Sky E.

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 12..............................................................................THE MIND-BODY PROBLEM AND CARTESIAN DUALISM 12 .............................................................................................................. Descartes and After 14 ............................................................................................................The Cartesian Fallacy 16.......................................................................................................... INTRODUCING THE GNOSTIC SPLIT 16 ............................................................................................. Phenognosis and Ontognosis 18 ..............................................The Body and Embodiment: Closing the Great Divide 19 ........................................................................Social Studies of Medicine and the Body 21 ............................................................The Discourses of Truth: Foucault and Beyond 24.................................................................................................. INTRODUCING REPLICATED BOUNDARIES 24 ...............................................................The Gnostic Split and Replicated Boundaries 26 ......................................................Replicated Boundaries: The Professional Grounds 30.......................................................................................................................................INTRODUCTION 31......................................................................................................LOBOTOMY IN MIND: METHODOLOGY 31 ................................A Historical Approach to the Study of Replicated Boundaries 32 ....................................................................................................... Reading Psychosurgery 34.............................................................................................................................ON PSYCHOSURGERY 38..................................................................................................... CREATING ONTOGNOSTIC LEGITIMACY 38 ...........................................................................................................Prehistorical' Sources ' 40 .................................Replicated Boundaries: The Professional and the Legitimate 43 .................................................................................................... Building the Heroic Ethos 44 ..................................................................................................................The Founding Tale 46 ............................................................................................................Out of the Laboratory 48 .........................................................................................................................Men of Science 50 ...................................................................................................................Locating the Mind 53 ......................................Medicalising the Mind: Symbolic Correlates of Ontognosis 57.........................................................................................LOSING GROUNDS: AWAY FROM ONTOGNOSIS 57 ................................................................... The Traps of Rhetorics: Facing the Debate 59 .................................................The Traps of Science: Methods and Rationalisations 60 ....................................................The Traps of Symbolics: Freeman and the Ice Pick 62..........................................................................FROM THE MEDICAL INTO THE SOCIAL AND BACK AGAIN 63 ...............................................................................................Social Control and the State 65 ..................................................................... Dystopic Prospects: Psychiatry in Charge 66 .......................................................................................Back to Society: The Social Cure 68 ...................................................Illegitimate Interests: The Costs of Mental Asylums 70.............................................................................................................................. THE HOMO VADUM 72 .....................................................................................................The Homo Vadum's Brain 74 ....................................................................Corporeality, Pain and Phenognostic Truth 77 .....................................................................................................Madness and Ontognosis 78 ...........................................................................................The Homo Vadum and Society 80............................................................................................................................CONCLUDING WORDS 82.............................................................................................................. THE NEURO-ONCOLOGY CLINIC 83 .....................................................................................The Clinic: Spatial Characteristics 86 ...............................................................................Schedules and Organisation of Time 86 ..............................................................................................The Neuro-oncology Meeting 87 ..............................................................................................................................The Patients 88 .....................................................................................................................The Consultation 89 ......................................................................................................................Family Members

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90......................................................................................................SOMETHING ABOUT BRAIN TUMOURS 90 ...................................................................................................................Types of Tumours 91 ....................................................Location of the Tumour and Functions Threatened 93 ..................................................................................................................................Treatment 96...................................................................................................................................... INTRODUCTION 97......................................................................................................................................METHODOLOGY 98............................................................................................AT THE CLINIC: THE DIAGNOSTIC PROCESS 100...............................................................................................................MEDICOSCIENTIFIC DIAGNOSIS 102......................................................................................................................THE WEB OF EXPERTISE 104.......................................................................ON THE ONTOGNOSTIC AUTHORITATIVENESS OF REPORTS 106 .............................................................................. The Sight of the Tumour: Radiology 111 ............................................................................... Sorting Things Out: Histopathology 113 ....................................................................................Figuring it out: Neuropsychology 114 ......................................................................................... Hands-on: The Clinical Report 117 ............................................................................................................................. The Patient 121 ......................................................................General Oncologists: Peripheral Experts 123 ..........................The Neurosurgeons and the Tumour Board: Peripheral Experts 124..............................................................................................................MECHANISMS OF INTEGRATION 125 ...................................................................................................................... Hierarchisation 126 ............................................................................................................................. Sequencing 127 ............................................................................................................................. Negotiation 129 .......................................................................................................................Peripheralising 130 ............................................................................................................................ Pragmatism 134..........................................................................................................................CONCLUDING WORDS PART V: THE BRAIN EXPOSED...............................................................137 ON NEUROSURGERY AND THE NATURE OF OBJECTIFICATION...................137 137.................................................................................................................................... INTRODUCTION 140....................................................................................................................METHODOLOGICAL NOTES 141................................................................... THE SACRED BRAIN: THE MATTER OF THE GNOSTIC SPLIT 143.........................................................................................................................................THE STORY 143 ....................................................................................................................................Prelude' ' 146 .................................................................................................................................The S-day 150 .......................................................................................................................Under the Skin 152 .............................................................................................................The Peak of Surgery 155 ............................................................................................... Closing up: The last stages 156 ..............................................................................................................................Just a Story 156...........................................................................................LIMINALITIES AND REPLICATED BOUNDARIES 156 ..................................................................The OR as a Space of Multiple Liminalities 159 ................................................................................The Temple of Ontognosis: The OR 159 ................................................................................ Keeping Phenognosis Out: Sterility 161 ............................................................................. Anaesthesia: Subduing Phenognosis 163 ...................................................................................................Space and Liminal States 164 ...........................................................................................................................Going Native 167...........................................................................................GNOSTIC SHIFTS AND 'THEORIES OF MIND' 170......................................................................................................................................CONCLUSIONS PART VI: CONLUDING WORDS...............................................................172 172 ...............................................................................................................The Bounded Brain 175 ........................................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

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Part I: Introducing the Work

The Study of the Human Animal
Sociology and anthropology have forever sought to

understand the ways in which the individual relates to the world, let it be 'society', 'nature', the 'other', or any category of entities or concepts. I believe, however, that one element should have been given a more respectable place in these endeavours: the understanding of what the human animal is in his own eyes1. That is, how does he conceive his experience in the world and how does he conceive his experience of the world. Can he regard himself as a thing among others, or can he only relate to himself as an experiencing subject, distinct from a world-out-there, from which would stem the things which he will perceive? The question which will follow us throughout this essay is not the question of how culture defines the 'self' in that, this work would hardly be original. Rather the question here is how the self defines the self: Which can be said to serve as a basis to what is
1

