. a Truth that cannot be challenged by external authorities. a Truth that does not have to be subordinate to the gaze of the world-out-there. his friend would euthanise him. Ken Kesey's influential novel "One Flew over the Cuckoo's Nest". The 'hero' was finally defeated: lobotomised and turned into a HomoVadum. 1946:444). This classical piece of literature became one of the strongest manifests for the liberation of individual thinking from the hands of a normalising society. the central character was calling for an alternative source of power: a Truth that feels true to the individual. Its mere popularity demonstrates the claims presented throughout this analysis. and the diminution of the fullfledged subject into a shallow façade of self: "exhibiting a purely objective mentality" (Golla.Black Butterflies Questions as to normalisation and the creation of Homi Vadum are apparent in other areas of culture. namely. The practice's discordance with emerging phenognostic conceptualisations of the self placed psychosurgery in the focus of debates on the significance of sentient experience. a 'thing'. published in 1973. the procedure came to symbolise "the substitution of a soulless robot for the insane patient" (Mayer-Gross. the idea that a rise in the discursive power of phenognostic Truth would place free subjective thought. Eager to empower a group of mental patients to trust in their own phenognostic sense of Truth. Yet. 1949:320). in an era where questions of value are so often approached with a phenognostic 78 . depicts its protagonist as resisting the system of the mental asylum only to be eventually lobotomised. although deviant. Over the years. in what they believe to be right.
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. but as a positive picture in and on itself. although often contrary to ontognostic evidence. This seems evident in the study of New Age spiritual movements. Gross view in mind. all clearly not supported by empirical evidence). as long as they 'feel' authentic. Concluding Words I have attempted here to present a historical motion involving two powerful sources of Truth. but rather as a full fledged discourse. Indeed. 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. 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 Truth as experienced by individuals in specific states of consciousness (claims of re-incarnation for example.Sky E.and ontognosis –based on observation of a world-out-there. to be reasonable by ceasing to be does not make sense anymore. All can 79 . nonmediated. genuine. these subjective experiences will be given high status as True. in the context of healers and shamanist medicine and the authoritativeness attributed to those able to experience it. Another example may involve the understanding of the credibility associated with states of trance. not necessarily as a negative picture of an objectifying gaze. to the individual. or sensing the presence of spiritual entities. phenognosis –based on inner experience. not as a prediscursive form.
As I try to ascertain throughout this work. This will be based on a synchronic. formed and reformed at several layers of the world of the sociocultural. In the next section of this work. Here. rather than diachronic view of the phenomena. 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. 80 . different references to bodies of literature. albeit with a different field. 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. it is precisely these exchanges and conflicts. I shall provide an analysis along similar lines. In effect. 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. and different empirical points of focus. One may find similar trends in modern psychotherapeutic discourses. faith. and beliefs. where one’s inner feelings are considered a priori legitimate.Black Butterflies benefit from the positioning of phenognosis against ontognosis on the issues of credibility. and to the complexity of the proposed forms of analyses. the boundaries between phenognostic and ontognostic knowledge are created. Along a similar line. different methodologies. and on a sustained in-situ observation rather than on a more macro outlook as proposed in this paper. The fact that these trends are all accompanied by oppositions and by countering phenomena may point to the power ontognosis maintains. one is often advised to seek for an 'authentic self' through deep introspection rather than through external appreciation of 'reality'.
The 81 . I followed members of a neurooncology outpatient clinic situated in a large hospital in Israel. 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.Sky E.
although on the days in which the neuro-oncology clinic is active (Mondays. The secretariat is shared by both groups of physicians (the latter's forming a more substantial share of the staff). a metal name-tag-holder that can be replaced at need.were later transcribed verbatim. and 68 patients were informally interviewed. a social worker. one with the radiology experts. patients.Black Butterflies team consisted of four neuro-oncologists (NROs). and 7 with 5 different patients-. and close-ones. formal interviews –13 overall. and in the course of three weekly professional conferences: one internal conference. a head nurse. Thus. 2 with family members. and Thursdays). where I gathered extensive field notes (simultaneously translated and composed in English) along with both formal interviews and casual exchanges with staff members. A total of 103 consultations were observed. The clinic includes about ten offices. and another with the neurosurgical team. Each office has. there is no permanent office for any of the NROs. Although forming but a small share of the data collected. 82 . The neuro-oncology clinic has thus no actual spatial presence: it is a virtual set of specialised knowledge held by 'visiting' professionals. according to the physician who happens to be using the room on that particular day. nailed on the wall next to the door. The NROs were observed during routine consultations. The Clinic: Spatial Characteristics The neuro-oncology clinic is an outpatient unit located in a general oncology clinic. I spent some twenty hours a week at the clinic.on the days they do not receive patients). and a neuropsychologist. 4 with NROs. the working physicians tend to be placed in a habitual office (used by other physicians -or even nurses . in rounds in the inpatient ward. Wednesdays.
ambulatory divisions. their impressions and interpretations of the images they survey). The spatial arrangement may reflect that. none of which is actually secured for the NROs. Gross Each Sunday is spent around professional conferences. The Neurosurgery conference (referred to as the 'tumour board'. when the conference room is used for other purposes. but it never serves as a meeting place for the different NROs. little cohesiveness or sense of 'team' between the NROs.is used for the weekly NROs' staff meeting. The conferences take place at different locations. in writing. in a small office. There is. However. or the inpatient unit. or the rest of the staff. albeit at some distance from the actual clinic. the NROs will find a temporary office at the clinic. luxurious office at the Moses Institute. 83 . Her office has an interesting standing: it is both the heart of the clinic. for that matter. while also contributing to this state of affairs. was some other group needing this room.. in terms of research mostly and administration at times. where nuclear medicine tests are conducted. where the experts usually sit and go through the MRIs (and reporting. Her office is actually located at the one floor where the services provided are not targeted toward cancer patients – i.Sky E. squeezing in into a room much too small. The conference room at the "Moses Institute" -a building with mostly oncology-related inpatients units. the head of the Neuro-oncology team has a large. The Radiology conference takes place at the radiology (MRI) unit. and out-patients clinics.e. the whole team will go up to another conference room. hinting to its more decision-oriented character) takes place in a conference room at the radiotherapy unit. at the hospital main building. at the neurosurgery inpatient unit. At times. Professor Lise. in fact.
the place is bright. surrounded by glass walls from which the conferences may be seen but not heard). At any given moment one-to-two neuro-oncology patients are to be found hospitalised.Black Butterflies The Moses building has many floors. Floor B is where Lise's office is located – just near the corridor leading to the general hospital. with instruments and names on the doors that would not shame any science fiction movie.e. It is a dark. which serves the general public rather than patients (whose pathological state allows them some access to backstage areas). some of which are underground: The -2 floor includes the radiotherapy (RT) facilities and completely lacks windows or direct access to the 'outer world'. and a coffee shop is located in the general hall located on the East. A small but lovely patio separates the Western and Eastern wings. The first floor is where the oncology inpatient unit is located. The third floor includes a large. usually due to secondary complications of treatments. Again. or as another patient called it: "the death wing". The outpatient clinic is located on -1. this is where most of the rounds take place. easily accessible. As expected from a frontstage area. and where the general hospital is directly linked to the institute's building. Naturally. i. The second floor includes the haematology inpatient unit. This unit is where most neuro-oncology patients are hospitalised. this is the only floor where the activity has little to do with oncology. No one could guess he had entered the "cancer building". 'spaceship'-like floor. This is where patients are 84 . interestingly enough. the reception area and the conference room (which is. alongside general oncology patients. leading almost directly to the hospital's mall. One will also find there the refurbished conference room serving the NROs on Sunday mornings' meetings. quite modestly but recently refurbished ambulatory service.
although most physicians turn up only by 9:00. usually begins at 14:00. The meeting with the neurosurgeons (the 'tumour board'). There. The last appointments are set for around 12:00.hospitalised patients as opposed to the near-death. with a consultation room of its own. perhaps much more than with hospitalised patients. The onco-psychological unit is also located on the floor. they will spend their 'free time' as 'plain' neurologists. and often unconscious. The reception hours tend to begin at around 8:00. they will take the opportunity to finish the rounds before the radiology conference. As most of the staff members (Lise excluded) also work as general neurologists. although this may actually last until 15:00.Sky E. If the latter happens to be the case. The Neuro-oncology Meeting 85 . The morning begins with a NROs' staff meeting. after a short recovery and observation period. in some cases) of the notyet. or end by 9:00. The team of psychologists usually works with ambulatory patients. This may last until 10:00. one or two physicians receive patients. Sundays are organised around conferences and rounds. Gross submitted to chemotherapy by perfusion and return home at the end of the day. condition of many inpatients. This might be explained by the longer life expectancy (and chances of recovery. The rounds usually do not take more than forty minutes. Schedules and Organisation of Time On each of the days in which the clinic operates. If the former is the case. the group will go straight to the next meeting (which is invariantly scheduled for 10:00) with the radiologists. the day ends as far as the NROs are concerned.
the head nurse. None of the NROs consider him\herself as mere clinicians. The meeting is organised around a briefing of each NRO on the cases he/she had seen over the week. at times by the NROs themselves. Each NRO presents about ten cases. the social worker and the neuropsychologist. fifth year medical students are allowed in. the meetings also include research presentations (such as dr. Thus.Black Butterflies The first meeting includes the NROs. while the others listen and make suggestions as to treatment options or diagnosis. and reviews of state-of-the-art literature. The neuropsychologist would typically not get involved in these discussions but neither would she try and resume them. and at others by peripheral experts such as the histologist or the neuropsychologist. and all are involved in research at one level or another. This usually happens when the presenting NRO specifically says that "this is a difficult case" or "that is an interesting case". since this 86 . Levitz' presentation of findings related to "chromosomal differences between infratentorial and supratentorial ependymomas"). From time to time. however eager she may be to continue with her professional presentation. While the first is filled with technical terms and arise much interest.are referred to this clinic from all over the country. the latter is often regarded more as an opportunity to discuss patients' personal lives and personal peculiarities: as cases are presented along with the results of the neuropsychological testing. the team members would take these on to describe curious encounters they may have had with this or that patient. as children are referred to a paediatric unit. The Patients Patients –adults alone.
gives his/her name to the reception clerk. Actually. upon his arrival to the clinic. The Consultation The patient arrives at the clinic. and once a month when on chemotherapy. As the NROs tend to be late. There is no particular social characteristic which makes the patients' population remarkable. Some would only come once a year (once every three months is more typical) to have their MRI done. Gross particular centre is considered to be providing the most professional and specialised care available (in fact. but allows to remain unseen. or did they already have an attack which rushed them into neurosurgery – only then to understand they have a brain tumour. His/her file is then placed on a pile which will be taken to the physician's office from time to time. This entrance demands making a small detour. 87 . and consider the progression of the tumour. The physician would not see 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. Most of the patients I see come to the clinic for follow-ups. Patients under active treatment will come up to once a week when under radiotherapy.Sky E. The physician will find. it has a reputation of being among top neuro-oncology centers in the world). The files of patients due to have an appointment are drawn from the clinic's archive the day before. They have either been referred to the NRO after a diagnosis has been given by another physician. a list of appointments for the coming day. they will also find a pile of files – meaning that patients are already ready to be seen. the second scenario is much more common. New patients almost invariably know about their condition beforehand.
he\she will stare at the computer for a few minutes. the physician will suffice himself with a general impression of the patient's condition). some answering the NRO's questions for the patient (even 7 At this point I would introduce myself as Sky Gross. The family members are a critical part of the consultation. Family Members The patients usually come with a family member. another will be given to the patient. the treatment currently undertaken. the current complaints. Then come the orders: how to continue the treatment. a researcher from the Hebrew University. Then. it has to be noted that at no point do the physicians use their time for 88 . Even when diagnoses are communicated (often very bad news). and the patient is expected to quick. comorbidities. the NRO would utter a "how are you doing?" without really hearing the answer7. Close to the time of diagnosis and often towards the patient's death.Black Butterflies The ways the NROs conduct the consultation is very similar: as the patient enters and take a sit. Using a barcode reader. age and diagnosis. if not. They usually take on an active stance. to-the-point and assertive if he\she is determined to obtain clear responses. if any test or consultation with another professional is needed. and when the next appointment should be made. usually as is costumed to fill in the consultation report: the gender. 8 8 Notwithstanding these comments. All but one patient agreed. I would then ask whether I could sit in the consultation. more members of the family tend to join in. The NROs take great care in gathering information in an orderly manner. One copy will be filed. doing research on brain cancer and brain cancer patients. the physician will then enter the patient's ID number onto the specialised software. the report of the clinical examination (if there is one. There is no formal room for questions. the patient may be hasted out of the room8. or when complex treatment orders are given.
Unlike many other forms of cancerous diseases. and secondary (or 'metastatic'). originating from another cancerous process elsewhere in the body. once a tumour has metastasised. that is. one may define two general types of brain tumours: Primary. The types of cells involved and the form of its spreading give indication to whether the tumour is primary or secondary. based on the types of the underlying cellular formation and the location of the tumour: 'astrocytomas' (the most common). the presence of necrosis (dead tissue). All tumours are assigned a 'grade'. there are no known risk factors to primary brain cancer. the number of blood vessels providing nutrients to 89 . and 'oligodendrogliomas'. 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.e. 'ependymomas'. and etiology is little understood. Something About Brain Tumours Types of Tumours At the most elementary level. There is thus no known way to prevent the apparition of the disease. Life expectancy differs dramatically. Gross in cases where the latter is well enough to answer himself).Sky E. that is. The largest group of primary brain cancers is referred to as 'Gliomas'. forming in the brain itself. i. there is little chance in effectively controlling the process. a I-IV classification relating to the current speed of growth. Gliomas involve abnormal growth of glial cells (the supporting cells of the brain) and include four main categories of tumours. i. 'medulloblastomas'.e.
may cause serious handicaps or even death. each controlling specific functions. heart rate and blood pressure. as well as the ability to remain awake and alert. respectively. The area where the brain connects to the spinal cord is called 'brainstem'. 90 . GBMs are deadly. It controls vital heart and lung functions such as breathing. digestion. Location of the Tumour and Functions Threatened The brain is divided into six primary regions. Grades astrocytomas' III-IV or tumours are referred to as 'anaplastic Anaplastic 'glioblastomas'. astrocytomas typically progress to become glioblastomas (GBM) at some point. since so many nerves go through the brainstem. It is the pathway for all nerve function through the spinal cord to the highest part of the brain. The Brain Stem. pathologies associated with this area can cause almost any form of symptoms. or weakness on one side of the body (hemiplegia). They can also be located in or near a part of the brain which. sleepiness. 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.Black Butterflies the tumour. and the level of differentiation (pathological deformation) of the cells . I saw only a few of these patients. abnormal functioning of facial muscles. nausea. Problems in the brainstem often cause symptoms such as double vision. However. often giving the patient a life expectancy of mere weeks. The following is a brief overview of each region and their correlating functions. Grade I-II tumours are considered benign.