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

Sky E. Gross
known in the world-out-there, and in the world of the self? The 'I' (myself), the 'he' (the 'other'), or rather the 'they' ('society')? Thus, this essay is about epistemology, in it asking how do we know what we know. In looking at the world and at the self, which kind of knowledge 'counts'? and And if one is considered more authoritative than another, how much is this hierarchy contingent upon cultural settings at both macro-level, and microlevel? These are grand questions indeed, and being able to attend to them, at any level, is a challenge in and on itself. It is this very achievement I sought in the years preceding the writing of this essay: tackling, in the most plain-spoken way possible, the issue of human understanding of the world and of himself within this world. Before entering the analysis itself, there are twosome issues that I would like to address. Both relate to my choice to study the 'Western world'. Much of anthropological attempts to understand human ways and culture sought knowledge in social worlds other than the one from which the discipline itself has sprouted from. This may be a somewhat curious fact, considering it is itself the source of the initial interest in and conceptualisation of - the issue. While acknowledging the value of these endeavours, I have chosen to come back 'home', and to try to understand Western culture in its own context, with its own dynamics, and with its own historical development (each as defined by its own narratives). One may oppose the reference to Western culture as if it were one whole, and I must join these expressions of discontentment. The Western world is indeed a mosaic of different 5

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cultures, whether defined as based on national aspects, religious beliefs, gender attributes, social stratification, etc. There is, however, one important institution, which can be said to hold greater homogeneity in respect to its epistemological and practical grounds: Biomedicine. This has been acknowledged by endless works in the sociology and anthropology of medicine, now well-accepted subdisciplines, and sources of many theoretical innovations in the social sciences in general. The power of biomedicine in the Western world can hardly be overrated: it may be one of the most dominant, influential, and highly regarded profession and body of knowledge. Its authoritativeness over the individual and the social allows it to be the source and the culmination of values assigned to Western culture in the most general meaning of the term. Thus, it seemed most promising to turn to this field as an empirical arena for the development of a general theory of knowledge as it applies to Western society, in its modern and postmodern manifestations. In my seekingmy search for the most promising field of study, I defined another vector of interest: the focal point within which the Western modern individual defines his identity mind and body, mind or body. There, many complexities began to arise: am I a subject, looking at the world from my own private perspective, defining Truth as it is sensed, thought of, felt, by me, as an conscious individual?; Or should I rather adopt a vision of myself as an object among objects, in a world defined by a general (and scientific) consensus on which is True, and which is False? Once having ascertained biomedicine's tendency to reinforce the second way of defining Truth (adopting a body-centred, or objectifying epistemology), I shall look at the ways in which it is resisted by a sense of truth as held by the experiencing subject.

Sky E. Gross
These relations of power stood at the centre of my research in the last years and will be placed at the centre of this essay as well. My hope is to be able to convince the reader that these may form a ground for a theory placing mind-body relations at a focal point in the understanding of modern and postmodern Western epistemological cultures.

The Three Papers

In the course of this essay, I will use three different ways to substantiate, exemplify, and clarify the claims above. First, I will propose a historical outlook on the ethical debate regarding psychosurgery, the use of surgical, material means for treating the mind; Second, I will bring the analysis of an in-situ work where I observed the ways in which brain tumour diagnosis is reached, when based on more or less objective forms of knowledge; And third, I will lay down an analytical first-person narrative to bear on the processes of objectification associated with brain surgery, as experienced by the field-worker. The sequencing will go from the macro, to the micro, to the reflexive a representation of the theory itself, by which the mindbody split infiltrates (as 'replicated boundaries') all layers of sociocultural phenomena from broad historical movements, to micro-interactions, to personal thought. Accordingly, methods will greatly vary, although remaining within the limits of qualitative analysis. Although referred to in the coming section more careful 7

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presentation of the methodology will be presented in each of the three chapters, thereby avoiding redudancies and repetitions, as well as making the compatibility between the work and the methods explicitly evident.

Surgeons of the Mind

The first paper will serve as theoretical grounds for the overall analysis proposed in this work. Thus, although heavily drawing on philosophical insights, its aim will be to build a framework for a social study of knowledge. In this, I will suggest a conceptual framing whereby modern Western biomedical practice and research sees two forms of knowledge coexist and fight for authoritativeness: phenognosis (knowledge based on subjective experience) and ontognosis (knowledge based on the enquiry of a world-out-there). Drawing on philosophical and theoretical insights from recent works on discourse, the body, and social studies of medicine, this paper will propose an analysis raising cultural aspects of mindbody dualism in modern and postmodern Western society. 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, yet fully sentient individual into a complacent object, lacking the capacity for subjective experience. An interpretative reading of the related texts will show how certain epistemological assumptions led to the overwhelming acceptance of the technique within modern medicine of the 1940s-1960s, and how these have increasingly become depicted as scandalous within a more recent post-modern bioethical debate. The analysis will then relate this transformation to the placing of human subjectivity above observable functioning as more relevant goals of medical and social practices. The study

Sky E. Gross
of the debate over psychosurgery will raise questions as to the ways in which mind-body epistemologies affect conceptualisations of humanhood and its association with self-consciousness (being a subject) and the ability to accept objective truth (being sane). This historical analysis will allow a bird-eye, macro-level view of the conceptual issues running throughout this work. It will assert the social embodiment of the mind-body problem using a broad perspective settled on the world of biomedicine. This will turn to be essential to the the understanding epistemological of the microdynamics at hand, i.e. associated with forces

phenognosis and ontognosis.

Experts and 'Knowledge that Counts'

Bringing these ideas to the realm of the clinical, this paper will provide a closer, in situ, look into the life of a neuro-oncology (brain cancer) clinic of a large hospital in Israel, based on a sixmonth participant observation. It will point to the many challenges involved in the solidification of brain tumour diagnoses by different experts and forms of knowledge, and present these epistemological and practical complexities as they are uncovered in daily routine. The paper underlines the technological and epistemological grounds of 'expertise' in the medicoscientific practice of diagnosis, and their roles in the assertion of expert knowledge's authoritativeness. When questions of authoritativeness arise, several mechanisms of resolution are used. These include Hierarchisation: ranking the relative validity and reliability of the different sources of information, eventually prioritising reports from more authoritative expertises (e.g. imaging reports would be considered more reliable than phenognostic patients accounts); Sequencing: relying upon the 9

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temporal dimension, and defining the discrepancy itself as a diagnostic sign (e.g. the degradation or amelioration of the disease); Negotiation: adjusting diagnoses via a preliminary exchange between experts and a consequent 'fine tuning' of the reports (e.g. radiologists being aware of clinical evaluations before finalising their reports); Peripheralising: turning to other expertises to 'explain away' symptoms that do not fit with a well established initial diagnosis (e.g. asserting that a symptoms source was orthopaedic rather than neurological); And pragmatism: using information only as far as it provides sufficient grounds for treatment decisions, leaving ambiguities unresolved. These five mechanisms will here be presented in the context of the daily work of the clinic, and associated with the theoretical thrust of this work, i.e., the relation of power between phenognosis and ontognosis.