Gross The Cerebellum. Located behind the frontal lobes. colours. our feel and understanding of weight. walking. which together. problem solving and selective attention. planning. Located on the right and left side of the brain (near ear level). the parietal area comprises a right and left lobe. Tumours affecting the right parietal lobe can cause a lack of spatial orientation and may hinder the ability to recognise one's own body. The Occipital Lobes. The posterior parts of the frontal lobes also houses nerve cells that produce movement. such as the control of behaviour and emotions and moral judgment. Presence of pathology in this lobe can cause partial blindness or the inability to recognise shapes. and at the top of the brain. Tumours affecting the left parietal lobe can cause difficulty speaking or difficulty understanding speech. tingling. It is also where higher functions. The Frontal Lobes. and eye movement. Located at the back of the brain above the brain stem. and other sense-related symptoms. Pathologies of the parietal lobes can cause numbness. the cerebellum coordinates balance. or faces. The frontal part of the brain is responsible for organising thoughts. size and texture. and may be involved in the 91 . talking.Sky E. as well as much of our cognitive comprehension of the world. posture. the occipital lobes are 'in charge' of vision. control our sense of touch. and coordination. Patients suffering from tumours in or near the frontal lobes may not only have symptoms related to motor functions. Located in the mid-back of brain. the two temporal lobes help us distinguish smells and sounds. but may also suffer from extreme personality changes. The Temporal Lobes. The neural network takes input from your eyes and turns it into the pictures that you see. The Parietal Lobes. and affects activities such as eating.
In most cases. The treatment is given for one month at a time. Unfortunately. able to reach brain tissue is in the form of tablets: Themodal©. this barrier is not penetrable by the chemotherapeutic agents known to be effective for tumours across the body. at the end of which blood tests and imaging 92 . provided usually in this order: Surgical resection. the progress of the mass is inevitable. although it may proceed over decades. There are three types of treatment. however.Black Butterflies experience fear. The NROs are unambiguous: there is no 'cure'. and radiotherapy. Treatment The term 'treatment' is misleading. Surgery is usually the first step. The right lobe is primarily responsible for visual memory while the left controls verbal memory. chemotherapy. The reason for that is that the brain keeps some of the body's material out. and may impact short-term memory. Brain cancer has its own set of chemotherapeutic agents. Treatment is thus meant to prolong life or to better the patient's quality of life. Surgery. Except for a number of first grade tumours. 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. One agent is. but against the neurological deficits that may result from the assault on the brain. Chemotherapy. through what is called the 'Blood Brain Barrier'. Surgical intervention is seldom able to remove the entirety of the mass' tissues – microscopic malignant cells almost always remain to begin the growth anew. Almost invariably do they then report on their being rushed to surgery. the benefit of surgery must be weighted not only against the risk involved in any serious operation.
but will eventually cause death). A major sign of brain cancer is the loss of strength (paresis) or paralysis of one or more limbs and/or enervated body part. burns on the scalp. including hair loss. It also does not have remedial powers. in the course of which the patient is to meet the NRO weekly and give blood on a regular basis. if the treatment turns out to be ineffective. These symptoms have usually no treatment available. Steroids are provided for the relief of oedema. In all these. does not cause hair loss. The oedema tends to become more severe as a result of radiotherapy and surgery. The radiotherapy causes many side-effects (which severity depends on the dosage and the areas being targeted). it will create but little a sense of "Cancer self perception". some of which must be continuously accompanied with a monitoring of the active agent's level in the blood. The series of treatments is usually given once in the entire course of the disease. Gross are given. Radiotherapy. perhaps 93 . If the blood tests do not allow the continuation of the treatment (typically – anaemia. and the patient will be referred to radiotherapy. oedema and more. However. at home. low platelets count or neutropaenia). Radiotherapy is typically administered daily for a number of weeks. thereby providing relief in epileptic seizures and intracranial pressure (a situation that may be uncomfortable at first. Epilepsy is one of the most troubling symptoms of the presence of the mass itself and the oedema forming around it. and has in fact little side-effects. Symptoms Relief. Themodal is self administered. or if two years have passed – it is terminated. it usually does contribute to the shrinking of the tumour and does slow its growth. Epileptic seizures are also treated with anti-epileptic drugs.Sky E. extreme fatigue.
There is relatively little pain involved in dying from a brain tumour. unlike with most other types of tumours. especially when given in high doses. there is no role for the NRO but to follow from distance the palliative care provided to the patient. Palliative and Supporting Care. usually in a hospice or at home. The end may be uncomfortable. however. especially breathing. 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. When the treatment panoply has been exhausted. But.Black Butterflies besides steroids which would relieve some of the pressure on the part of the brain involved. making the surroundings accutely aware of their condition. It will also give the patient a typical bloated look. 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. Questions of self and the brain tend. Steroids are eventually devastating for many body systems. 94 . when more basic functions begin to deteriorate. to be of little concern in the everyday routine of most members of society. 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.
As is often the case in fieldwork. Brain tumours brings about the neccessity to visualise the brain (through imaging tests not usually undertaken by healthy individuals). The aim of this paper is double: first. I would be soon taken aback: almost no patient sought an understanding of the mind/body conundrum as it applied for him\herself . changes in personality). that the solidification of neuro-oncological objects is less than straightforward.e.Sky E. those related to the creation of a web of knowledge hierarchised and utilised in high accordance with the gnostic split. 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. amenable to 'discovery' through different ontognostically-based practices. Introduction The majority of medical texts represent brain tumours as involving fairly clear-cut entities and categories of entities. to face consequences of brain pathologies (such as motor and cognitive losses. even with the most philosophically-akin subjects. to underline the technological and epistemological grounds of 'expertise' in the medicoscientific practice of diagnosis. 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').This. i. however. A closer look into the life of a neuro-oncology clinic proves. I unwittingly revealed other interesting phenomena. Gross One instance in which the brain becomes a central focus of one's life is when it becomes the site of life threatening pathology. This will be the focus of this next study. Yet. in both epistemological and practical terms. and their roles in the assertion of expert 95 . however. but perhaps most significantly.
1992. namely with the head of the clinic led to the gradual gaining of the staff's confidence. Finally. 2005). 96 .Black Butterflies authoritativeness. Dr. Drawing on this now considerable body of research. Lynch. X. 1988. this paper will present an ethnographic study which allowed for a sustained in situ look into the daily micropolitics of the diagnostic practice. By the end of this process. a lengthy and laborious work of negotiation and clarification. to propose analytical tools to approach the complexity involved in the creation of knowledge. van der Geest and Finkler.the potential frictions it may create. the physician's home ground. 1993. and second.e. while referring to staff members in a manner that would reflect their professional roles. again. Anspach. 1996). a formal permission from the hospital's board of ethics (the 'Helsinki Committee') allowed me to begin my work. In this case. 2004. and the mechanisms of their resolution. rather than on ad-hominem aspects of their work (i.). Considering the level of intimacy I developed with the patients. 1986. Anonymity is ensured by the use of pseudonyms throughout. for both patients and staff. in a way. naturally conditional on the informed consent of both the professional and the patients taking part in the research project. Rabinow. seeking closer attention to the everyday practices of 'making science' (e. Latour and Woolgar. Mizrachi. I was accorded access to the most inner stages of the clinic. Pickering.g.g. Being. Methodology Over the last decades. I felt more comfortable using first names as pseudonyms. the hospital constitutes a precious setting for understanding the world of medical experts (e. Shuval and Gross. a new approach to the study of medicoscientific work has arisen.
97 . This was particularly salient as I did. Reporting diagnostic information such as biopsy and MRI studies. At the Clinic: The Diagnostic Process According to textbook medical knowledge. to the request of the staff. visual disturbances. I spent months prior to my insertion in the field studying related medical texts. create their own blood supply. In fact. where the NRO assesses previous findings. to these schemes. and as cooperation was ensured. Still. a brain tumour arises out of the proliferation and multiplication of a single cell. total or partial paralysis. for reasons little understood. Gross In view of the intricate nature of the field of neuro-oncology and the complex terminology used in interactions. The tumour presents itself through a neurological realm of signs and symptoms. in some cases.Sky E. the types of cells involved. however critically. gathers clinical history. loss of sensation in the limbs or. which. provided that proper ethical directives were followed. and performs a physical examination. wear the traditional white robe. At the histological level. along with clinical impressions allow NROs to determine the locality of the tumour. If judged necessary. which may include epileptic seizures. this did not seem to eventually form any significant obstacle. undergoes molecular mutation. and its degree of malignancy. I had to repetitively make clear to patients that I retained neither medical nor counselling role in the clinic. this process begins with the first encounter with the patient. personality changes. it seems one can hardly communicate the 'real life' work of the professionals without referring. these will reproduce. At the clinic. That being said. its size. and eventually become numerous enough to apply pressure on adjacent nervous tissues. speech malformations. There is a fairly ritualistic intake of new patients.
The second meeting proceeds at the MRI unit. the 'tumour board' –which includes the NROs. his/her colleagues offering their opinions and evaluations. Routine assessments of cases are typically performed in the course of three weekly conferences. neurosurgeons. treatment options (including. The formers then report their impressions. the participants (i. if applicable (viz. the reporting experts) are expected to conflate their way to 'speak of' the disease to the NROs’. the tumour is metastatic). 2002). clinical trials. radiotherapy. during the NROs’ staff meeting: there. among typically a in this wide order: array neurosurgery. as the integration of reports into a compiling diagnosis requires the adoption of a common way to ‘speak of' the disease. such as radiologists and neurosurgeons. Its place within the diagnostic complex is limited. tut tut tut”). with the primary oncologist.seeks a collective appraisal of the applicability of different surgical or radiotherapeutic protocols ('treatment algorithms'). 98 . albeit only once options are discussed in conjunction with other experts. a fact that reinforces their centrality in the diagnostical process. thus placing the latter in a junction of significant power (Mol. first orally to the staff (“things look bad. and.e.Black Butterflies immediate intervention is considered. The only common participants in these three sessions are the NROs. and radiotherapists. where the radiologists go through recent imaging tests while the NROs provide clinical information on their patients. and later in writing (“a slight compression of midbrain structures was observed”). of biomedical chemotherapy. In either case. Indeed. each physician is expected to present the files of the patients he/she has seen throughout the week. and the approach is largely task-oriented. The third meeting. First. and palliative care) are deliberated relatively professionals.
99 . most prominently in fields where diagnosis remains complex and critical (Reiser. we try to obtain a complete. 1992. adding to the intricacy of medical work (Howell. This is accompanied by the need for a constant reshaping of the definition and conceptualisation of disease. 1996). we gather together in a file of his own all the information we have about him. 1978.. (Foucault. where each re-assessment demands further exchanges of reports through the web of expertise. Patients attend the clinic up to once a week while under a radiotherapeutic regime. Clark and Mishler. the practice of medicine has become increasingly dependent on expert medicoscientific observation. 1995. Dew. 1963: XV) With the proliferation of diagnostic technologies. diagnosis is literally a lifelong process. and once a month when under chemotherapy – typically referred to imaging tests every few weeks. For the NRO. The 'case'. usually towards a worsening in all diagnostic values. Gross The interaction between professionals is critical both before and after initial diagnosis. 2001. remains in a certain state of fluidity. 2003). for a brain cancer patient. We ‘observe’ him in the same way that we observe the stars or a laboratory experiment". Casper and Koenig. objective idea of his case. Clarke et al. each diagnostic function defines a point on a temporal line which presumably depicts a logical evolution of the disease.Sky E. In fact. thus. 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.
g. 1994. expected course. clinical examinations. 2004). 2004). Different expertises are sustained within their own technological. Good.g. Lynch. 1963. assigned attributes and boundaries within its specific 'styles of reasoning' entrenched within formal and tacit knowledge (e. 1982. Moreira. They will they be placed within a 100 . As Polanyi (1998) and others (e. an object (e. 1999). an MRI machine). 1997). 1986. 2004). 1996. expert conceptualisation of pathologies is further mediated by technology (e. In many biomedical settings. 1963. and alternating definitions of 'the Disease' as one epistemological object (e.g. Latour. 1998. blood test results) and the preconceived nosological scheme of knowledge regarding diseases’ characteristics. each creating what shall be referred here as 'expert-mediated objects'. Haraway. Moreira. the analysis of the spatial characteristics of a tumour) and a hermeneutic agent (i.g. where they can be 'spoken of' in a common language. and epistemic systems (Goodwin. Boumans. and mediates the definition of the disease as a thing-out-there. Rabinow. Berg and Harterink. this process involves a multiplicity of experts: within each expertise. and likelihood to respond to certain treatments (Foucault. This ‘gaze’ then provides further interpretation of reality within these styles of reasoning (Latour and Woolgar. 2000). 2001) have shown. This integration of pathology and nosology requires a ramified process of creating. Mol. Berg and Mol. Hacking. Bos. changing. 1988. Koenig. diagnostic elements are observed. a form of attention (e. 1988. rhetorical.Black Butterflies Facing sets of signs and symptoms. 1994. 2004). 2002. communicating.e. Knorr-Cetina. This quest aims at a reconciliation of accumulated diagnostic data (e. explained.g.g. physicians are expected to 'reveal' the one underlying ontognostically-reachable element: ‘the Disease’.g. what does this finding mean?) (Foucault. 1993. These will then be made comparable and manipulable within an established nosological order. Collins.
which will be discussed later in the text. Mol. 1987. NROs --being ultimately in charge of diagnosis making-. 1992). 1996. 2004). Within the scheme proposed here. 2002. epistemological inconsistencies may arise once these are juxtaposed.e. organised conceptual chart of identified pathologies (Lynch. and create as many objects as the number of gazes laid upon it (Berg and Mol. Latour. The Web of Expertise In order to create the neuro-oncological object as a coherent 'ontologically asserted' (or 'ontognostically-based') referent (Bos. Anspach. 1998. Reports may be as numerous as the number of expertises involved. Gross delineated. i. 1985. often demanding an implicit evaluation of the forms of authoritativeness associated with each of its sources. the artefactual products of processes of observation and translation (Young. Bos. As this work will seek to demonstrate. this involved 101 . and amenable to integration or alignment with other objects. With this aim. Beaulieu. Hacking. 2002). 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. 1981. the NRO has to draw beyond his or her own field of expertise well into the neighbouring provinces of knowledge and technology.Sky E. they were seen to apply – often implicitly and always subtly – several mechanisms. 2004).tended to strive towards the assertion of the nosopathological uniqueness and integrity of the 'brain tumour' object.
exchanges between what I shall define as three relatively distinct diagnostic expertises. Reporting experts provide expert-mediated objects aimed at assisting in the overall assessment of each particular case. At the clinic, these included several professionals, including the histopathologist, radiologist, clinician, and neuropsychologist. In Marfa’s case, for example, her file showed the radiology report on the disease as an object with measurable spatial characteristics ("a two centimetres neoplasm located in the left parietal lobe"); The histopathologist, on a qualitatively distinct object ("a mixedcell oligodendroglioma with a necrotic centre"); The clinical, on a set of observable patterns ("a contra-lateral hemiparesis with frequent grand-mal seizures"); And the neuropsychologist on a series of scores along different scales ("a normal IQ test; low tendencies towards anxiety; normal results in the capacity to comprehend abstract notions"). In general, the fact that these expert-mediated objects are communicated in different forms seldom challenged, in itself, neither the ontological status, nor the pathological definition of 'the Disease'. However, reaching a sensible overall diagnosis did, as shall be shown, require translation and juxtaposition of these heterogeneous reports. Independent experts remain external to the main positions: reporting, independent, and compiling
expertise's (e.g. neuro-oncological) sphere while being potentially involved in the assessment of a patient's condition, depending on his/her known co-morbidities and general health status. Here, these experts (such haematologists or general oncologists) served as autonomous physicians holding their own clinical complex and definitions of disease. Still, while conducted independently, their diagnostic and record-keeping activities (including, typically, a separate file) were occasionally integrated into the patient’s
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neuro-oncological case, although chiefly in its margins. This placed them, in relation to the NROs, at the periphery of the diagnostic web. The compiling expert faces a multiplicity and disparity of objects presented in reports gathered from independent and reporting experts. Occasional disparity of mediated-objects, however, can potentially threaten the establishment of an integrated and congruent image of the disease as a relatively welldefined entity. This tension positions the compiling expert (here, the NRO) at a unique and most instructive junction which will be expanded upon throughout the paper.