The World of Brain Surgery

In this essay, I will try to show how issues of objectification can be discussed from the viewpoint of the objectifying party. Resisting a dichotomy between physician-objectifying and ethnographer-humanising, I will portray objectification as being of a fluctuating nature, rather than a necessary by-product of professional tendencies, epistemological bases, practical necessities, and processes of socialisation. With this in mind, I will propose a further look into the settings within which these discursive dynamics take place and come about through artefacts, space, symbols, etc. I will first briefly portray my relationship with Ivan, a brain cancer patient whom I have followed over a period of eighteen months, and then focus my attention on my observation of the brain surgery he had to undergo. As it is presented from a first-person perspective, this account will provide a glance into the

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ways in which clinical or clinically-situated exchanges are not only observed but also experienced. Considering the breadth of the methodological and empirical bases for this work, each chapter will be structured as relatively independent unit, with its own body of literature and methodological sections. This is, in many ways, the presentation of three stand alone journal articles, as customarily composed and structured in the professional academic press. First, references are used only as far as they are directly relevant to the essays; and secondly, the textual content is refined and condensed to create a succinct and to-the-point exploration of the issues at hand. Nevertheless, the integration of these papers into a unified scheme allows a broader and more compelling development of the theoretical framework which will serve the analysis throughout: the idea of the 'gnostic split' and the suggested concept of 'replicated boundaries'. I believe that neither of the papers, in and of themselves can provide sufficient ground for the conceptual schemes proposed here.

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Part II: The Argument and its Theoretical Complex

The Mind-Body Problem and Cartesian Dualism2
Descartes and After

"Cogito ergo Sum"

(I think therefore I am)

In these few words, Ren Descartes (1596-1650) offered his definition of the mind as an entity outside of the realm of matter. More specifically, he would define how mind and matter were distinct: Matter has a spatial extension, i.e., it has a place and a
2

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

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dimension; Matter has proper characteristics and attributes, such as colour and shape; Matter is public and accessible to all, including to scientific observation. The mind, in contrast, will have no spatial extension, no attributes, and exists in the private world of the subject (Garber, 1992; Kendler, 2001). Along the same lines, Descartes will claim that a human being is not one entity, but rather has different parts: some mechanical and some non-mechanical. The mind, in belonging to the latter form, will thus constitute a form of 'ghost in the machine' (Ryle, 1949; Koestler, 1967). The question of the nature of the relations (or lack thereof) between 'the ghost' and 'the machine' will become one of the more important foci of postCartesian Western philosophy (Leibowitz, 1982). The most prominent philosophers would argue for this or that view of the problem, giving birth to an immense body of works. Among the ways in which the problem was tackled, one may find some that may be viewed as dualist and others as monist. Much like Descartes himself, philosophers adhering to dualist views conceive of the problem as based on the relations between two distinct ontological entities (entities that 'are' in the world). Monists, however, will speak of one dominant substance: this being either material (materialists) or spiritual (idealists) (Schimmel, 2001). Dualist explanations, in turn, can be subdivided into interactionist or non-interactionist ('parallelism'). As Descartes saw mind and body as interacting entities (more specifically through the 'pineal gland', an organ located deep within the brain), one could define him as an interactionalist (Schimmel, 2001). Leibnitz (1646-1716), in contrast, would see mind and body existing in parallel, without having one affecting the other (non-causal 13

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dualism, or non-interactionism). This 'identity theory' will have mind and body as two manifestations of the same phenomenon thereby not claiming for a duality of substances but for a duality of properties. 'Mind will appear when the question is approached from a subjective angle, and 'matter' when approached objectively. Trying, like monists and 'substance dualists' do, to ask whether water is water or H2O, makes no sense to the 'property dualist': these are not two phenomena, but rather two ways of looking at one phenomenon (Kendler, 2001). 'Functionalism' will hold a somewhat related concept: the mind-brain relationship would be comparable to drive-car relationship, that is, rather than one being a by-product of the other, there would be between the two a relation of function to matter (Ben Zeev, 1996). An additional important dualist theory is referred to as 'epiphenomenalism'. According to this view, mental phenomena will be but a by-product of material substance, a Hegelian 'foam on the wave' of brain activity. With the rising power of brain research, these views, along with clear-cut materialism, have become ever more pervasive.

The Cartesian Fallacy

The mind-body conundrum can be defined around the logical fallacy arguably entailed by Cartesian dualism. Benjamin (1988), for instance, brings us four prepositions, each considered 'true' prima facie, yet logically incompatible with the others: The human body is material. The mind is spiritual. Mind and body interact.

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Spirit cannot affect matter and matter cannot affect spirit. In order to make have these assertionsthem 'make logical sense', one would have to give uprelinquish at least one of these assertions. This is, in the broadest terms, the basis for the different philosophical approaches described earlier: The body would not be material (idealism); The mind would be material (materialism); Mind and body would not interact (non-causal dualism: e.g. identity theory, or ephiphenomenalism); Spirit can affect matter and vice-versa (causal

interactionism). With the development of modern science, idealism has lost most of its vigour. With the evolution of experimentalism and the focus on pragmatism in the development of technologies, positivism has gained much strength. With it, materialism in its less or more extreme version seemed to have led 20th century's Western thought. This until recently, when modern physics (notably quantum theory) raised questions as to the ontological exclusivity of 'matter'. This, aAlong with more general trends of New Age culture, this seems to have revitalised concepts regarding 'mind' as a powerful entity, or to the very least, as a consequential actor in the 'world', were it the world of 'nature' or the world of the 'social'. This process will stand at the very centre of much of this current work. The accumulation of scientific knowledge leaves little doubt: there is to the very least some correlation between the mental and the cerebral. The question remains as to the idea of a causal 15

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relationship: is brain activity a result of mental activity or viceversa? Science keeps reinforcing the concept of correlation, yet does not take us closer to resolving the problem of causation (Midgley, 1996). The answer must thus be found in the realm of the cultural, of the social, where conceptualisations on the nature of 'the world' originate and manifest themselves. With this in mind, I will present some aspects of Western modern society's marked cultural character, as expressed in one of its most powerful discourses: biomedicine. I will show it to be based on movements between two distinct forms of knowledge, each holding claims to the ultimate Truth: ontological (what IS in this world, what are its fundamental essences); and phenomenological (what is it like to BE, how is the world experienced). For the sake of conciseness, and in order to avoid ambiguities with related terms, I will term the former ontognosis (gnosis Greek for 'knowledge') and the latter, phenognosis. After proposing an essential definition for each, I will turn to picture the evolution and manifestations of these two epistemological forms within broader contexts, affirming their relevance and consequentiality in the sphere of the sociocultural.

Introducing the Gnostic Split

Phenognosis and Ontognosis
My analysis will follow a philosophical division of the mindbody conundrum into two set of predicaments: the easy problem, and the hard problem. The 'easy' problem involves a view of mind and body as different kinds of fundamental essences of a 'world out-there' (there is matter and there is mind, whether experienced or not). The 'hard' problem emphasises an epistemological gap between first-hand experience (felt) and public, scientific

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knowledge (observed), or between subjective and objective knowledge (Ornstein, 1972; Young, 1990). This 'hard' problem rightfully earned its appellation. The subjective/objective split presupposes a form of consciousness encompassing a set of 'truths' (often referred to as qualia) inaccessible to scientific inquiry: the sight of the colour red, the sensation of an itching toe, or a tooth ache which whose actuality could never be disputed by a dentist. Arguably, no progress of science will ever allow being, feeling, or aching in the place of another, and no map of the brain, however elaborate, will be able to convey subjective experience (Damasio, 1994; Edelman, 2000; Searle et al., 1997). As Nagel (1974), in his famous article "What is it like to be a Bat?" eloquently notes, true knowledge of 'what it is like' is an epistemological privilege reserved to the sentient subject, i.e., to the bat itself: Only a bat would know 'what it feels like' to see with sounds, and only a particular bat would know what it feels like to be this particular bat (Jackson, 1982; Heil, 1988; Gertler, 2001). Facing an outside world, this first-person standpoint is the site where one turns acquired knowledge (of the world, of oneself) into which he/she will define and often declare to constitute the 'Truth',. This, regardless of whether the source is the world-outthere agreed upon by several individuals or ones own hallucinatory world. This first-persons position is also the focal point where facts become meanings and where data become experience, this again, regardless of whether the meaning assigned to a phenomenon seems objectively acceptable or based on some sort of psychological distortion (Edelman and Tononi, 2001; Metzinger, 2003). This locus of 'Truth', based on 'I know', 'I think', 'I feel' (phenomenological Truth), will often be challenged and questioned by a claim for Truth based on 'There is', or 'This is' (ontological Truth), a claim most often originating from the world of science and biomedicine. 17

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Thus, in the terms proposed here, I will base ontognosis on a materialistic approach to the easy problem portraying the world as essentially material. With phenognosis, on the other hand, I will adopt the notion of experience as addressed in the context of the hard problem, emphasising the irreducibility of the subjective into material elements.

The Body and Embodiment: Closing the Great Divide

Phenomenology has its basis in philosophy and finds itself at the centre of much contemporary work in the philosophy of mind, namely in the field of neurosciences. For instance, one may find such a view in Bennett and Hacker's famous essay, "Philosophical Foundations of Neurosciences": "A human being is a psychophysical unity, an animal that can perceive, act intentionally, reason, and feel emotion, a language-using animal that is not merely conscious, but also self-conscious not a brain embedded in the skull of a body" (Bennett and Hacker, 2003:3) [my emphasis, S.G.] The Cartesian mind-body split has ever been the subject of philosophical attempts to either deny its existence or dissolve its problematic aspects. One such important and relatively recent attempt can be found in French philosophy and human sciences (Lanigan, 1991): Maurice Merleau-Ponty (e.g. 1962) sought the resolution, or rather, the conceptual annihilation of the Cartesian split. According to him and to many of his existentialist and phenomenologist predecessors, although the body could be seen as an mere object, 'experience' or 'mind' cannot. The latter will only exist as far as it is embodied: the mind is not the 'ghost in the 18

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machine' it is rather the experiencing, first-person, faade of the machine. While the body may be without mind, the mind cannot be without body: both empirically and philosophically, perception, action, cognition, emotion are all 'embodied phenomena'. "[The body] is in the world as the heart is in the organism: it keeps the visible spectacle constantly alive, it breathes life into it and sustains it inwardly, and with it forms a system" (Merleau-Ponty, 1945 in Lanigan, 1995a: 203). In other words, for phenomenologists such as Merleau-Ponty, while the body may be regarded as a mere physiological and natural entity (an 'objective body'), it will, once experienced, turn into a 'phenomenal body'- unified with (rather than distinct from) this physiological entity. The phenomenal body, thus, must be viewed as one with the objective body: experience is experience of the body, rather than an entity IN the body.

Social Studies of Medicine and the Body

Scholars, notably in the fields of the social studies of science, have taken up these leads and engendered considerable research on the existential and phenomenological groundings of the self and its relation to 'the body'. This was associated with an ongoing effort to account for possible gaps between 'sentience' and 'science' at the level of the self, a self problematised as dual (mind vs. body) by external expert knowledge (most notably by medical practitioners, dealing directly with the 'body in pain', or the 'experiencing flesh'). These works generally sought to merge the bodys objective faade with the less tangible subjective experience of which it serves as the locus. This would lead to the understanding of culture and experience "insofar as these can be 19

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understood from the standpoint of bodily being-in-the-world." (Csordas, 1994:143). Along tangential lines, feminist literature took on the task of revealing conflicts between sentient knowledge on the one hand, and biomedically based knowledge on the other, often relating epistemology to constructions of gender (e.g. Root and Browner, 2001). According to these views (which were generally put under the umbrella of a 'sociology of the body'), culture, as a system of thought both external to the individual and concurrently present within the individual, represents the body in a way that is socially contingent (Martin, 1994). While agreeing with this basic premise, scholars of 'embodiment' will claim that the sociology of the body does not take into account the lived-experience of the body, a fact that eventually only reinforces ideological and political dualisms. In relation to the context of gender, these very works will be claimed to adopt a 'mentalist discourse' (seeing 'mind' as being superior to 'body') by which men are the 'mind', that is, related to public realm, while women are the 'body' and belong to the private sphere (Williams and Bendelow, 1996; Webb, 1998). Thus, sociologies of embodiment (e.g. Shilling, 1993;

Crossley, 1995; Turner, 1996; Lupton, 1994; Williams, 1996) have shown how much 'we are our bodies' and how much of the mindbody split remains unchallenged by current sociological work (Nettleton, 2006). Thomas Csordas, one of the leading scholars in the field, explains that the shift from looking into the body to considering the phenomenon of embodiment: "corresponds directly to a shift from viewing the body as a nongendered, prediscursive phenomenon that plays a central role in perception, cognition, action