On the Ontognostic Authoritativeness of Reports
The last century saw biomedicine develop more and more elaborate tools to assert objective grounds for its practice and science, including dimensions such as accuracy, accountability, validity, transparency etc (Boumans and Beaulieu, 2004). For instance, medicine will seek to redefine itself from a focus on 'artisanship' based on personally-owned tacit knowledge, to an emphasis on 'profesionalism' based on accumulated agreed-upon scientific knowledge. 'Objectivity' is also sought through the development of well defined protocoles, a growing use of technology in both diagnosis, treatment, and follow-up, and a quantification and standartisation of reports. The report is both an artefact allowing communication among professionals, and a channel through which independent and reporting experts translate the observed disease into expertmediated objects (Berg and Harterink, 2004; Joyce, 2005). As suggested by Callon and Latour (2006), it is through such
translation processes that epistemologically distinct objects come to be linked together. In practice, the translation (i.e., in the production of radiology, histopathology, clinical, or other forms of reports) was often poor: the reports seemed to serve more as means of asserting expert authoritativeness than to communicate information among experts or to patients. For example, the clinical report was handed over to the patient at the end of the consultation, whether asked for or not. As the reports were characteristically composed in a cryptic language, the patient typically read and re-read it once having left the room, often baffled by the swiftness of the consultation. As one perplexed patient said: "This is a summary of my disease, so I know whether I am better or not. I will show it to my children". She would remain unsure of whether she was "doing well" or not until having the report deciphered for her. The radiology reports were no more 'user-friendly'. For example, Alyosha’s MRI report read the following: "CVB 3, in MRS CHO/CR=4/3, CR/MI=0.9". This was obviously unapproachable, even for Alyosha, who usually tried to keep informed. Indeed, reports, say Good (1994) and others (Bourdieu, 1992; Beaulieu, 2002), tend to use jargon and rhetorics which make them appear more reliable, conceal areas of uncertainty, and ultimately reify the experts' position as holding exclusive knowledge and thus epistemological authoritativeness. This can be said of reports produced by each
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and every reporting expertise at the clinic. In the case of radiology, however, this may be more salient: as the visual medium may point to a lesser need of expertness in reading (it is "right there", "in black and white" some patients told me when asked whether they could recognise their tumour on the MRI), the need to assert the uniqueness and complexity of their expertise was obviously more critical. This will have clear manifestation in the form of a relative indecipherability of the reports.
The Sight of the Tumour: Radiology
The radiology meeting takes place in the general hospital's building, on the underground floor, where the MRI machines are located. This is where patients are examined and results are processed and interpreted by the experts. The NROs and MRI experts stare at computer screens while patients’ ID numbers are called by one of the neuro-oncologists. For each patient two MRIs are uploaded on the screen: the 'before' and 'after'. The NROs then all offer their opinion, hoping to be approved by the MRI expert: "the tumour has grown", "the tumour has not changed", "wow, this is a big one". The questions to be answered are of two kinds: spatial and temporal. Where is the tumour? Between now and then, is it larger, smaller, or unchanged? There are two radiology experts: Prof. Soren and Dr. Martin. Soren is a quiet but impressive man of about 60 year old, with a beard that gives him the appearance of a wise oracle. Unlike his junior colleague, he is never turned to by his first name, but rather with his full title: "Professor Soren". Martin is younger and his lack of experience is critical: in the field of radiology, tacit knowledge acquired through experience is which allows the expert to 'see' phenomena which may pass unacknowledgded by others. Training the senses may be the only way of reaching accurate 105
It included several carefully operationalised components. Clinical information was more often sought and drawn from when the picture seemed inconclusive (i. in practice. a worsening in the patient's symptoms was used to settle the interpretation – the tumour must have grown as well). Soren worked with the team. Therefore. the colouring of its centre and borders. whenever possible. 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. if unsure of whether the tumour has grown or not.. albeit for the neuro-oncology team's use only. as well as the head nurse. thus not knowing what she was writing. In this sense. When Martin did replace Soren. she served more like a mediating device than an actual 'professional'. This. along with the clinical and 106 . She never made any comment on patients. In fact. the regularity of its margins. All four NROs were present at each of the weekly meetings. Gila entered the evaluations she received from the group. Joining them was Lise's secretary. she never expressed any interest beyond what was directly dictated to her. She often did not understand the jargon.e. etc. plugged onto the hospital's intranet. 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). while his colleague continued working on 'general patient's reports. Gila. Gila sat with Lise's laptop. and equipped with the software especially designed for keeping and documenting patients' cases. the meetings were tenser.Black Butterflies interpretations. nor shown emotions when news were particularly diffficult. each conceivably contributing to the diagnostic effort: the location of the tumour. the number of foci. usually as summarised by Lise.
This has grounds on several broader cultural stances. 1990. 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. 2006) and vision as an unmediated perceptual source of knowledge: the images themselves purportedly allowing an ontognostic. Dumit. 2004). with 'seeing' being almost inseparable from 'knowing' (Lynch and Woolgar. Gross histopathology reports. Cartwright. 1995). This report played an important role in the continual examination and re-examination of the state of the disease. 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. and ruling out phenognostic interferrences and interpretations not intended by the reader (Bastide. Daston and Galison. non-interventional access to the truth (Foucault.if their MRI had not been yet deciphered by the expert. 1993. 1990. and a characterisation of its cellular bases. It is easy for MRI technicians to forget that there is a 'body' there (Rohrer. Boumans. enabled a grading of the tumour. so much as to have patients sent home --without being examined-. including the medicoscientifical tendency to regard sight as evidence. Knorr-Cetina and Amann. Although the MRI is by definition a mediated view of the patient. 1992.Sky E. Draper. that is: that the screen shows an abstraction of something. Joyce. 2004. As far as the team was concerned. 1990. Jenks. Ala. 2002. 2007). and make the subject of this thing transparrent (Duden. 1995. 107 . 2004). This materiality is what enables them to approach the thing. a mediated 'something' rather than the 'real thing'. 1963.
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.Black Butterflies Once the visual is alleged to provide the most authoritative access to the object of disease. Joyce. more accurate than would any direct assessment of the 'object itself'. 2008. its spatial characteristics. The site of the symptoms often directly reflects the location of the tumour. non-systemic disease. 2005. radiology would undoubtedly represent the epitome of diagnostic science (Gunderman. the patient). The symptoms tend to be in correlation with the surfaces of the brain affected by the disease. In fact. unlikely to metastasise to other parts of the body. some will claim that radiology may make things 'more real than real' or 'hyperreal' (Baudrillard. 1992). The diagnosis of a brain tumour. and to the rate of its spreading. Burri. 'Space' is another crucial element in the assertion of the authoritativeness of radiological knowledge (Leigh Star. indeed involved an emphasis on spatialisation: brain-cancer is a local. however. in the NROs' own terms 'a space occupying process'. when Lise left Simon's 108 . Frank. 1989): "Wow. when speaking of a patient's pathology. 1988. it is indeed large. including phenognostic assessments by the object itself (i. 2008). Often. 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.e. that is. For instance.
He looked at the MRI and without uttering a word. has powerful epistemological affinity and mimetic relations with the disease as it is conceived: a spatial diagnostic technique.Sky E. This is when Franz solemnly announced: "The radiotherapy had no effect. on the right side of the face. In fact. Franz read the file: Simone had just completed a round of radiotherapy. he said. Gross room and discussed his condition with her colleagues. a 25 year old woman. including in the clinic. completely lethargic. Franz bluntly answered. and yet. Radiology. The spatial attributes of the tumour are strongly tied to every aspect of the physicians' work. This is well examplified in the case of Simone. but understood that something must be wrong.e. like in a biopsy?". Albert. she naturally placed her hand on the left side of her skull. now more clearly drawing around the edges of the tumour. thus. Her husband. Simone sat on a wheelchair. i. as if the visualisation of the tumour actually explained anything. she looked considerably worse. only to go back and doze off again. the tumour has grown. as a space-oriented measure. with advanced cancer. "explains how she is". and surgery is now impossible: the tumour takes on half of the brain". turned the screen towards Albert: "Look". Yassar remained unsure of the thing he was supposed to 'look' at. rather than where the (very visible) paralysis was. Franz pointed at the screen. 109 . "This". keeping an empty smile when spoken to. Albert: "Couldn't you suck it up. for a spatially defined pathology. accompanied her along with her mother to Franz' office.
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. "You didn't think she looked tired?" "I thought it was the radiotherapy that made her tired". Within days. after 30 days of radiotherapy. It was as if he finally 'got it'. right?" to which I answered with a smile. especially in terms of correlating pathology with existing 110 . Albert proudly showed me how her hair had begun to grow again. He was by now completely deflated. the entirety) of the mass removed and sent to the laboratory expert. one of the first steps taken after the initial diagnosis is to have a portion (or. I was interested as to whether actually seeing the tumour made any difference: Just a few minutes before. This is when the mother burst into tears. asking a rhetorical question: "she'll be alright. This assessment is extremely complex. 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). in some cases. I don't understand". I asked him whether he was surprised to see the MRI: "Yes.Black Butterflies annoyed by the naïve question: "This is not a liquid! You would suck up all the brain out!!". now joined by Yassar. After the consultation. Thus. it isn't supposed to grow. now. as it is the most accurate source of defining both the grade and the cellular basis of a tumour.
To mention only a few criteria of histopathological categorisation: one form of gliomas. and its position at the cutting edge of research contribute to its prestige as providing an exclusive corpus of knowledge. These sophisticated schemes of identification and classification are. 1991a. provides the laboratory a distinction drawn on a halo of pure science. and well-defined areas where scientific work can proceed. clear of the 'fuzziness of reality' (Foucault. astrocytomas. Removing the personal particularities of the patient enables a more clear-cut alignment with existing nosological categories. may be either well-differentiated or anaplastic. 1999). Cicourel. and. This. with low or high degrees of cellularity. Bourdieu. its high tech procedures. etc. isolated from subjective time and space (and thus from subjectivity itself) to create alternative sterile. Another characteristic appears to be involved in this assertion of authoritativeness. one must note. in a way. however. or about their cancer being either malignant or benign. the removal of biological tissue and its analysis outside of its human context allows 'social distancing'. either fibrillary. In sharp contrast to the 'hands-on' clinical evaluation. The living person becomes literally out-of-sight. out-of-time. 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. Gross (and continuously growing) nosological schemes. 1977. 2003). or gemistocytic. motionless. central to the creation and preservation of the ontognostic medicoscientific ethos (Foucault. Thompson. pilocytic. 1964. both within the 111 . in turn. 1963. Rosenberg. Reiser. low or high degrees of pleomorphism. 1963. Patients. out-of-site. Histopathology’s ever-growing categories of mediated-objects.Sky E. 1995. Keating and Cambrosio.
Black Butterflies realm of histopathology and within the broader neuro-oncological compiling diagnosis. such knowledge – however justified and materialised in the form of standardised and empirically confirmed scales and numbers . but also guided psychology students who are obligated to practice giving these tests to patients. 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. whose task was to provide patients emotional support. Keren was assigned patients that seemed to suffer from cognitive or emotional deficiencies related to the organic effects of the tumour. or to side-effects of the treatment provided for the tumour. the neuropsychologist (Keren) was regarded as a diagnostic source. She administered psychological tests and interpreted them. Still. Her contacts with the staff were very limited. 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. never to be read by the NROs. neuropsychological evaluations tended to be presented as highlydetailed statistical reports.remained illustrative rather than demonstrative. neuropsychology played little or no part in the actual medical decision process. If the neuropsychologist was so seldom consulted. it was probably based on the low authoritativeness and epistemological profile of psychological methods (and 'psy112 . Arguably with the aim of establishing medicoscientific status. Figuring it out: Neuropsychology Unlike the psycho-oncologists. and her reports were usually filed. Yet. That being said.
as advertently or not. it was presented through a filter of 'epistemotechnics' that would 'truthicise'9 it in the context of scientific medicine Indeed. and reflexes. numbers and standardisation allowed a rising of psy-knowledges towards the level of authoritativeness assigned to more conventional biomedical sources. Changes in sensation will be identified by means of a probing of different parts of the body. 1985. assessment of a number of parametres. 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. if psychology wants to take full part in a purely medical practice (here: neuro-oncology). 1991b. 1992. According to textbook directions. usually non-instrumented. Gross knowledges') in the medicoscientific complex (Rose.Sky E. it must relates to 'epistemotechnical' aspects of its work that put it in the same (or close) epistemological level as medical science. and coordination by observing body movements. 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 workshe refused to have neuropsychology remaining as peripheral to neuro-oncology as it was now. Hands-on: The Clinical Report The first component of the clinical exchange. the physical examination. these include the tone of each muscle group. 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. Porter. Hacking. 1995). although rarely meticulously followed in practice. Relying greatly on statistics. Reiser. The knowledge was allowed in. Also central to the examination is the 9 'make true' 113 . muscle power. comprises a direct.
past medical interventions. visual disturbances. and associated complaints. objectivity. frequency. nausea) which must be characterised by time of onset. 114 . 1988. Gertler. The clinician is expected to provide expert deduction and gather relevant information from the patient. 2006). The second component of clinical practice.Black Butterflies evaluation of gait. demands a systematic gathering of information (e. patients have a 'privileged access' to their own inner world of experience. motor or sensory dysfunctions. This impinges upon the ethos associated with ontognostic thought. precipitating circumstances. Porter. A history of administered treatments must also be sought. and the method itself based on phenognosis and overall 'primitive' (Joyce. and preciseness attributed to this practice is critical in the evaluation of the validity – and thus authoritativeness – of knowledge portrayed in such reports. In order to retain ontognostic authoritativeness. whereby the physician would necessarily have epistemological supremacy as holding total and absolute knowledge of the phenomenon of disease. 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. 1993. location. history-taking. and are able to reach a phenognostic 'truth' that is beyond scientific exploration (Heil. The lack of neutrality. 2005). while drawing on haptic skills and limited technological aids (Foucault. Arguably. as well as should a more general background of co-morbidities. progression or remission. headaches. 1963. seizures. pain. Moreira. during which the patient will be asked to walk back and forth. duration.g. and cases of severe illness in the family. rather than to the patient's life-world: his/her belief system. severity. 2001). the expert must bind his/her perspective to observable and accessible aspects of the 'reality' he/she faces.
they are denied any status of expertise: the expert is the 'reader' of the body. emotional issues. tastes. the reports included clauses such as: “according to the patient. Anspach. quoting from one clinical report: "[The patient] describes events of abnormal smells. Mishler. "He complains of some difficulty getting his words out in conversations". The first was assigned some legitimacy as the reporting physician ipso facto provided a seal of approval to the actuality of the symptom.g. etc (Cicourel. 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.was presented during meetings as if of higher authoritative status than the 'described'. noting their relative unreliability. and –to a lesser degree-. the deciphering agent of the narrative. a clear form of power. 2005). Gross background. The second portrayed 115 . 1983. A similar trend was found in oral exchanges: the 'had' – as in "the patient had headaches". Gunderman. 1988. The patients themselves cannot be assigned 'expertise'. and panic feeling up to 10 times a day" or. 1984.Sky E.than the 'complained of'.. overemphasise some minor symptoms in order to assure full attention and treatment). While the patients may influence the actual process of diagnosis (e. written reports showed patients' accounts preceded by a sort of 'disclaimer'.reliable givens At the clinic. particularities. personality.. both of which are –more or less-. Typically.” or..