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and nature to a way of living or inhabiting the world through one's acculturated body." (Csordas, 1994: xiv). Overall, while ascertaining the presence of epistemological conflicts in micro-settings where third-person and first-person views collide (IT vs. I), even these 'embodiment'-oriented undertakings showed little concern for the changing hierarchies between the two forms of Truth (subjectively experienced vs. objectively accountable) as broad discursive forces. For instance, while Turner (1992) brings up the distinction between leib (the lived body) and korper (the physiological body), he uses it as to show the preciousness of the leib over the korper as a source and grounds for culture. Still, the relationship between the two as 'Truths' is never analysed as such. Throughout this work, I will seek to provide such a complementary outlook, using Foucaults (1986) notion of discursive practices as entailing human desire for 'Truth' about the world and about the self. In an attempt to do so, I will first propose a theoretical framing and then attempt to work the theory into the canvas of the social settings from which individual cases were drawn from: the history of psychiatry, the clinic, and the surgery room.

The Discourses of Truth: Foucault and Beyond

Biomedical and scientific discourses generally comply with ontognostic views whereby Truth would be accessible through the unravelling of the world of material essences. Medical knowledge is essentially of a reductionist nature, paying little or no attention to the subjective aspects of disease. This ontognostic epistemology is, in turn, associated with the foundation of a powerful ethos, the establishment of an authoritative system of 21

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rhetorics, and the drawing on highly evocative symbolic elements all of which serving to support its discursive supremacy. Biomedicine has had indeed notable success in achieving this demarcation as highly respectable, trustworthy, and distinctive from other social spheres, such as religion, politics, and economics (Gieryn, 1983, 1999; Mizrachi et al., 2005). This distinction persists within a particular power structure where a hegemonic regime of truth is established, defining the forms of knowledge considered admissible while dismissing competing claims for Truth (Foucault, 1972, 1980, 1986; Armstrong, 1983). This will ipso-facto place non-scientifically based knowledge including phenognosis - in a subordinate position (Foucault, 1982). Phenognosis, however, should not be seen as comprising mere 'leftovers' of this biomedical ontognosis. When considering the development of post-modernism, the linking of subjectivity with power relations will reveal that it may indeed constitute a rising discursive force. In the 1979 Stanford Lectures, Foucault stated that what troubled him since his first book was: "In what way are those fundamental

experiences of madness, suffering, death, crime, individuality connected, even if we are not aware of it, with knowledge and with power? I am sure I'll never get the answer; but that does not mean that we don't have to get the question". Foucault's analyses distinguish between discursive events and prediscursive events i.e., 'things' that are not based on discourse, and that have not been produced by the social. These include pain, madness, and experience of self. I shall claim here that Foucault may have had the question misspelled: what if these 22

Sky E. Gross
experiences were not prediscursive, but rather discursive? After all, following his claim that 'Man' is but a discursive event, a "new wrinkle in our knowledge" (Foucault, 1972; Goldstein, 1994), why not consider 'Man' as a discursive event based on the phenognostic authoritativeness of human experience? Thus, although, according to Szakolczai (2000), Foucaults own lifework can be defined as revolving around this issue of discursive subordination, both his writing and more recent literature has, by and large, omitted the option of a symmetrical opposite, by which phenognosis itself would serve as grounds for legitimacy and, therefore, for power. When at all acknowledging subjective forms of knowledge, these works rather deal with them in oppositum to the hegemonic power/knowledge, that is, through the challenges it may present to the material-ontological bases of biomedicine, science, and modern Western social order (e.g. Eisenberg, 1977; Rosenberg and Golden, 1992; Rosenberg, 1999; Mizrachi et al., 2005). Traditionally then, phenognosis, as a consequent discursive formation in and on itself, rarely seems to be deserving particular interest, again making the relationships of power between phenomenological and ontological forms of knowledge critically understudied. This lack of attention remains somewhat enigmatic considering recent historical developments. The second half of the 20th century witnessed a gnostic shift in the form of hierarchical changes in the statuses of the two forms of knowledge. This shift had both roots and repercussions within what social sciences have traditionally referred to as the rise of the postmodern (Lyotard, 1984; Harvey, 1989). This postmodern era would see critiques of science joining existential, phenomenological, and relativist influences in the social sciences 23

Black Butterflies
(and in general culture, most particularly in art and literature), to pave the way toward a destabilisation of the grounds upon which ontognosis drew its force. Grand ontological and metaphysical accounts lost grace to local, negotiated, and provisional forms of knowledge, thereby allowing experience to ascend as a legitimate source of Truth. Still, although overwhelmingly rooted in phenomenological thought, more radical postmodernism will reject the whole idea of Truth, including if ever considered- phenognosis (Bourdieu, 1992; Dickens and Fontana, 1994). Thus, while postmodernist thought may have notable affinities with ideas associated with the concept of phenognosis, one cannot stress enough the distinctiveness of the two worlds of notions, whereby stands the value of the proposed reconceptualisation. This issue shall be clarified as this analysis develops.

Introducing Replicated Boundaries

The reconceptualisation of the mind-body conundrum will serve to assert the sociocultural correlates of the philosophical problem, both at the macro-level and at the micro-level, both synchronically and diachronically. This work has led to the formulation of a theoretical framework for the understanding of such processes: the definition of replicated boundaries.

The Gnostic Split and Replicated Boundaries

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Sky E. Gross
If indeed the mind-body problem does stand at the basis of social phenomena, how can one discern, detect, or recognise its manifestations? How are phenognosis\ontognosis reflected in the institutional, symbolic, interactional, spatial, professional, epistemological spheres? The systems of classification we hold ordinate the creation of boundaries at many layers of cultural phenomena (Abbott, 1995), thus forming 'replicated boundaries'. In broad terms, replicated boundaries refer to the presence of epistemological groundings here, as a relation between two forms of knowledge- which will replicate themselves in several spheres concurrently, and still keep structural similarities. These spheres may include both lay and professional epistemologies and practices, and may encompass beliefs, classifications, actions, symbols, etc. If, for instance, one finds a process of subordination of one form of knowledge to another, this will come about in the subordination of one professional sphere to another (e.g. one group of professionals losing their status), in changes in the ways in which space is distributed (e.g. forming a panoptical advantage in spaces where the more powerful form of knowledge is exercised), and so on. The cases at hand will be used to illustrate this concept, and assert that ontognosis' failure to conquer and subordinate phenognosis led to a rejection of the latter from the territories of the former; and that this was followed by the creation of robust limits to forestall any 'leaking' of the phenognosis into ontognosis' terrains. I shall further claim that these bounding limits will not remain within the layer of the abstract, and will have powerful manifestations inat several layers simultaneously: the splitting of brain and mind in the professional layer (e.g. neurology vs. psychiatry), in the layer of the spatial organisation of biomedical 25

Black Butterflies
areas (e.g. where the operation room becomes a well-bounded ontognostic shrine), in the symbolic layer (e.g. the apparatus used to keep each form of knowledge distinct in social settings), the conceptual layer (e.g. in the case of brain tumours - the conceiving of oneself as either body or mind) and in the more general discursive layer, where definitions of authoritativeness remain crucial (e.g. hierarchies of sources of information in the forming of diagnosis). The phenomenon of replicated boundaries will accompany us throughout the analysis, in which I hope to be able to establish it as a valuable theoretical concept.

Replicated Boundaries: The Professional Grounds

Professions constitute social fields where particular

organisations of knowledge are often manifested in a most palpable way. In the course of this study, I have thus chosen to lay special attention to the professional developments of the fields where the mind\body split would come about most noticeably, that is, biomedicine, and most particularly, neurology ('the profession of the brain') and psychiatry ('the profession of the mind'). The rise of the professions is related to the processes of secularisation in Western society around the late eighteenth and nineteenth centuries (Parsons, 1971; Goldstein, 1994). Parsons (1971:145) sees the professionalisation as a "criteria of cultural legitimacy", and sees it as the "single most important component in the structure of modern societies". Foucault (1982) joins him in pointing to the importance of the professions in Western modern societies. Associated with the interest in professions and the attempts to define the phenomenon has always been the study of knowledge and of epistemological subordination. As claimed by McDonald (1995: 160), professions 26 are knowledge-based

Sky E. Gross
occupations and therefore the nature of their knowledge and the occupations strategies in handling their knowledge base are of central importance. For Foucault, for instance, the unbreakable link between abstract knowledge and the profession would be based on the idea of the 'gaze', most often present in discourses related to the practice and epistemological grounds of medicine (Goldstein, 1994). Medicine holds several ''core generating traits" (Larson, 1977) that enable it to be referred to as a profession, rather than a mere occupation. First, it holds a body of abstract knowledge which must be mastered by its members; Second, it holds a degree of exclusivity in the relevant field of practice and knowledge; Third, it is autonomous in the definition of its practice; And finally, it holds a 'service ideal', that is a disinterested practice that is based on altruistic rather than self-centred objectives (Wilensky, 1964; Goldstein, 2001). The need for professions to bind bindisolate themselves from other forms of culture and to gain power through knowledge involves processes of 'boundary-work'. There are several ways in which biomedicine, as an ideal type of profession may 'do' boundary-work (Gieryn, 1983, 1999; Mizrachi et al., 2005): First by expanding its authority or expertise into domains claimed by other professions or occupations; Secondly, by creating a clearer contrast between itself and its rivals; Thirdly, by monopolisation of professional authority and resources; Finally, by labelling rivals as pseudo or amateurish and exclude them from its turf. Along related lines, Halpern (1992)willhas claimed that the resolution of jurisdictional (and knowledge-related) conflicts between professions may entail three possible forms: the control of one profession over a field of jurisdiction; split jurisdiction; and 27

Black Butterflies
subordination (Halpern, 1992). These relations find themselves replicated on several layers, hence my proposed definition of replicated boundaries. This involves symbolic, rhetorical and professional modes of boundary formation around and in parallel to these forms of knowledge. From a more recent perspective, Gieryn (1999) defined 'science' the basis for biomedicine's authoritativeness - as placed on 'a map of culture', bounded off from other territories such as common sense, politics, or mysticism. In my view, these 'nonscience' territories can all be seen as belonging to the subjective realm, as the interest of science is to remain the home of objectivity, reason, and truth. In this case, drawing a map of science is but replicating a map of a gnostic split. This essay presents particular cases of professional

boundary-work, in which notions of scientific truth were challenged and redefined. Through the understanding of the enactment and then challenging of boundaries, I will try to propose that Cartesian boundaries are involved in the demarcation of two forms of 'truths' the phenognostic and the ontognostic. I will show how specific demarcation principles of the scientific versus the non-scientific are related to a battle on the hierarchy of these two kinds of truths.

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Part III: Surgeons of the Mind Frontal Lobotomy and the Mind-Body Problem
The first section of this work, the story of psychosurgery, will serve as a case-study where the key concepts of 'ontognosis' and 'phenognosis' are taken to their extreme. The boundaries between the two forms of knowledge will come about at the level of temporal developments as well as at the level of professional dynamics. Its value as a basis for analysis is manifold: First, the case reflects a daring attempt to bridge Cartesian dualism acting 29

Black Butterflies
upon matter to alter the realm of the mind-- making this chasm remarkably explicit. Furthermore, it relates to the cultural significance of the brain in biomedical thought. Finally, one cannot overrate what is at stake here: i.e., notions of humanhood, experience, existence, and consciousness (Kleinman, 1997). This may account, at least partially, for the fact that, while over the years many medical procedures were eagerly embraced only to be consequently rejected, few arose as lively debates and as much moral outrage as psychosurgery's.

Introduction
"It is better [] to have a simplified intellect capable of elementary acts than an intellect where there reigns disorder of subtle synthesis. Society can accommodate itself to the most humble laborer, but it justifiably Walter distrusts the mad thinker". 1942 Freeman, psychosurgeon,

(cited in Kucharski, 1984:766) Drawing on insights from a range of recent works on discourse, the body, and social science of medicine, I will suggest here an integrative analysis of the cultural and philosophical aspects of mind-body dualism in modern and postmodern Western society. I will picture this chasm, now broadly referred to as Cartesian, through the study of the practice of frontal lobotomy3 (psychosurgery): a modern endeavour using brain surgery to transform the mentally-ill -- yet fully sentient-- individual into a self-content object only partially able to sense subjective experiences. I will demonstrate, with the aid of an interpretative reading of texts related to the debate, how certain epistemological
3

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

30

Sky E. Gross
assumptions associated with the Gnostic Split have led to the overwhelming acceptance of the technique within modern medicine of the 1940s-1960s, and how these have increasingly become depicted as 'outrageous' within a more recent postmodern bioethical debate. More specifically, I will then relate this transformation to the placing of human subjectivity above observable functioning as the ultimate goals of medical and social practices.