The Patient A clinical evaluation. Observations of the field suggest that a classification of patients into reliable ('good patients') and unreliable ('bad patients') is most sensible. the ideal patient is cooperative and compliant. In general terms. He still needs to be able to ask intelligent questions. also applies to the patient's ability or willingness to internalise the biomedical gaze and its ontognostic claims for epistemological authoritativeness (Gross. reflect on. In general. being too knowledgeable may be seen as an annoyance. asking the right questions and responding in an appropriate way to the the physician's inquiries. and effectively communicate the nature of the symptom by offering a description. This classification has its basis on a range of characteristics. He does not have to be knowledgeable on the subject of his illness. does not solely rest on the examination of the patient's body.Black Butterflies the patient as able to observe. I shall argue. This makes the definition of the authoritativeness of phenognostic. Yet compliance does not merely involve following 'doctor's orders'. These. may provide. rather than speak of a vague. or to refrain from asking questions at all. thereby re-affirming the physician's skills in providing all relevant information. the patient is expected to be straight and to-the-point in reporting his complaints. however subtle. but also to the conceived credibility of different forms of clinical information: from the more phenognostic sources to the more ontognostic. as defined above. first-person information highly 116 . and in fact. emotionally-laden complaint. but also on the accounts he\she critical. variations provided clues not only as to the authoritativeness assigned to clinical knowledge. 2009a). The term.
The oncologist told her she was overmaking it. Adi turned from 'a bad patient' to a 'good patient' when her reports. He\she would then quickly adjust his\her account accordingly. he would be expected to accept the superior epistemological status of the physical sources. I never had such headaches – you know. I'm not faking it!!!' " The 'good patient' reports symptoms that are compatible with the physical profile of the assigned pathology. Gross For instance.Sky E. when I had insane headaches. Friday. Such a patient will tend to think some symptoms more relevant than others – or some symptoms being simply 'psychosomatic'. and Saturday. Shortly after the oncologist declared her "better": "There was one weekend – Thursday.if they would not fit into the scheme proposed by the physician. 117 . Was a patient to report on symptoms that were not compatible with the diagnosis. were truthicised with ontognostic measures. I've been living for thirty years. at first not taken seriously by the oncologist. yet: "After [I applied] very intense pressure.e. you bow your head to brush your teeth or something… I felt my head will explode and drop to the floor". They sent me for radiation right away and gave me steroids […] I felt like telling them: 'You see. The reported symptoms' alignment with the determined diagnosis is a clear sign of the internalisation of the 'medical truth'. the authoritativeness of the 'observed' (ontognosis) over the 'felt' (phenognosis). I had several brain tumours. i. he sent me to do a head CT.
but in the ears". Lise's account of an exchange she had with a patient: "His wife doesn't understand the drug thing. such as feelings of numbness or pain. The field teaches us that the patient must provide specific forms of accounts that eliminate. In fact. being succint but informative. She argues with me and won't agree with me. although. the person may simply be not truthful (lie). or diminish these two considerations: he must speak of symptoms in a credible way talking about witnesses. The good patient also never argues with neither the diagnosis nor the advised course of treatment. 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. without him holding true knowledge of it. phenognostic accounts. This has two major reasons: one. where brain cancer is involved. I think". and second. the person may not be aware of his own condition.Black Butterflies The 'good patient' must also report symptoms that 'make sense': problematic accounts may include "feeling as if crossedeyes. one may wonder whether there is such a thing as being 'overly' anxious. [In my view. A good patient will provide just the right amount of reporting. the woman did not show any sign of mental retardation] Although some information may only be sough from the patient's account. He must also not be "overly anxious" (this being a typical term used). would be compatible with the textbook account of the disease. There is also a right timing when the 118 . She is retarded. it is considered most credible when the patient seems to 'incidentally' report symptoms that. one may distrust these first-person mediated.
Ultra-orthodox are quickly assigned to this group. too early. 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"." She refused. 2008). The team was amused. and will at time refer to it with some sense of humor. marrying the wrong partners. 119 . he may seem 'hypochondriac' or as more often used – 'suffering from anxiety'. Gross symptoms must be mentioned: an eagerness to report symptoms may have one lose credibility. When we looked at the MRI. 'Bad patients' tend to come from less educated backgrounds. and often from lower socio-economic status. so I told her. turning to a Rabbi for advices and so on (Gross and Shuval. Riba. again reifying the epistemological inferiority of patients' accounts over MRI results. if you don't feel well [as if trying to catch her bluff]: go to radiotherapy. told the team a story about one of the female (deemed 'hysterical') patients: "She won't admit it but she's getting better. Riba has the morale of the story: "A month later she said she felt much better and stopped telling these overly dramatic stories. the headnurse. They may arrive to consultations with too many family members ("they must think it's a party!" said the headnurse about one such family). The staff members are well aware of the suggestibility of patients.Sky E. there was no real improvement". 'Bad patients' will get raised eyebrows in exasperation when leaving the room. also because they are seen as making choices that give rise to clear indignation: having too many children.
Lise responded with a dry "no" and went on ("Does she think it's like giving out candies?" she would later say). 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. 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). she tends to take on a subordinate. including his wife. and sent to more elaborate testing. and not unlike other specialists. he arrived (from the provincial area of Tiberiade. a middle aged woman. Lise.Black Butterflies One memorable case of such 'bad patienthood' is Benjamin Abitbul's. two sisters. a brother. speaking outloud. just so to make him [Benjamin] less upset". in charge of breaking the news of Benjamin's impending death. Benjamin was recently diagnosed with a brain tumour. She is relatively assertive and confident (although always cordial and gentle) with her patients as well as with the clinic's clerical staff. this. He himself seemed embarrased to be followed by what the staff will disdainfully refer to his 'Tiberiade' family. although she would often have consultations with three or more persons present. 120 . passive. more than 100 miles away from Jerusalem) accompanied with no less than five family members. She would later scornfully describe the incident to her colleagues: "These people" were "impossible to work with" and "didn't know how to behave". position. In her exchanges with the NROS. however. and a sister-inlaw. The group was quite assertive with their presence. passing snacks and water from one to another. 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. Little did she know the sister soon approached me with the exact same request.
Gross The physical basis of the clinic is in a general oncology clinic. besides the head of the clinic. which also points top the importance of the nosological difference between brain cancer and body-cancer. This is particularly interesting. they are general neurologists (who. Indeed. in many ways. Knowledge in general oncology is rarely required where brain cancer is concerned. since neuro-oncologists are not trained as oncology specialists. 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. The rooms do not hold any specific characteristics that would point to any particular specialty (such as drug posters. and seldom does the tumour spread to other organs. Lise. all work as neurologists either in the hospital or in the community).Sky E. Levitz. 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. anatomical illustrations and so on). with some on-the-job experience in neuro-oncology. This is in line with the general trend of regarding brain-related disciplines as most distinguished. The brain responds to only a few chemotherapeutic interventions. It's an intelligent field". Thus. the neuro-oncological clinic and its related interdisciplinary web is organised along a nosological concept. 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. Rather. which facilities the NROs use three days a week. the diagnostic tools are well defined. The clinic is an environment which accepts specific nosological categories but also 121 .
finds the chosen cases most instructive, perhaps as a by-product of the nosologically-based criteria of inclusion: "By operating a process of selection, it alters in its very nature the way in which the disease itself, is in manifested, the body and that the is relationship between what is present is the disease appropriate to it, which is not that of the patient, but that of its truth" (Foucault, 1975: 26). This perhaps defines best the importance of the nosological complex that would define or be defined by the institutionalepistemological separation of neuro-oncology from oncology.
The Neurosurgeons and the Tumour Board: Peripheral Experts
Once a week, the neuro-oncology staff (the four physicians and the head-nurse) meets with the neurosurgeons. The name of the weekly meeting, 'the tumour board' is somewhat enigmatic: as if this was when the tumour would be defined, identified, and characterised. This has in fact little relevance to what actually ocurred in these meetings. The neurosurgery staff comprises three middle-aged men, assertive and at times even aggressive in their manners. The athmosphere is quite different from the radiology meeting's: the power dynamics put the NROs on contested grounds as far as their expertise is concerned. This aside, the meeting is not diagnosisoriented, but rather centres on decision making: 'can and should this patient be operated on?'. Each meeting focuses on no more than three to four patients where surgery might be considered. 122
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Then, clinical evaluations are brought up along with radiology reports, and treatment options are deliberated. Although the NROs are the ultimate decision-makers, and will never suggest surgery when deemed impossible or not beneficial by the surgeons, the latter remain highly authoritative, probably due to the high status brain surgeons have in the medical field and to the uniqueness of the tacit knowledge they may have acquired over the years: a form of knowledge innaccessible to the NROs. One must remember, however, that the neurosurgeons play no role in actually diagnosing the patient, and are therefore somewhat outside of the scope of this scheme.
Mechanisms of Integration
The raison d'être of neuro-oncological expertise lies in the contention that brain cancer is a distinct, well-defined, and conceptually unified disease entity. Asserting the coherence between mediated-objects not only reaffirmed the soundness of each individual form of inquiry and validated the meta-diagnosis of one particular case, but also served to support the general notion of brain cancer as a cellular based, spatially spread, and scientifically detectible form of disease, one for which a specialised compiling expert should be ascribed. In other words, the ontological, pathological differences between 'body cancers' and 'brain cancers' are replicated in the field of relations between professions and profesionals: between oncologists and neurooncologists. These boundaries are further replicated in the spatial organisation of the clinic, as described at length in an earlier chapter. In terms of the web of experts, the hierarchical distinction between neuro-oncologists and general oncologists was 123
continuously sought to be preserved not only by the NROs forming a 'clique of their own' as one onco-psychologist put it, but also via the establishment of disease categories and diagnoses pointing to the particularities of brain cancer over other oncological diseases, and the affirmation of the diagnosis as requiring neurooncological, rather than oncological, expertise. When faced with a collection of disparate reports, the NROs thus sought to establish the case as of a well-asserted neuro-oncological nature. In this sense, the meta-diagnosis also served to delineate, and then preserve the areas of jurisdiction and epistemological boundaries of the compiling expertise (Abbott, 1988; Gieryn, 1983, 1999). This secured the NRO's prerogative to elect and determine treatment options, to provide reliable prognosis, and to centralise documentation and records for future research: to be the compiling expert. As claimed above, this endeavour involved five relatively distinct mechanisms: hierarchisation, sequencing, negotiation, peripheralising, and pragmatism.
Forms of knowledge, as well as the objects produced by this knowledge, are created and sustained by having its different forms become authoritative, and others subjugated, marginalised, or excluded from the sphere of legitimacy (Foucault, 1980; Latour and Woolgar, 1986; Latour, 1996). As shown throughout the text, the forms of expertise associated with neuro-oncologic diagnosis differed not only in terms of instruments and types of knowledge applied to the mediated-object, but also in terms of their perceived authoritativeness, and, consequently, hierarchical position. The NRO, confronted with the task of incorporating the disparate reports, could (and often did) choose to constrict the
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range of available knowledge by discarding information from less authoritative sources, settling for a diagnosis based on narrower --albeit more solid-- foundations. This was the case with Ilya. At the radiology meeting, his latest MRI took Lise by surprise: "this looks bad…", she told her colleagues, "It’s amazing, he has no symptoms! This guy walks around with a ticking bomb in his head, but is completely asymptomatic…". In other words, the MRI suggested a progression, while the clinical picture pointed to a more stable and benign condition. The pictures were unquestionably there, thus the 'anomaly' had to be located at the clinical level, the less authoritative of the two forms of knowledge. As well put by Gunderman (2005:342): "We radiologists sometimes find ourselves giving more credence to the images than to the patient, rendering the patient’s experience subordinate to the images on the monitor." Lise declared a worsening in Ilya’s state: now judged ineffective, Tal’s chemotherapeutic treatment was discontinued.
Brain tumours are conceived as having a dynamic
constitution. First, it is granted that the tumour may progress from one grade to another, may respond to therapy --at times long after the treatment itself has been interrupted or concluded-- or may simply remain unchanged. Moreover, symptoms tend to accumulate and aggravate, and their response to medication may decrease over time. Sequencing uses this set of temporal factors to account for diagnostic changes without challenging the unity of 125
'the Disease', substituting ontological fluidity for temporal fluidity: the object may not be stable as an entity, but still retains a continual consistency as a neuro-oncology-mediated object. On one occasion, for example, Karl’s wife called Franz to report that her husband had a new symptom: he felt 'tingling' in his left arm. She was surprised as the MRI, taken two weeks earlier, suggested a shrinking of the tumour. Considering the authoritativeness assigned to medical images, Franz did not readily discard the imaging report as unreliable. Rather, she answered that the disease had probably worsened since. As MRI images were never compared unless taken at least one to two months apart, this was an assertion that, while sensible, was impossible to be put to the test, and thus also impossible to challenge. Yet, as it allowed the initial diagnosis to remain valid, it was accepted, to the very least until other evidence came along (the next MRI suggested that the tumour was indeed growing). In general, in case presentations, the sequencing of the events is very much put at the centre, and the temporal dimension is central to the characterisation of the disease. Only with little exceptions does it not make complete narrative 'sense' as the development of one (or several concomitant) diseases.
It is during the weekly radiology meeting that 'negotiated processes' (Moreira, 2006) could be observed. There, the four NROs would sit behind a radiologist who gave 'live' interpretations of the images. Led by the NROs' instructions, he focused on particular sites, paid attention to specific patterns, all the while well aware of 'what it is we are looking for'. The clinical and the radiological were often – again, never deliberately - adjusted 'on the spot', that is, well before the written report was issued. 126
which were delivered also orally.Sky E. She advised Friedrich to phone her the subsequent Monday for a more definite answer. the clinical picture suggested a slowing down of the tumour's progression. performed a dual role in the web of expertise: once as a compiling expert and once as a clinical reporting expert. The NRO. thus having little to add to the 127 . According to Lise. by the time the file reached the NRO as the compiling expert. Secondly. First. Lise briefed the radiologist on Friedrich's clinical improvement. when clinically evaluating one particular patient. histopathology was conceived. Thirdly. the histopathology report was customarily communicated solely in writing. the NROs were provided with nonnegotiated reports. while the MRI report remained 'incomprehensible'. emphasising the fact that he had recently received treatment. some degree of compatibility could already have been incorporated into the reports. compared to reports resulting from the MRI-NRO meeting. In the course of Sunday's meeting. as involving a lesser degree of human interpretation. Hence. overall. The NRO. the NROs tended to regard themselves as more competent in reading MRI pictures than in the deciphering of cellular formations. and thereby as being more rigid to processes of negotiation. could thus favour interpretations that were most consistent with his/her overall preconceived impression. facilitating the reaching of the meta-diagnosis. Gross On some occurrences. Negotiation was less apposite where histopathology reports were concerned. unlike MRI reports. one may recall. tended to be vague and obscure. One such report was Friedrich’s. These. The highly negotiable nature of the imaging report permitted the team to agree that the MRI showed some decrease in the tumour's size. The use of this mechanism was also evident where clinical reports were concerned.
a symptom now completely discredited. the importance of the histopathology report was often only tangential to decisions on treatment. I do have some headaches…". Lise asserted: "I don't believe you should feel any change" Misha: "Well. and conseqently abided to this normative statement. Finally. Peripheralising Sofya.Black Butterflies histopathologists’ interpretations. and was conducted significantly less frequently than radiology tests. mumbling: "OK…right. Negotiation was also present in clinical exchanges with the patients.. a 52 year old woman with a highly malignant cancer." The headaches.. For instance. Lise: "It's… I don't think it's really something". when Misha came to hear about his latest MRI and discuss his condition. Now almost completely blind. holding her face in her two hands. she mumbled in response: "but my head aches so much that I can’t even touch the tips of my hair without feeling like 128 . Misha. was told by Franz that "the latest MRI shows [she is] doing better". were never brought up again. he was almost literally told what he 'should' be feeling. Looking carefully at the MRI. The MRI showed that the tumour had slightly grown over the last two months.