Lobotomy in Mind: Methodology

A Historical Approach to the Study of Replicated

Boundaries
"Sociological explanation is necessarily

historical. Historical sociology is thus not some kind of sociology; rather it is the essence of the discipline" (Abrams, 1982:2). Historical analysis is often most resourceful when tackling central interests of sociology (Abrams, 1982). It enables a drawing of infinite changes and shifts in the relations of the subject matter with other contexts. Boundaries can be understood as a belonging to a process through time: their locations are drawn and redrawn, at times strengthened, at others weakened. This and more, the two sides of the borders are ever changing, both defining and being defined by the boundary, or the relationship with the 'other'. This is why a proper study of boundaries should involve a temporal vector, as well as a study of the set of changing relationships between two entities, were it professional, sociocultural, or epistemological entities.

31

Black Butterflies
Still, this analysis will remain sociological in its nature: I will seek the theoretical drawing on a historical case, and not a detailed description, or critical reconstruction of an event. Psychosurgery is brought here as a "historical individual" in Weber's sense, that is, as a form of historical ideal type of the phenomenon at hand, or: "a complex of elements associated in historical reality which we unite into a conceptual whole from the standpoint of their cultural significance". (Weber, [1930] 2001:47). And it is the cultural significance associated with the dealing with the mind/body split which I wish to put at the centre of this analysis.

Reading Psychosurgery
The insights presented here find support in an empirical groundwork study of texts pertaining to the portrayal of psychosurgery and to the debate it generated. The focus on professional publications mainly medical, but also from the social sciences-- provided a relatively continuous frame of analysis, that was, as a rule, devoid of dramatisation tendencies often present in lay reports. Primary sources included books and journal articles published since the 1930's, the selection criterion being their referring to terms related to psychosurgery or to its main practitioners. I have included both French and English sources collected in two central libraries in Paris, and four in Israel. This revealed 384 articles and 14 major book publications. I interpreted the texts along a chronological thread, as well as through several overarching themes: the criteria for the evaluation of the procedure; the rhetorical devices employed; positive/negative 32

Sky E. Gross
stances; and finally, the drawing on symbolic aspects of medical practice. I then defined the debate as rotating around a number of issues. First was the inadequateness of theoretical and empirical bases- using a method of trial and error on groups of patients diagnosed with etiologically, nosologically, and symptomatically diverse mental pathologies. Second were the procedure's mutilating aspects and the irreversibility of its effects as it inflicted great damage to both affective, cognitive, and physical functioning by the severance of brain tissue not targeted by the procedure. Third were issues of obtaining informed consent from mental patients, some going as far as claiming the latter to be infeasible in the case of such extreme mental transformation: in terms of personality, the patient giving his consent may not be the same person going through the postoperative phase. A fourth matter included questions of human

experimentation, with practitioners having limited tools to predict the outcomes and calculate the risks of such an intervention. Another issue was the immense power accorded to the psychosurgeon in social and political spheres: Critics, in fact, often associated the procedure with contemporary Hitlerian concepts of euthanasia and eugenics. And finally was the theme of abuses and aberrations observed through the implementation of the different procedures, including interventions on children as young as four year old (Valenstein, 1980a, 1980b; Kucharski, 1984; Bouckoms, 1988;

33

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

On Psychosurgery

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Sky E. Gross
In 1936, Egas Moniz, a Portuguese neurologist, reported preliminary success in the severance of brain tissue for the treatment of mental illness (Moniz, 1936b). Soon, and once experimented on a small group of patients, the most prominent neurologists and psychiatrists embraced the procedure. These included Adolf Meyer (past President of the American Psychiatric Association and the American Neurological Association, and cofounder of the American Board of Psychiatry and Neurology), Edward Strecker (vice-president of the American Neurological Association and president of the American Psychiatric Association), and Harold Solomon (president of the Association of Nervous and Mental Disease). Some promised a full recovery to a significant share of patients. In 1949, Moniz was granted the most prestigious scientific acknowledgement: the Nobel Prize (Berrios, 1997; Ligon, 1998). Three years later, the Pope himself accorded psychosurgery his blessing (Rouvroy, 1954). In the words of one of the practitioners: [Prefrontal lobotomy is] the realization of a new stage in neurosurgery []. The introduction of surgery in the treatment of affective disorders is a momentous event. (Wertheimer, 1948:497) or, "Psychiatrists, neurologists, and

neurological surgeons may well look back upon the period before the discoveries of Egas Moniz as equivalent to the Dark Ages." (Freeman, 1956:771). It is evident that, at the time, the practice was considered as one of medicine's greatest promises: In the US of the 1940s, many 35

Black Butterflies
would consider it unethical not to propose lobotomy to some patients. In fact, both asylum psychiatrists and neurosurgeons viewed it as no less than a breakthrough in the scientific understanding of the mind. By 1960, tens of thousands of psychosurgical interventions were conducted worldwide, most particularly in the US, but also in Continental Europe, the UK, and Japan (Hirose, 1972; Donnelly, 1978; Kucharski, 1984). Between 1942 and 1954, 10,365 were counted in the UK. Until mid 1941, more than 18,600 operations were performed in the US (Swayze, 1995). Globally, according to Silverman (2001), since 1945 the number of lobotomies doubled each year: from 240 in 1945, to more than 5,000 in 1949. A meta-study of 10,000 lobotomies performed in the UK between 1942 and 1954 shows that 41% were fully cured or greatly improved, 28% had little improvement, 25% seemed not to be affected by the operation, 2% saw their symptoms aggravated and 4% would die as a result of the procedure. Indeed, a great part of the studied literature shows a distribution of approximately a third of 'favourable' results (where symptoms disappeared altogether or at least greatly improved), a third of 'medium' results (where some improvement can be observed) and a third of failures (no change, or the patient's condition has worsen). Still, and although already in the 1930s most professional widely and openly acknowledged the ill effects of the operation, both physicians and family members tended to consider the postoperative patient as better off, or even cured. Essentially, psychosurgery offered a source of hope for the deliverance of the mentally ill from the misery of their existence. This enthusiastic embrace, however, soon waned. By 1960, psychosurgery did not only lose grace, but also acquired a gruesome image as one of medicine's darkest episodes. Fewer