Franz interrupted her short monologue: "That.Sky E. albeit in its periphery.e. Overall. I can’t explain". providing the NROs a certain degree of slack in their meta-diagnostic work. 2004). Such objects could then serve either as contextualisations of the meta-diagnosis or as evidence of its accuracy. their thrusting aside. the place of independent-expert-mediated objects was to a large extent assigned by the compiling expert. however. and relatively little room for intense radiotherapy. extrinsic rather than intrinsic – the NRO held considerable leisure in their re-interpretation or. the independent expert was sought once a diagnostic element could not be accounted for within the neuro-oncological sphere: the dermatologist could. Pragmatism In neuro-oncology.i. the 129 . 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.. treatment options are comparatively scarce. as in other cases. alternatively. In practice. once treatment options run out. Here. They include a few forms of chemotherapy. This dermatology-mediated object could then be incorporated into the view of the neuro-oncological disease. Gross screaming!". he concluded. a limited array of surgical interventions. or challenge the already well-established diagnosis on the other. Only one fifth will be expected to survive for more than five years (Coldman. Phillips and Reid. As these objects belonged to a sphere of expertise defined as 'independent'. he referred her to a dermatologist: "it could be a different problem". explain away the 'hair ache' without openly dismissing the patient’s complaints on the one hand. As she attempted to persuade him that her pain was real.
Patients rarely demanded much more details. to rather refer to hazy notions such as 'my condition'. At this point. she will be given something for her symptoms. in some cases. for many patients. 130 . was surprised to hear me refer to the 'oncology clinic' when we set a location for an interview. formal diagnosis remained futile. a 84 year old woman. i. seem somewhat less crucial. spent months visiting the clinic without showing any interest as to whether his tumour was graded III or IV. "Am I doing better?"). This being the case. typically in a hospice or among his/her relatives. a large dose of the most common steroid used in brain cancer: dexamethazole©. however. Oren. the neuro-oncology clinic saw patients only once a brain-tumour diagnosis was reasonably established. and. whose precise type and grade of tumour were unknown. Treatment prospects seemed more salient: "Will I have to go through chemo?" "Will I lose my hair?". or 'the lump'.Black Butterflies NRO usually ceases to be involved. In effect. more often than not. As a rule. This was the case with Grushka. the diagnosis remained vague: "There is a finding in your brain. rather. for example. avoided using the term 'cancer'. elaborate and minute diagnosis may. patients themselves were little interested in precise diagnosis. The group was unanymous: she will not have her tumour biopsied. He said he never noticed it was a clinic that "also deals with cancer". Although undoubtedly aware of the grading system. Simon.e.this after five years of follow-up. for example. Indeed. he "never thought of asking". beyond general notions of improvement or degradation ("Has it grown?". we are still unsure of its exact nature" was a classical opening. The patient will then be offered supportive and palliative care.
precise diagnosis did not serve any prognostic aim. or "each case its own". In line with the "pact". told me he read "a lot" about his condition.Sky E. as far as patient-physician interaction was concerned. While family members did occasionally sought online information on the expected lifespan of their loved-ones ("for practical reasons". Gross Recently diagnosed patients tended to use the more hesitant "I was diagnosed with…" than the definite "I have…". As to his life expectancy: "Really?! Do they [the websites] say anything about that?! It must be in small 131 . where the precise diagnosis was regarded by both as merely tentative. they would typically claim). In the course of more than one hundred such consultations observed. prognostic information was only vaguely sought. "We’re never sure of anything. only a few patients inquired into expected consequences of their diagnoses: the "how long do I have. rather than "will I live?". but we have to do what needs to be done". 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. Both patients and physicians entered a sort of unspoken pact. doc?" question was never raised. Physicians themselves never went beyond a general: "it’s all just statistics". a computer programmer well acquainted with the web. under any variation. In fact. one of the younger patients. with a "can this be treated?". When at all.
In the case of Alexey. a more pragmatic approach was be adopted. here. single or multiple. an 18 year old boy. He "doesn't want to know too much": "The only information I have is what my sons tell me. like many other patients. the neurooncologist (here. Although aware of many aspects of his condition. he seemed completely oblivious to the fact that his life expectancy was of a year or so. he would go on and on about becoming a physician. just heard about his melanoma (skin cancer) having metastasised to his lungs and brain. The prospect of medical school was poor. as the presence of metastases remained an almost definite death sentence. As far as I'm concerned. Patients were then less concerned about the precise nature of the neuro-oncological aspect of their disease. Also. a 66 year old man. during which he will probably be increasingly handicapped. Gabriel. or I must have missed this line [where life expectancy was mentioned]…". he would simply deny this reality. as was his life prospects in general. serving as an independent expert) tended to provide an assessment that was more quantitative than qualitative: the tumours were either present or absent. I don't need to know anything beyond the tip of my nose [places his finger on his nose]". At this point. However. active or stable.Black Butterflies letters. focusing on treatment options and palliative care rather than on elaborate diagnostic 132 . as far as the NRO was concerned. the compiling expert) suspected the presence of cerebral metastases. These were referred to the clinic after the treating oncologist (being. This trend was also evident among another significant group of patients.
Perhaps most interestingly. this stance of pragmatism typically involved tacit avoidance of definite and elaborate diagnosis. which the NROs regarded as of weak empirical validity. Gross undertakings. whether a glioblastoma multiforme or an anaplastic astrocytoma. whether the tumour was defined as a grade-IV or –III. In these cases. This process of alignment little usually of involved the reporting of and its independent experts: these would typically treat this diagnosis as ascertained. for example. and involve highly heterogeneous epistemological forms. The disease may itself be loosely defined as belonging to a more general diagnostical category. while unspoken. however. 133 . This was in many cases. Concluding Words As part of a larger attempt to consider issues of dynamics of knowledge and their relation to social phenomena. NROs often favoured the use of as little information as needed for the determination of the most advantageous course of therapy. being aware looseness epistemological grounds. In these cases. this study demonstrated the significance of the web of expertise in the production of diagnosis. pragmatic considerations could eventually have some bearing on the overall diagnostic process: once a tentative object of disease was defined. little more than a bureaucratic formality. Still. In practice. stating. most particularly where the latter tends to be ubiquitous. other forms of diagnosis could align. the NROs accepted the fluidity of this definition and proceeded to consider treatment options.Sky E. an official diagnosis invariably appeared on the reports.
peripheralising. the undertaking of diagnosis. little research was based on thick descriptions of expert exchanges in the backstages of a hospital setting. and pragmatism. The analysis presented here may seem abstract. it eventually comes down to the effort to save patients’ lives. Many of the patients discussed here died before this manuscript was finalised. As and defined a above. yet mesmerising 134 . sequencing.e. Others will soon die. The ability to witness the processes of diagnosis from various angles.Black Butterflies While widely acknowledged in past literature. some more in comfort than others. but also in reifying the legitimacy of neurooncology as a compiling expertise. the use of five mechanisms of consolidation: hierarchisation. and with different sets of expert relations. to give them more time with their family and loved ones. These mechanisms were shown to involve different cases at different conjunctures. i. All being said about the ontognostic 'reality' of these 'objects of disease'. I propose concluding with an afterthought. including different actors and different settings. expert gaze incorporates into one sets of epistemologies and technologies. The replicated flows of artefacts. and interpretations among experts were shown to have an important role in asserting both reporting and independent expert authoritativeness. Participant observation of the in-situ workings of the clinic suggested that this reification involved. emphasising the complexity of diagnostic work. both of which mediate diagnosis reduce multileveled phenomenon single manageable object. allowed for a thorough and detailed presentation and schematisation of the microdynamics of a central aspect of medical work. to make their last moments more bearable. In an ironic. negotiation. on the part of the compiling experts. concepts.
it thus only makes sense to place the brain at a most significant juncture of this work. and eventually the experts themselves. or less painfully ended. It is through dynamics of knowledge exchange. or objective insularity. that actual. 135 . They are encroached in the flesh. This section will be based on a notion of the brain as an intermediary between matter and consciousness. when the individuality and subjective depth of one particular patient will be brought to the fore. and an ontognostically observable 'thing'. by reflecting biomedicine’s utopian vision of diagnosis as sterile from non-scientific spheres (e.Sky E. symbols. in the suffering. and indeed should not. lose sight of the fact that ethos. through mechanisms of diagnosis and decision-making. do not live in an abstract world of theory. A discussion of these very issues will stand at the centre of a latter section of this work. experienced lives are altered. Gross way. this work was narrated in a way that suggests the presence of a similar bias. Yet.g. technology. in the existence of actual men and women. it is through exchanges between experts. brain is both the assigned locus of phenognostic knowledge. phenognostic forms of knowledge). of human exchange that the enterprise sustains itself. One cannot. prolonged. epistemology.
with its tensions and its burnings. Merleau-Ponty. Focusing upon this dualist epistemology. 1975: XI) As described earlier in this work. the body will keep its singular phenognostic status as the locus of a subjective consciousness (Sartre. (Foucault. 1962. are challenged as to their objectivity by the reductive discourse of the doctor. modern Western culture has always held an intricate view of the body: while still being considered as an object among others.thus the articulation of medical language and its object will appear as a single figure". the whole dark underside of the body lined with endless unseeing dreams. as a dominant discourse of modernity. as well as established as multiple objects meeting his positive gaze…. social studies have repeatedly shown how biomedicine. 1956. Lanigan. 1995a. the silent world of the entrails. tends to refer to the body in terms of the 136 .Black Butterflies Part V: The Brain Exposed On Neurosurgery and the Nature of Objectification Introduction "The presence of disease in the body. 1995b).
Indeed. subjective experience (Babbie 1970. 2004). 1998). Csordas. Young. ontognostic entity (e. Armstrong. Thornquist. Eisenberg 1977. a significant range of research has accumulated. Cartwright. the observable and ontognostically-graspable body will take precedence over which remains beyond biomedical epistemological reach. where it would be treated as a machine. 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. Mishler et al. Lock. 2001). 1984. 1994. Arguably.g. i. 1984. According to this claim. Wiltshire. As the former will relate to the body in abstract decontextualising terms.g. These lines of argument have become the dominant voice in broad areas of social study of biomedicine. 1990. 1994.e. Barry et al.. Good. 1981. Synott. 1983. 1997. Gross former. this tendency toward objectification will have biomedicine centre its attention upon the body as a material. Scheper-Hughes and Lock. and the portrayal of biomedical epistemology as reductionist and materialistic is by now little questioned. Scambler and Higgs. Toombs. 1990.g. Arney and Bergen 1984. 1994). over the last decades. and thus favouring the ontognostic over the phenognostic. 1997). Dew 2001). Martin. 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.Sky E. The split between experience and the body is perhaps most salient in studies of patient-physician interactions (Murphy. discarding the latter (e. 1987. associating biomedicine’s practices and epistemological bases with stances of depersonalisation and objectification of the patient (e. 1997.g. 1995. observable through expanding scientific technologies and knowledge (e. Walters. An overbearing claim – albeit often implicit – in these texts is that since medicine seems to disregard 137 . and based on phenognosis as a source of knowledge (Mishler. 1992. 1999).
Csordas.Black Butterflies this life-world. as if a necessary consequence of his/her position (e. 1992. or by applying more sensitivity toward the complex.. lived aspect of the body. subjective. This means that a phenognostic-based attitude toward the 'other' is not a mere default position.power. 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). 2004). 1991. or even political characteristics of the profession. Taking this a step forward. Phenognosis. it is neither a constant position. The researcher.g. personal aspects of human existence. Berg and Akrich. necessarily applied unless 'disciplined' by ontognosis. Although biomedicine might indeed use a dualist. nor is it a necessary by-product of epistemological. Featherstone et al. 2004). passive and active stances. the patient is defined and redefined in interactions. 1991. Indeed.g. technological. held in nonmedicalised settings by not medically-socialised individuals. It is a discursive power in and on itself. If the body is imbedded in contexts within which it appears. and definitions as either patient or person (Berg and Akrich. exclude the researcher from these microdynamics. as I have argued before. in important works studying the body as a site of conjunction between the two spheres (e. which requires fit contexts upon which to attach itself in order to gather – and retain. Haraway. Rather. 1994). a consequential discursive force. 1993. Turner. historical. I will argue that one cannot. and if 138 . 1990. however is not a mere pre-discusive form. the researcher is typically portrayed as more aware to the phenognostic. alternating subject and object positions. or materialistic view of the person. is hardly immune to objectification tendencies. however reflexive and empathetic. and must not. It is.
this is a pseudonym 139 . Any participant observation in the social studies of medicine will have to address this issue prior to the actual insertion into the field. and eventually accompanied him into the surgery room where I would witness his brain exposed. There. both ethnographer and biomedical practitioner will find themselves in transition between stances of objectification and empathy. an informant encountered in the course of my fieldwork at the neuro-oncology clinic. An interesting feature of this case is that. was discussed. 1988). while becoming increasingly intimate with both him and his close ones. as an illness (Kleinman. As I accompanied this 32 year old man throughout his battle with brain cancer. it seems the complexities of our relationship would be taken to their extreme. Methodological Notes I will present this movement using a first-person narrative of my own relationship with Ivan10. I followed his disease as an ontologically-asserted physical entity but also as it was experienced by a person with full subjectivity.Sky E. among others. Tied with the development of his 10 As with all names mentioned throughout this work. I also had continual access to the purely biomedical aspects of his condition this by attending staff meetings where his case. I attended the many clinical exchanges he had along the way. Along parallel. Gross dependent on its characteristics and positions. Six months of intensive participant observation pursued by a year-long follow-up allowed a close rapport to develop. yet at times intersecting lines. where a last attempt to prolong his life was undertaken.
Turner. Frank. In an attempt to understand this fluctuation in my stance toward him. Ivan became a principal research subject and.Black Butterflies illness trajectory. 140 . 'the other'. If. However. Western medical thought is largely based on an organoriented view. at times as part of the clinical team. 'the self' all meet. 1962) the brain is where 'the world'. as a lay (i. Its ontognostic components are further based on the concept of efficient causation – of biological processes being 11 The idea of replication of boundaries is discussed in the introductory chapter and will be developed here at later stages of the analysis. and as made ever more evident in this work. I use this essay to reveal my internalisation of different roles. It is where subjectivity and objectivity ultimately link: a conceptual pineal gland. a friend. I shall claim that one organ holds particular features. according to some theories. features which make the analysis around it more complex. I gradually took on the role of a confident and provided some of the mental and emotional support he desperately sought. I depict the ways in which my own experience was altered by replicated11 ritualistic and symbolic elements. the social is imbedded in the body (e. but also more promising: The Brain. The Sacred Brain: The Matter of the Gnostic Split The brain is not just another body part. non-medical) researcher with strong personal relationships with the subject. to some extent. 1990. at others.e. 1992) and the body is what is situated in the world (Merleau-Ponty. cognitive and emotional processing take place. It is the site in which all bodily activities. These elements may be discerned in many arenas where the body prevails. sensual perceptions. often said to serve as facilitating medical objectification.g.
At a different level. Another example can be found in Popper and Eccles' work (1977:177). pain. Social science literature has brought us several illustrations for the centrality of the brain in biomedicine. and can be referred to as beating heart cadavers or neomorts (Youngner. rather than the body as a whole. for instance. 1998). Gross linked together as sequences of cause and effect. 1994. Webb.g. OkhuniTierny et al. 1998:1). The central position of the brain in Western society can also be seen in its cultural emphasis on reflexivity. 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. such as in cases of phantom limb syndrome. brain-dead individuals have lost their personhood or humanhood. the brain can have primacy over the body. when the brain creates a seeming perception of one's body. It is the source of action and the endpoint of both internal and external sensory input.. although biologically viable. of the self" into the latter. holds paramount significance in the definition of selfhood and subjectivity. Kaufman. and "the paramount cultural and material importance of the mind" (Webb. This leads amputees to experience sensations (e. 2000). in being both the causal source of every bodily process (from blood circulation to muscle coordination).Sky E. the brain. Then. This phenomenon may be explained by the presence of neuronal representation of the arm or leg at 141 . tingling) as having their source in the limb removed. and the point which every bodily process eventually affects. The brain plays a central part in this anatomical-causal complex. 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. 1989. First may be the conviction that.
in a way. 2000. Greenberg et al. such as 'Joe' or 'Mary' (Sacks. reverse) condition is of 'asomatognosia'. He was diagnosed in 1999. patients may go as far as calling this limb by a name. Tsementzis. Based on the following ethnographic description. 1985. We were now at the end of 2006. external to the brain. In these cases. The last patient had left Lise’s office and Ivan's dossier laid on the top of the pile. will have clear ritualistic expressions in the surgery room. I looked at his name and remembered his case. which was just brought up during the last staff meeting: my field notes read "Ivan Katz is a 31 year old patient with a grade II oligodendroglioma". replicating the liminality and the boundaries created as a result of this liminality. Feinberg. This idea of the brain as the apex of subjective/objective liminality. 2006). This phenomenon has its source on disorders of brain activity.. set at a coffee house near the hospital. can 'feel' as the 'real thing'. again providing a vivid instance of brain's domination over the body. It will create multiple dimensions within which the subjective will be dealt with. The Story 'Prelude' I had barely begun my fieldwork when I met Ivan. which.e. a type of brain cancer with a life expectancy of seven to ten years. was incidentally the day when Ivan experienced the first 142 . having nothing to do with his/her perceived 'self' (i. A related (and. The day of our first interview. 2002). when cerebrally activated. This takes place when a person's limb 'feels' like an external object 'glued' onto one's body.Black Butterflies the level of the brain. I shall turn to the analysis of these dimensions.
while I remained indecisive. he was probably emotionally drained from having to recall his seven years experience with brain cancer and. he collapsed. Lying on the floor of the staircases. There was little need for professional deciphering: the tumour grew considerably. he regained consciousness surrounded by strangers. It was the tumour "having its will when it had its will". The latter reached the coffee house and almost out of breath. mostly nurses and other hospital employees. Ivan had an MRI taken. On his way back. we were to spend the next seven hours together. I would be the first to see the image. As to my question on the specific episode and its timing. Later this week. usually reserved for staff members. We were able to use – unquestioned – the back entrance. although 143 . "He doesn't feel well" was all he said as he was leading me to the staircases. as I regularly participated in staff meetings. Ivan would continue to see this as a direct reaction to his emotional experience. 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. calling out my name and describing me to the security man. As far as I could gather from the situation. a fact which explained the seizure. 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. ten minutes into the interview he left the table to freshen up in the bathroom. On the day of this dramatic interview. I knew that the seizure was a clear sign of relapse. There. asked me whether I knew a 'Ivan Katz'. he immediately asked for me. As I was later told. I was told a few days later that the chemotherapy ceased to be efficient and that his tumour was growing. Gross epileptic seizure he had in the last two years. however. The following year would be his last.Sky E.
Black Butterflies continuously troubled by the question: was this a purely bodily phenomenon – with its own causes and effects . subject and body. typically leaving the other completely functioning 144 . I was well aware of that. sending cues in the forms of signs and symptoms. more aggressive treatment became inescapable: Ivan went through radiotherapy. as my research placed Ivan –rather than the medical team. it was the clinical (his seizure) and pathological (the MRI). His seizures grew both in intensity and frequency. now up to a five times a day. biomedical (and thus ontognosis-oriented). As the months went by. Toward the end of the year. to remember phone numbers. It would have merged which has become the two spheres within which I operated: the professional. and the personal. 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. which spoke of the disease. However. experience-focused (thus perhaps more phenognosis-inclined).or was I to take Ivan's account as a fact. This double. and very much dualistic. his hair fell out. however. As a behind-the-scene. aware of his condition). At another level. backstage observer. at least consciously. there was little doubt that Ivan's condition was deteriorating. After the last chemotherapy round turned out to be 12 A neural weakness on one side of the body. he gradually lost his ability to communicate properly. The disjunction became ever clearer: Ivan was both a talking corpse. as The Truth? In medical terms. and an embodied subject. even while Ivan still did not (as he was not. perspective became omnipresent in all exchanges related to him: Ivan was both person and patient. to focus his sight.at the centre. he became hemiparetic12 and suffered an almost complete loss of sensory and motor capacities on the right side of his body. eventually mediating the knowledge of his disease via his conscious self.
or to my understanding of him. the team offered one additional surgical intervention in order to remove a part of the tumour.Sky E. Sadly. There. and swore me to talk to him afterwards about "what [he] looks like inside". refused to give up without what he considered as a fair fight. Ivan was amused when I first asked him whether I could join in on the operation. Ivan. I wondered whether knowing what his brain looked like would add anything to his understanding of himself. The increasing doses of steroids had 145 . Palliative care was all that remained. and right after Ivan’s brain surgery. and as to whether he would have had the same request was another organ the target of surgery. His brain said nothing. Gross almost lethal. seeking advice. As far as I was concerned. 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. the size of his brain had more to do with the space-occupying presence of the tumour. however. When I inquired about it. he responded that "it wouldn't have been that cool". The S-day The morning of the surgery. The surgery was to take place a month later. on how large his brain was. He and his family turned to another hospital. now in Tel Aviv. the baring of the 'organ of the self' bared nothing of his 'self'. during. I could only speak figuratively. the Jerusalem team gave up on treatment. as if it reflected his intelligence. He dared me to go through this. That. they thought. might possibly allow for the chemotherapy to be more effective. They had nothing else to offer. 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. and tong in cheek.
his mother. He looked at me and made a slight attempt to smile from time to time. when his body did not declare that it was a cancer patient's.Black Butterflies his face so puffed-up that he looked like a giant squirrel. eight years ago. I looked curiously. I kept asking myself who this body was. at times detached. Not able to make genuine eye contact with him. where he was completely insensitive to touch. a bit detached. He now did not only feel like a cancer patient. all clinical details of his case seemed to evade my mind – I was with him. as Ivan bought his first hat. as we were chatting about this and that. Throughout. at this grotesque figure being wheeled to the OR. that we were all three captivated by the scene. and I spent at the hospital inn (where he was staying for the course of his radiotherapy). Ivan ran to the window: Jerusalem was covered with a white blanket of snow. and whether it was at all somebody's. after having lost most of his hair. In fact. he proudly told me how he "gave the man [the salesperson] a heart attack" when telling him he was buying it "for the radiations". I followed the wheeled bed down the elevator along with his parents and sister. huge bold blemishes. in these moments. but raising his heavy eyelids seemed extremely painful. There. he looked like a cancer patient. On the top of his head were scattered a few chick hairs. I myself could now hardly recall the way he looked 'before'. I had to remember to hold Ivan's left hand rather than his right. and a long purplish scar at the centre of which stood a bulging bump of fatty tissue– both remainders of his first surgery. Reaching the door to the surgical area symbolised the breaking of our serene silence and 146 . We reminded ourselves of the evening Ivan. So little snow ever falls in Israel. his hands nervously petting his skull. but somehow. at others immersed in his experience.
where patients were kept and monitored right before and after surgery. rather than as a patient. His eyes still painfully shut. 147 . as I was about to cross into the biomedical realm. efficiently phrased information. to take care of him. firmly instructing us to be careful not to cross this boundary and to say our goodbyes now. gesture of concern. and provided clear. 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. My answers surprised the anaesthesiologist who. I followed the nurse to the Intensive Care Unit (ICU). the anaesthesiologist approached his bed and began asking questions. Gross sense of 'normality'. The scarce attention he gave to my response seemed to reflect his lack of interest in 'gatekeeping'. As I rubbed his good arm. here. only at this point. a fact compatible with the analysis of his position in relation to the the replicated boundaries as provided later in this text. and asked me. in tears. I quietly arranged his pillow – this familiar (albeit futile). even now. the nurse abruptly halted. I explained my position as an anthropologist. 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).Sky E. As if suddenly awakening us all. I used the medical jargon I knew so well by now. as if reminding me to treat him as a friend. The family kissed Ivan. short. Ivan’s bed was positioned between two other patients’. asked me who I was. Since Ivan found it difficult to answer -his speech being highly hindered at this point – I intervened and answered myself. and my affiliation to the Jerusalem neuro-oncology team.
Treating me as courteously as one would a guest in his own home.. I must take off my casual clothing and wear it directly on my bare skin. I immediately stressed that I was given permission by Professor Zosima (the head surgeon) to attend to surgery. impressive man wearing his 'scrubs'. she will be joining us. a young. I answered that I was a doctoral student conducting anthropological research at the neuro-oncology clinic in Jerusalem. his gaze pierced my eyes: "and who are you?". 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. 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.. he announced Ivan that he will shortly be brought to surgery.. Once I have reminded him of my name.. no problem at all".Black Butterflies Shortly after Ivan had signed the consent forms (which he could obviously not see at all). [This is] Sky Gross. now my uniform. he called on who turned out to be the OR head nurse: "This is – what is your name again?. He smiled and replied "of course. the surgeon then arrived. carefully bagged in plastic.". As he approached the bed. I could feel it on my skin as I unwittingly adopted a 148 . he turned to the nurse again: ". Much more careful as a gatekeeper. were dispensed. Entering the changing room dressed as a lay person. she is from neurooncology in [the name of the clinic in Jerusalem]. I remained there virtually naked for a few moments. my identity in Dantean limbo until I wore the uniform. Can you show her where she can get ready?" The nurse reluctantly showed me to the changing area.
Deep into the realm of idle objects. Ivan's bed was wheeled up into the OR and 'prepped' for surgery. Was he to open his eyes at this moment. his large blue eyes shut with tape. I could not pet neither of his arms now. My position as an outsider would be hidden behind these clothes: fully camouflaged. as both were insensitive. anaesthetised. I could see the back of his head. As I passed through the ICU. nor would he have recognised me behind my mask. These were available only very near the entrance to the OR. he would not have seen me. his body scrapped clean and sterilised.Sky E. the material. Upon joining the staff. All I could see was an idle body. Ivan lost all awareness as the staff completed his transformation into a living corpse. an assistant 149 . The room was relatively free of tension. Under the Skin As I was struggling with the hair cap – reminding me how little I 'really' belonged there. his puffy face concealed. Gross slightly different walk (faster than usual) and handled my body differently (less eye contact and a more upright position). a surgical intern. I found him unconscious. unaware his brain was being picked and probed. graspable loci of his subjectivity. from accompanying him to accompanying the surgeons. As Ivan increasingly waned as a subject I shifted roles. an even more restricted area. I could then identify myself and be identified as a member of the biomedical team. his open skull and his brain. His body was at the centre of attention. From where I was now standing. I was told by one of the surgeons not to forget to put the hair cap and mask on before entering the OR. The staff (which at this point included a junior surgeon. but Ivan was nonetheless completely absent. draped from head to toe. and consist of the last piece of garment promising me a place in this in-group.
material phenomena over patients' reports. I held on to a model that is classically claimed to pertain to the world of physicians: valuing visible. yet something about the sight of this bulging lump of flesh made it more 'real'. I remained standing over the orifice. the room gradually turned silent. I found this portrayal curious. the visible seemed to provide me more 'evidence'. Although I never questioned the subjective truth he communicated. a year before that her son's head was a closed box. As the two junior surgeons removed the white eggshell pieces and dropped them into the stainless steel bowl. The cutting revealed five pieces of bone stapled as to form a sort of jigsaw puzzle. In the surgery room. the ontognostic. and seemed thus more authoritative. and she was afraid his brain will 'leak out'.but was rather directed by an acute sense of curiosity. When the first stage of the actual operation began. the physical. and a neurophysiologist accompanied by his assistant) moved freely around the room. 150 . organising their gear in relative leisure. literally. an anaesthesiologist. still. the brain herniated and literally broke out into the open air. a head-nurse.Black Butterflies nurse. a practical nurse. 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. I applied myself as I followed the knife going over the long crescent-shaped scar and two centimetres further down. a remainder of the previous intervention. The staff showed interest in the unusual extent of the phenomenon. I could empathise with his pain as he moaned and groaned. The skin was pinned to the sides. the dura. When I heard his mother tell me. kept the majestic organ in. For me. only a thin layer of tissue. feeling surprisingly little awe or disgust -as one would perhaps expect from an 'outsider'. talking. allowing the opening of a fist-wide cavity at the centre of the wound. Swollen and eager to escape its captivity.
Gross The Peak of Surgery As the team was getting closer to the handling of the actual brain – and entering deeper into the body. except for a beam of pale light illuminating Ivan's Skull. the OR became silent. It did not. The lights were turned off. covered with a sterilised sheet. After intensive and extensive scrubbing. the head surgeon could observe a live MRI picture of Ivan's brain as he inserted his instruments. At some level. At this point. albeit at a less central position. but I did not know how Ivan's brain would look like. Time went by as the surgeons were methodically vacuuming tumour tissue and were carefully closing blood vessels. and I became increasingly focused on the physical biological presentation of the tumour. carefully prepared in advance. curiously resembling a king's throne. Seeing the brain without seeing the mind. I knew how the brain looked like. beside (rather than directly behind) Ivan's head. As I was to realise later on. I expected it to look like him. like Ivan. and tensed. only once objectification reached its peak did the head surgeon make his appearance. still. From one of the screens. he sat on a high chair. He sat on a similar chair. He then set 'coordinates' which will serve him in the spatial handling of this complex organ. the mind is nowhere to be found. The LCD screens. Other members of the team remained standing. For instance. observing its actuality. I felt I had developed a relationship 151 . from which the site of the operation was 'broadcasted' to the OR audience. its fleshiness. The junior surgeon also took a sitting position at this time. one has to admit: in the OR. with some level of freedom of movement which was only rarely taken advantage of. the ritualistic aspects of surgery became more dominant. I found myself disenchanted.Sky E. were turned on.
I said I knew it13 "since it was this little!". as if I had been speaking of a child. which made the team giggle: Impressed by the tumour's current size. prognosis is a form of knowledge which is habitually held away from patients. prognostic information (and at times. unwelcomed by the patient. the 'it' and the 'he' are interchangeable 152 . 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. 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. a relationship that was in many ways independent of its carrier. Was I taking lightly the sight of 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. 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. This was perhaps most striking when the surgeon showed the latest MRI image on the screen: its shape. and thus localise functions in the areas neighbouring the site of intervention. In cases of life-threatening brain cancer. its shades of grey were all-too familiar as I recalled the many staff meetings it had appeared in. even diagnosis) is clearly. including the detrimental health impact receiving bad prognosis can have. and manage his condition without burdening him with details he is not able to deal with (such as one's impending death). I remember the remark. The latter expects his physician to act as a 'responsible adult'. I had almost as many direct encounters with Ivan's brain as with Ivan himself.Black Butterflies with Ivan's brain. in the course of the last eighteen months. After all. Ivan the person. Ivan's surgery was planned to be performed 13 In Hebrew. and this for various reasons.
as the surgeon moved an electrode on the surface of Ivan's brain. Wires were attached to Ivan's legs. and 153 . the neurophysiologist reported on movements detected meaning essential motor tissue was stimulated. however. since his tumour layed in the midst of critical senso-motor function areas. was decisively too deteriorated and the idea was abandoned hours before the intervention. my mediation was little needed. the fact that the organ involved in this latitude-longitude definition was the brain. and a neurophysiologist was asked to join the team. making the mediation of a subject redundant. The clinical gaze involves the creation of a spatial dimension which will create the disease as an entity. 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. As his phenognostic account became of little value. the body as an ontognostic-based 'thing': "… a space whose lines. volumes. in accordance with a now familiar geometry. and. and supervision was loosen. Ivan's body was electronically probed and mapped. reporting to the family whether Ivan was awake. While perhaps not unusual in the field of medical diagnosis. Once alll would have access to Ivan as a tangible. 1975:8). that the functions observed were speech and movement (both typically associated with purposeful volition). source of knowledge into his own wellbeing. surfaces.Sky E. by the anatomical atlas". palpable. Ivan had to be treated as an ontognostic source: a more 'objective' – and objectifying—measure was used. (Foucault. since only once he regained consciousness were family members (one at a time) allowed in. Gross thus. His condition. and routes are laid down.
considering what they observed in surgery. As if now having gone through an initiation ritual. the tension was released. lights were turned on again. during which I remained standing – directly looking into Ivan's skull. I followed the head surgeon as he went over to discuss the operation with Ivan's parents. which he will spend in nursing and palliative care. and movement became freer. they will not be able to offer him any more chemotherapy. However. Closing up: The last stages Once the thrust of the surgical intervention (i. 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. Again. Not entering into details. the younger surgeons included me in their small talk. Only when directly questioned did he admit that. As the pieces of bone were placed back and the skin stapled. The operation lasted more than five hours. The despair with the intractability of his condition and "the impossible mess the tumour made in his brain" was reserved to backstage discussions. the removal of tumour tissue) over.e. the head surgeon told the juniors to "close him up" and left the room. the surgeon gave a relatively reassuring impression: Ivan survived and the surgery did buy him some more time. I knew what my informants did not: the surgery was in vain – this serious and dangerous intervention only gave Ivan a few more weeks. cables and electronic devices were removed.Black Butterflies that the process took place in 'real-time' made this event particularly intriguing. masks were taken off. leaving the hospital. once having taken off 'my scrubs'. and Ivan's face and body were again visible. It was as if I now returned to myself 154 . it was only a few hours later. Overall.
and as they relate to recent and contemporary work in adjacent subjects. one important aspect of narratives is that they are typically told in hindsight. I shall now like to unfold some of these points as they arose in the field. Just a Story The account of the past is almost inevitably tainted with current interpretative schemes. 1998). 2008. not only mentally but also in terms of how my body felt to me. and to thereby justify current claims: First. that my experiencing and perceiving of Ivan as a subject and object was of a fluctuating nature. i. that these contexts all involved some extent of boundary definition (replicated in the conceptual. Gross as a lay person. 2009b).Sky E. focusing on concerns that are particularly meaningful to the teller. 1990. 1995). Liminalities and Replicated Boundaries The OR as a Space of Multiple Liminalities 155 . Williams. And finally. 2008. that this reflected on and was reflected by contextual elements within which our interactions took place.e. professional. Mattingly. symbolic layers) between two seemingly opposite sources of Truth: phenognosis and ontognosis. Gross. It also allowed me to create a common thread of meaning around a series of noteworthy moments or 'events' (Polanyi. Becker and Kaufman. The 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. 1985. which makes past events appear as if naturally leading to the 'now' as it is understood (Mattingly. Second. spatial. Thus.
and between forms of 'presence': i. 1983. 2005). more particularly the distinction between things that belong and things that do not belong in the OR. 1954. Rituals. Moreira. 1960. This liminality and confusion of categories demand a clear ordering of things through elaborate rituals. Turner. Douglas. Wilson. van der Geest. and most particularly liminalities where scientific thinking ceases to exert its conceptual control (Van-Gennep. As has been well shown in previous studies (e. OR rituals are associated with the need to facilitate the transition between categories of things by clarifying their distinction. Along with specific rules and practices. Goffman. 1988). a state of simultaneous presence (as a body) and absence (as a person). these allow a conversion of the life-world into an object that can be dissected 156 . 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. Katz. 1981. 1981. Fox. Foucault.e. 1979. This is where the invisible becomes visible. 1966.g. 1969).g. 1975. 1992). the patient can be allowed into the OR (Katz. 1961b. They may also convert mundane objects into entities that belong to the 'sacred' and are thus less likely to form objects of liminality. and secluded from the less distinct areas of the hospital (e. For instance. can do more than create boundaries. as restricted both physically and symbolically from everyday life. The OR is also a space where states of liminalities are omnipresent. however. the inaccessible accessible. 2004). Felker.Black Butterflies The OR might be regarded as the epitome of biomedical practice. the sacrosanct of biomedicine. when transformed from a sentient whole into an operable body. This includes the patient oscillating between life and death. Katz and Kirkland.
In other words. If phenognosis is the matter out of place (Douglas. 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'. 157 . 1982. to my own knowledge. Hahn and Gaines. In this shrine of objectivity. Hirschauer. practically. In all three cases. and while the issues of purity and danger (and their relations to social practices and categories) constitute one of the pillars of cultural anthropology. Here. and as shown by Mizrachi. 1991).Sky E. it is not only categories of life and death. between an ontognostic biomedicine and a holistic. the subjective will need to be conquered. 1966). and epistemologically replicated as comprising a 'dirty' element (phenognosis) and which can be regarded as its mirror reflection: the 'pure' element of biomedical ontognosis. Shuval and Gross (2005). hidden (draped). in settings such as the OR. but also categories of subjectivity and objectivity: of sentient person vs. or restrain phenognostic presence. dominate. at times 'spiritual'. approach to the patient. This is in fact much similar to the type of boundaries shown to be drawn and replicated in other layers of the gnostic split. ontognosis will be seen to annihilate. between an 'ontognostic neurology' and a 'phenognostic psychiatry'. I shall advance the idea according to which the gnostic split is symbolically. present body. been directly attempted. or made sterile (disinfected). of inside and outside which boundaries must be reinforced and safeguarded. the wedding of the two subject of interest has never. the subject must be either subdued (anaesthetised). 1985. While the discussion of objectification in medical contexts is omnipresent in the social sciences of medicine. as its epistemological resistance contests ontognostic authoritativeness.g. Gross and manipulated in the setting of the OR (Gaines and Hahn. e.
not sterile. which create clear boundaries between areas of objectification. it is never almost sterile or mostly sterile. sterile." (Katz 1981:345346)[my emphasis. 1987). I shall now discuss each of these.G. S. language and technology associated with this stance. and. therefore. These worked in unison to replicate a movement from the subjective to the objective and from the personal to the biomedical. therefore.g. Second. and gloved. which 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). or gloved.] According to Katz (1981) and others (e. An instrument is either sterile or nonsterile. with sterilising practices. First. with spatial definitions. the lengthened minutes of scrubbing immerse the professional into a state-of-mind by which the patient turns into a physical entity 158 . gowned.Black Butterflies In the case of surgery. Third. with anaesthesia. Keeping Phenognosis Out: Sterility "Rituals exaggerate the discontinuity in the operating room and they proclaim definite categories. Cassel. which transforms the sentient self into a passive body. and. Finally. or subordinated. with components such as clothing. gowned. constrained. The Temple of Ontognosis: The OR Questions of objectification arose in the field around several elements. boundaries cannot and will not remain blurred: surgical intervention is the pure manipulation of matter. however. or he is not scrubbed. Whichever is not clearly assigned to this sphere must be either eradicated. A person is either scrubbed.
My observations. i. 1991:91) involves transformative practices in regard to the experience of surgery (Landzelius. the the anaesthesiologist kept holding his mask rather loosely. As a rule. 1981:349). the entering of Ivan into the anaesthetised condition and his gradual emergence into full consciousness: Then. I will claim for an association between levels of objectification (by different professionals. however. I was the least sterile. Listerism and sterility would play no role other than promoting practical aims of preventing infections.e. namely in keeping a view of the body as belonging to the world of matter. whether germs are involved or not. The "precise and beautifully choreographed ritual" of scrubbing (Cassel. Interestingly. the more one would be required to be sterile. Although I did wear a sterilised surgical robe and did put on a mask and cap. at different stages) and the demand for elaborate scrubbing. I was not 159 . Throughout securely the course and of his Ivan's vital operation. his active presence was required only at the temporal edges of surgery. arbitrary. suggest that these rituals cannot be explained away by simply turning to this 'germ theory'. Ivan anaesthetised signs anaesthesiologist sat at one corner of the room and engaged in online crossword puzzles. to abide to this "stylisied. he would take on a more religious attitude towards his scrubbing attire. occasionally joining me and offering me trivial information on this or that procedure. More specifically. Gross interacting with and endangered by other physical entities: germs. between dying or viable would be most challenged. 2003). that is.Sky E. but it is also then that the boundaries between conscious and unconscious. repetitive. It is then that he would have most contact with Ivan's body. Along these lines of arguments. stable. In more concrete terms: the more one would treat the patient as an object. and exaggerated" behaviour (Katz.
2005). 1994a). as well as an insider's. this faith is not granted ad hominem – i. The patient often willingly accepts but always ceases to resist the overpowering of his/her own subjective experience (Mizrachi Shuval and Gross. 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. By eliminating the patient's subjective presence. When sedated. Yet. but to a basin of knowledge and an embodiment of skills: to the praxis as well as to the epistemological soundness of biomedicine. as if in the absence of its owner. never to be really seriously considered. you don't have to" the junior surgeon declared). In the surgery room. They are intimately associated with patterns of observance of the place of subjectivity in the OR. asked (by the looser gatekeeper: the anaesthesiologist) to touch Ivan by holding a cotton ball over his perfusion wound. at one point. In submitting him/herself to sedation. anaesthesia creates a lifeless body to be manipulated. This was especially curious as I was. Anaesthesia: Subduing Phenognosis The effect of anaesthesia on objectification is undoubtedly powerful. This again suggests that sterility guidelines are not followed in a mere attempt to physically keep things clean of germs. 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. a person's state of wellness becomes defined in terms of pulse rates or levels of oxigenisation as shown on a computer screen (Collins. the anaesthesiologist 160 . as in Ivan's case.Black Butterflies asked to wash my hands ("that's OK. The consent forms are typically signed to never be read. the summary the surgeon14 may give the patient. trust is not bestowed upon a particular person or persons. 14 Or.e.
15 This is also when the team's sense of humor was more readily exercised. 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. In cases of life-threatening brain cancer. alarming news on the patient's prognosis. that never in reference to Ivan. 1961a. right on the surface of the exposed brain. 2002). and did not offer an analysis based on the observer’s position. 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 in fact precisely at this point. anaesthetised) as his death sentence was declared. the extent of the damage. prognosis is a form of knowledge which is habitually held away from patients.). As discussed earlier in this work. Gross the patient surrenders any claims for epistemological supremacy: phenognostic claims cannot be made if subjective knowledge is not generated. Ivan himself was absent (i. Hindmarsch and Pilnick. I must admit. For instance. when one is unconscious. 161 . while Ivan was deeply sedated. This is a statement that could hardly be made in the presence of a patient or his/her loved ones.e. they focused rather on the team than on the patient. However. Perhaps most strikingly.. as in this case. announcing as if of a matter-of-fact that the tumour was enormous and that Ivan's prospects of survival were grim. Pilnick and Hindmarsh. when the critical spectator turns absent.Sky E.e. i. the head surgeon called me over and showed me. I was not impressed that this was merely due to my presence. that the team is able to make the transition to a backstage form of interaction (Goffman. 1999. which could not have been enacted in the presence of an outsider: the patient. the language becomes more technical and inside information is more freely communicated15 – including. and this for various reasons. Backstage. including the detrimental health impact receiving bad prognosis can have. Still.
Another issue arose when. I found myself in the role of the 'I know. but I know better than to have you know what I know' – an expression of epistemological power I did not wish to hold against whom I wished to remain a subject rather than a 'patient'.Black Butterflies prognostic information (and at times. although often not explicitly. based on my own experience of a world of matter. as Ivan's subjectivity has been made to disappear. I was again to wonder as to the nature of our relationship: As I knowingly withdrew information from him. my attitude becomes simply phenomenological – that is. or made irrelevant. and manage his condition without burdening him with details he is not able to deal with (such as one's impending death). even diagnosis) is clearly. Intersubjectivity is present only when two subjects experience a common situation. unwelcomed by the patient. 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. This backstage stance was increasingly difficult from my position as an ethnographer. Not certain if the patientphysician 'pact' regarding prognosis applied to me. If one of the parties become absent. This stood in contrast to what Alfred Shutz (1970:31) termed the 'we-experience': experiencing the other experiencing. The latter expects his physician to act as a 'responsible adult'. Space and Liminal States 162 . it refused to enter the stream of my own. I could not create an intersubjective relation with what seemed as a 'thing'. It was thus little surprising to see myself perplexed when confronted with instances where my own knowledge regarding Ivan's diagnosis greatly surpassed his.
my mediation was little needed. and most vulnerable to unforeseeable and rapid deterioration. when re-becoming a 'normal body' (Kaufman. At the point where there is less danger to the ordering of the orthodox state-of-being (Van Gennep. 2001).Sky E. Going Native There are other elements affecting my own stance of objectification. elements belonging to one of the oldest concerns of anthropology: the adoption of the research subjects' ('emic') 163 . Still in a state of limbo between life and death. Landzelius. The ICU was where a taxonomic order that has been loosen and endangered in the OR could be reconstructed (Turner. and supervision was loosen. clearly served as a space of transition between the outside and the inside. In my study. the patient may be released to the outer circle of the 'sacred' space: into the ward. for example. the patient is there followed with elaborate rituals and monitoring. 1969. 2000). intensive surveillance is relieved. reporting to the family whether Ivan was awake. palpable. since only once he regained consciousness were family members (one at a time) allowed in. 1960. between the sacred and the mundane. the spatial organisation of the hospital reflects conceptual elements central to biomedicine's epistemological bases. 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.e. source of knowledge into his own wellbeing. Gross As Young (1999) asserted in her work. Turner and Turner. 1978. and as described above. ontognostic monitoring becomes less essential. 2001).. until fully awake. Landzelius. Once alll would have access to Ivan as a tangible. the ICU. 'stable' and 'out of danger'. i. As life-world modes of interactions become available (the patient regains consciousness and is able to report on his/her subjective experience). and biomedical.
I undertook an elaborate preparation which included the study of the technical and more theoretical aspects of the profession. what Bolton (1995) defined as the inherent bias of non-medically informed anthropologists: The incapability to really understand medicine. Achieving. to the best extent possible. and the keeping of an outsider's ('etic') distanced position. non-physician anthropologists tend to romanticise the physician. which might not be available unless abandoning this lay naïveté which is often overbearing in anthropological accounts of medical practice (Collin. thus to really enter the physician’s state of mind. Whereas this argument seems well developed in other fields of anthropology and ethnography. 1995). This knowledge allowed me to avoid. an emic look into the surgeon's world would then allow a more elaborate and accurate depiction of the field. According to Collins (1994a. to underrate instrumental aspects of 164 .Black Butterflies viewpoint. to watch sequences of both general brain surgery and tumour resection operations. For instance. I acquainted myself with the different aspects of neuroanatomy and clinical neurology and was able. 1994b). 1994b). and will provide valid contributions. In an attempt to achieve such an understanding and become an expert observer (Bolton. In biomedical settings the expert observer will perform as a nativeethnographer. through the internet. or go native. One way to attain a deep understanding of the native’s perspective is to find oneself within this perspective. it seems little attended to in mainstream social studies of biomedicine. at least partially. this lack of understanding of the physician’s lifeworld (or verstehen) leads to significant biases in ethnographies of medical settings. 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.
distancing was a fluid state-of-being highly contingent upon the setting. one may find oneself holding 16 I again use the masculine stance here. 1989. 1992. but also to refrain from developing emotional attachment to patients. Fox. It worked not only upon the 'medically taught' participants. Considering the methodological advantages of expert observation. in the social studies of medicine. Good. Without having gone through clear medical socialisation to distancing. 1995. Still. 1961. and as seen in this particular field. as elaborated in Anspach and Mizrachi's work (2006). Leder. so as not to impair the readability of the text 165 . 1979. or hold clinical detachment from patients as human beings (Goffman. Frank. I was still able to sustain the surgery observation without extreme emotional response. 1994. Francis and Lewis 2001). When undertaking the task of surgical intervention. For me. 1994. an attachment that is often emotionally straining (Hafferty. 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. It allows physicians not only to treat the case more objectively or to be less sensitive to awkward and at time repelling tasks. Gross medical practice. this enculturation has also affected my view of Ivan as a subject. 2004). as this case shows. 1988. nor is it simply a form of tacit knowledge acquired through practice.Sky E. but upon the lay observer as well. and overrate the reductionism of medical texts. Most particularly. Smith and Kleinman. Walters. the specific rituals and symbolic elements work to suppress feelings of identification and compassion. Thus. distancing is not only a skill taught in medical school. Good. the researcher might experience a tension between his16 position in his disciplinary field and his position in the ethnographic setting. Medical education includes the teaching of the ability to keep role distancing.
however. in terms of daily interactions. 2003. there would be two ways of 'knowing the 17 Here again. It also showed that relating to phenognostic forms of knowledge is not a 'natural' unquestionable given: it requires. part of one's exchanges with the world.Black Butterflies incompatible ethical imperatives. but not only that. I will use the masculine form 166 . including his own body (Mead. According to Western tradition. a ground upon which to assert its power and act to apply itself in the field. 1934). rather than on the disciplinary or professional background of the different actors. perhaps unavoidable. Dickson-Swift et al. depending upon the field he regards himself as being a part of (Dingwall. 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. based on considerations of style and readability. This type of objectification is an inevitable consequence of the gnostic split.. the human being learns to regard himself as distinct from the surrounding world. I have focused on the setting itself. 2006). 2006) on the positioning in the field of a researcher. 1980. like any other discursive formation. as a natural. the latter returns to the philosophical fundamentals: can 'the other' really be seen. experienced. While the former view relates to the more detrimental effects of referring to another as an object. This is when he realises himself as a subject facing objects. Here. Gnostic Shifts and 'Theories of Mind' Objectification can be seen as either 'medicine's biggest fault or. There is little doubt as to the effects of professionalisation and disciplinary field (Anspach and Mizrachi. as it binds attempt to understand the 'other' as a subject. understood as a subject? From his17 very own birth and throughout his infancy.. Goodwin et al.
This problem has been addressed by philosophers. the aged. 'things' others may consider as objects (i. as well may be one's own body (Gallagher. women. Some will have broader theories of mind to include animals (which may squeak in pain when tortured. I find the 'objectification' preferable 'dehumanisation' outlook. 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.Sky E. ethnic minorities. foetuses (or 'unborn babies'. whether experienced first-hand or scientifically ascertained. including comatose patients (or 'vegetables' conflicts. and in some religions. namely around notions of solipsism and the presence of a 'theory of mind'. The first relates to the fact that one can only be confident of his own subjective presence: as far as can be ascertained. According to many philosophers. 'Others' can alternatively be characters in a dream one would be the protagonist of. 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. etc. thereby seeming to have a subjective presence). 2000). the other will seem as an object. others can be automatons claiming to 'feel' and experience an inner world of their own.e. In either way. The idea of a 'theory of mind' turns to the understanding of the mechanisms by which human beings DO ascribe 'minds' to others. Considering the inclusion of non-human categories – such as animals. objectify) – in to theories the of mind. Gross world': the phenognostic first-person perspective which provides subjective certainty. opponents in . thus. 167 accordingly). or the ontognostic third-person perspective which has been made secure by scientific method. accordingly). Others will have more limited theories of mind.
sounds. This included his increasingly grotesque appearance as his disease advanced. blending in the crowd) the more he would be objectified (treated like one piece of a faceless whole). wearing uniforms. It also included the sense in which he was 'reachable'. he acted and appeared as less than a full ideal-type person. and this had deep effects on 168 . as he was attached to non-biological electronic. dehumanisation as strongly linked notions. and mechanical devices (creating a sort of cyborg as the mechanical extended to his own body). depersonification. these can almost be used interchangeably. digital. In the setting of the clinic. being insensitive and non-reactive to pain). his hemiparetic state outside the OR and the effects of anaesthesia inside the OR. in the modern Western World. or respondent to communicative stimulations. Not only was his ability to perceive affected by this. The less human one acts (being cruel. More than that: as more 'object'-looking one is (e. I will have to treat objectification. disregarding basic taboos. acted. such as touch. being still.g. having masks over one's face. as in the modern Western World 'things' considered as holding subjectivity tend to be anthropomorphised. as well as his cognitive and language processive deteriorating skills. and so on: e. and was treated like a person.g. The instances where Ivan most resisted objectification were when he looked. The less 'person'-looking one is (e. acting 'like an animal'). and perhaps to a larger extent in the OR. words. This had to do with the level of pain he was suffering from. and his draped inertness in the OR. the more he would be dehumanised. In all cases.Black Butterflies However. human deemed subjective beings tend to be referred to as 'persons'. and as. his responsiveness to communication was gradually altered throughout the general course of his disease and in the more specific setting of the OR. Again.g. the more he will be depersonalised (and can thus become a target to violent acts of indignation). but his ability to respond was as well.
Gross stances of objectification. Often defined in terms of a loss of human concern over another. and replicated over different layers: This was true on this first day. objectification is overwhelmingly used in a pejorative tense. Here. The ethnographer is not immune to these influences and might find herself involved in the objectification of her research subjects. I sought to show how it might be a necessary. The patient is then absorbed into a small. practices. eventually found ourselves within a complex. undeniable. when I only knew him as a medical case. both the biomedical team and myself. and symbolic elements. Neither is objectification a process limited to 169 . objectified body-part (Hirschauer. 1991. as a researcher. yet basically dualistic attitude. perhaps no less than biomedical practitioners are claimed to. and unavoidable part of biomedical work. With Ivan. depersonalised. on both my part and the biomedical staff's.Sky E. The OR has its own rituals and is in many ways an extension and intensification of biomedical epistemologies. and remained no less salient as our relationship developed. the boundaries between absolute objectifying distancing and complete personal identification seemed to be in a continual flux. the tendency toward objectification is affected by ritualistic practices and symbolic elements. In fact. I created Ivan's body as much as my own presence is created by the network of objects and relationships: both are of a fluctuating nature. 1991). This involves the transformation of a life-world into an object which can be manipulated. Indeed. as if in a dynamic flip-flop between the patient as object and patient as subject. McNay. Conclusions In the case presented here. contingent upon the setting and my own role-taking. however.
the most empathetic actor may take on a position oscillating between these two attitudes. nor does she merely participate in transformative rituals. I claimed that. Pratt. two roles (physician-ethnographer). Ethnographers.she also experiences them. and highly dependent upon the symbolic and ritualistic setting. on occasion. often sway from objectification to empathising positions (Fabian. taking on the concept of epistemological fluctuation in ethnographic studies of biomedical exchanges. in particular. 1983.Black Butterflies biomedical settings. Clifford and Marcus. Wiltshire. 1986. The ethnographer does not merely observe. The not medically-disciplined actor does not necessarily adopt a phenognostic discourse as default: It iself needs to be encroached in a form of knowledge\power in order to sustain itself. 1986. I raised the need for a multi-faceted approach to questions of objectification. 170 . experiences. 1999). This interpretation of exchanges in biomedical spheres points to the inherent tension between these two tendencies (objectification-empathy). 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. Using insights from my own ethnographic work in a neuro-oncological clinic and a neurosurgical unit. and forms of rapport. and two phenomenological states. and is phenomenologically affected by them. two perspectives (biomedical-personal). nor is it exclusive to physicians: anyone can objectify anyone. yet so can be said about the adoption of phenognostically-based attitudes.
but only interpretational and culturally contingent. science. and the world of academics seeking the understanding of Western society. and theoretical work on the issue has too seldom been undertaken. I suggest. Gross Part VI: Conluding Words The Bounded Brain The brain is the apparatus through which we experience the world and relate to it. bioethics. is not nearly as problematised as one would hope. knowledge about the brain can never be universal. Hence.Sky E. This makes it both organ and concept. My 171 . thus. or fundamentally 'true'. that a deep and attentive study of the notion of 'brain' is likely to offer unique. the association of the mind-body split with broader social terms such as professions. meaningful insight into the fundamental questions troubling the sociocultural world of modern Western society. history. both object and site of meaning. Still. discourse. and is the ultimate locus of our selves. both biological and hermeneutical.
to carefully extract the most powerful points I chose to advance. The significance of the association of the papers stands at their similarities rather no less than at their diversity. objective and subjective. and the role these forms of knowledge may take in both diachronic and synchronic perspectives on the sociocultural world of biomedicine.Black Butterflies contribution wishes to stand precisely within these nascent fields of studies. The understanding of these processes. would be reconceptualised in a way to assert clearly bounded categories: science and non-science. As shown here. the site of the clashing of two ultimate realms: the world-out-there. as required in professional academic publishing. and to most thoroughly consider their actual contribution to selected bodies of literature and areas of concern. Indeed. but also to distil my ideas. I hope. and the inner world of experience. I have claimed. a colossal pineal gland. and replicated. I chose to present this analysis in the form of three relatively independent essays . challenged. I believe that this served not only to portray research in advanced scholarly language. subjective forms of convictions. it is almost a truism to say that the consequentiality of theoretical advances cannot be tested upon its elucidating one phenomenon 172 . This clash. the brain can be regarded as an interim. This work presents instances where these boundaries are encountered. allowed a refinement and elaboration of concepts of scientific vs. at both ontological and phenomenological levels. reason and emotion. each with its own empirical foundations. Somewhat unorthodoxly. This also demanded an intense focusing on which I considered as the most essential aspects of the phenomena at hand.each with its own body of literature and theory.
Sky E. I proposed a detailed picturing of the adoption and then relegation of psychosurgery as a decreasingly 'purely scientific' ontognostic medical procedure. as was the case in and around Ivan's brain surgery. This was shown to represent a case of 'replicated boundaries': an occurrence in which boundaries are drawn and concurrently replicated at several levels. In this. while still holding a substantial empirical range. rather than a mere pre-discursive default. In all three cases. As it remained still beyond the reach and control of the ontognostic endeavour. it was to be kept strictly outside of the practical. rhetorical and symbolical of the ontognostic realm. three fields were chosen as epitomising the theoretical suggestions made throughout this text. epistemological. phenognosis was sought-after as a site of knowledge to be tamed and conquered by science and biomedicine. First. 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. Phenognostic resistance to this reduction to the realm of matter created a clear threat to the discourse of objectivism as potentially omniscient. in and around the debate 173 . I offered here a first 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. Finally. 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. hence the great attention given to the creation and sustainment of these boundaries. Gross or another – it is its applicability and relevance throughout a full array of empirical worlds that endow it with promise.
and despite some exceptions (e. and is still of critical consequence in broad domains of research (e. 1996. and functional imaging studies .this explanatory gap remains insoluble. Martin. Williams.g.Black Butterflies on psychosurgery and in and around complex processes of diagnosis. Crick and Koch. where both macro-levels and micro-levels. 1996. 1998). Searle. and has been overwhelmingly portrayed as the most perplexing epistemological chasm of postenlightenment society (e. Rosenberg. unstable. 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. Nagel. where both institutions and personal thoughts were looked upon to identify the replicated boundaries of 'Truth' around an obstinate gnostic split. This dualism continues to create areas of contest where symbolic actions as well as rhetorics are used to reassert an uncertain. 1999). one thing seems to be clear: Western culture has not yet overcome the gnostic split. As mentioned. 1994).g. and still holds on to the two forms of 'truth'. the mind-body problem has indeed enticed endless contemplations. In terms of its social revelation. 1990. idea of 'what the world is'. Chalmers. Cartesian boundaries were presented not as a philosophical but as a cultural phenomenon: a phenomenon where both professions and rituals. 2000). Dennett. Still. Over the years. my aim here was to refer to the mind-body problem as one such conceptual complex. 1988. Withstanding all efforts of reconciliation – notably in the field of neurosciences.g. 1983. notcommonly shared. Martin. 1995. artificial intelligence. Levine. 1992. 1986. a clear disparity hangs 174 .
I shall claim. and study its sociocultural grounds and implications. In other words. Yet. long before the neuroscientific revolution of the 1960s. Long before the 1990's 'decade of the brain'. 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.Sky E. and sensomotor activity. Gross between philosophical advances on the matter and efforts made by social sciences to recognise. These include the exponential growth of neurosciences and the rising power of post-modern and New Age epistemologies. 2000). Today. if only by definition. to see the sunshine. Subjectivity and our sense of 'being-in-the-world'. 'what it feels like' to be. that a number of recent developments have created a more urging need to attend to this conundrum. to experience pain. emotions. after all. and electrical bases of mental activity. The last decades saw a growing interest in the physiological. Science finds there its 175 . however. it would seem almost as nonsensical to claim that our sense of existence can be utterly reduced to the brain. the cerebral organ has raised considerable interest from both medical and scientific endeavours (Hyman. research has gain tremendous successes in identifying the physical correlates of thought. Over the years. biological. personality. as well as an exponential growth in neuroscientific technological developments. chemical. is doomed. define. As has been well addressed throughout this essay. the brain indeed holds peculiar attributes which makes it such a fascinating object of study: It is. the apparatus through which we experience the world and relate to it. it would be nonsensical to deny the presence of some form of correlation between mind and brain. and is the ultimate locus of our selves. to remain in the private world of inner sensation and beyond the reach of objective query.
however. Other sociocultural developments raise a need to deal more substantively with the mind-body problem. 176 . Phenognostic sources may have predictive elements. and relations of power.Black Butterflies ultimate boundary. will claim that. the 'post-modern' claims for a multitude of 'truths' contingent upon perspectives.e. As well put by Horgan (1999:4): "Inner space may be science's final – and eternal -frontier". and now both will share a common battle ground: Modern Western epistemological culture. when scientific evidence will not support a claim based on subjective experience. may have a strong case against the probability of the divination of the dead. Many New Age movements will take this stance even farther.e. i. beyond ontognostical metaphysics). cultural biases. These may go as far as to portray 'experience' as not only a legitimate source of Truth and as holding strong authoritativeness. and the most important threat to its ultimate authoritativeness. Most significantly perhaps would be the rise of the post-modern. Science. as it felt true to an experiencing individual – it IS true. may be able to alter an ontognostically-known 'reality' and work beyond the forces of the world-out-there (in ways considered 'supernatural'. 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). This calls for a more accepting stance towards claims to truth based on subjective impressions and inner experience. The believer. phenognosis. This social and cultural phenomenon should stand among other areas of concern in which contemporary social scientists are engaged. i. Here again. two sources of truth will interact and fight for authoritativeness. In many cases. the latter will be considered superior. for example.
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