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and fewer neurologists showed interest in the technique, research grew scarce, and its uses were to be confined to the darker rooms of mental asylums. From a symbol of scientific progress, psychosurgery came to be regarded as the craft of mad scientists with ill-defined intentions of mind-control at best, and of pure sadism at worse. In the popular press, changes in the attitude towards psychosurgery were evident (Diefenbach et al., 1999). The first publications, initiated in 1936, were brief medical reports, becoming increasingly detailed by 1941. The tone was largely positive, the descriptions overstating the practices miraculous effects. Between 1945 and 1954, the press became progressively more critical, with a rising number of negative reports. It is only in the late fifties that a strong polarisation occurred, with a typical depiction of the practice as a form of menticide or mental euthanasia (e.g. Baruk, 1953, 1956; Umbach, 1976; Chorover, 1974, 1979). With the rise of anti-institutional and antigovernmental movements in the late sixties and early seventies, many texts, mainly in the lay press, began to associate psychosurgery with other forms of governmental excesses of power, including malicious brain-control techniques. 'Brainwashing' was so entrenched in the public imagination, that psychosurgery immediately joined the list of techniques thought to be in the arsenal of the opponent, whether in the form of agents of secret services, or as radical communists seeking control over the American mind. Today, the concept of frontal lobotomy has some grim connotations. Although by now, with the introduction of antipsychotics, the use of the technique has become extremely rare (and much more advanced in both target, technology, diagnosis etc.), an aversion towards the very concept of psychosurgery, 37

Black Butterflies
invariably seen as destructive and abusive, is still clearly present in a wide range of texts. When considered, ideas of brain control and psychiatric abuses of power are woven into a fearsome tale of the terrible consequences an unrestrained science may have. The practice has become particularly notorious for its effects on personality, and is said to produce individuals with no subjectivity or 'sense of self', transforming disturbed patients into jolly, selfcontent beings. Here I shall refer to these "soulless" or "empty" patients (Valenstein, 1980b; Sachdev and Sachdev, 1997) as Homi Vadum, Latin for flat, or empty, human beings, products of an ontognostic invasion of the 'mind'. I will suggest that, in contingence with the gnostic shift, these Homi-Vadum were alternately seen as cured or simply damaged.

Creating Ontognostic Legitimacy

In line with the scheme of this work, I will argue that the embrace of the practice was based upon one critical component: the implicit and explicit use of rhetorical, symbolic, and institutional measures in the creation and maintenance of a scientific faade. This, I shall claim, will place psychosurgery within the unquestioned ontognostic truth-basis of medical and scientific work, thus forming a solid ground of legitimacy.

'Prehistorical' Sources
Although often ignored in historical accounts of the

development of the practice, the roots of psychosurgery can be said to go as early as 1890 with the experiments of the Dutch scientist Friedriech Golz. Golz reported the effect of the ablation of the brain cortex in laboratory dogs, and suggested that this operation had a calming effect on the subjects.

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This report led to the more ambitious (and controversial) experiments of Gottlieb Burckhardt, the head of a large Swiss mental asylum. He put forward the idea that the creation of a barrier -in the form of a surgical cutting through nervous tissue between the cortex (conceived as responsible for the reception and processing of sensory information) and the lower areas of the brain (the 'motor areas') will relieve some of the pathological behaviour of mental patients: and most particularly, behaviour that involved the patients lack of control over themselves (Stone, 2001). The first patient, Frau B., was considered to be "the most dangerous and difficult" patient of the asylum. This 51 year old woman, diagnosed with schizophrenia, was impulsive and violent. She has been hospitalised for the last 16 years, mainly in isolation. She once almost strangled to death one of the nurses, and did not seem to be responsive to any kind of treatment known at the time. Suffering from chronic diarrhoea and of a lack of proper hygienic manners, she had to be assigned with two nurses around the clock. She was particularly difficult to maintain under control as she spent many of her days screaming in the halls of the asylum. Burckhardt (1890, in Stone, 2001:83) then began to wonder whether it would make any sense to: "extract this impulsive emotional element from her brain mechanism, transforming her from an excited patient to a calmer dement schizophrenic. Four surgical operations were conducted on Frau B. in the course of the next fourteen months. Almost 15 grams of her brain tissue were removed. Each operation seemed to have had a calming effect on the patient. As Burckhardt himself put it: 39

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

Replicated Legitimate

Boundaries:

The

Professional

and

the

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I shall claim here that the boundaries created between neurology and psychiatry represent replicates of layers of broader sociocultural boundaries in Western thought: the boundaries between objective and subjective. They reassert an ethos, a way of thinking the world. Thus pure reason becomes pure objectivity, pure science: neurology as a mainstream biomedical and scientific endeavour on the one end; and the fuzzy, the emotional, the soiled, the subjective psychiatry on the other. Inside the category of pure reason reigns order and inner classification, and outside: chaos. Neurology of the mid-1930s was among the most prestigious and fast-growing academic fields (Abbott, 1988; Pressman, 1988). Comprising a rather small group of physicians, neurology sought an alliance with psychiatry, a more commonly practiced, albeit less prestigious, form of medicine (Abbott, 1988; Gelfand, 2000). By the 1920s, a unification of the fields was undertaken, to the benefit of both professions. As knowledge on the anatomy and structure of the brain began to accumulate, 'neuropsychiatry' of the early 20th century became dominant in research on the cerebral basis for mental illness (Marti-Ibanez et al., 1954; Lishman, 1992). However, while 'pure' neurology pursued the incorporation of functional (or 'mental') diseases into the medical field, psychiatry remained associated with psychological i.e. nonmedical disciplines, such as psychoanalysis (Fadda, 1988; Eisenberg, 1995; Shorter, 1997). Once the physical lesion of a disease was understood, it was passed over from psychiatrys managing know-how, to neurology as an expertise founded on complex and abstract knowledge (Alexander and Selesnick, 1997; Seli and Shapiro, 1997). Psychiatry was to rely on subjective, introspective accounts, or symptoms. Neurology, on the other hand, could attain diagnoses 41

Black Butterflies
through quantifiable, communicable, and scientifically reliable signs (Audisio, 1968; Price et al., 2000). The disciplinary separation of what will become the fields of psychiatry and neurology is strongly correlated with the distinction made between physical and mental pathology. As more and more once believed to be mental disease, have found their physical basis in brain pathology, neurology has grown to encompass an enlarging group of brain (and central nervous system) pathology. Indeed, over the years, diseases such as aphasia and epilepsy have been relocated from the blurry field of psychiatry to the more medical-like field of neurology. The physical nature of disease will be attributed to any brain-related pathology which physical basis can be understood and clearly tagged. The psychic nature of disease will be attributed to any mental syndrome for which no apparent 'physical' cause could be found. The former group of diseases will belong to neurology as a medical expertise, while the latter will be left in the hands of psychiatrists, then conceived as mental asylum practitioners, mainly directing day-to-day life conditions for mental patients (more 'technicians' than 'experts'). Medical treatment for actual 'psyche-related' disease will be inconceivable, since the basic definition of such a disease is related to the absence of known brain-pathology. In other words, the separation between mental and therefore non-medical disease, and physical and therefore treatable within medicine disease, shaped the separation of psychiatry from neurology, turning psychiatry into a mere nursing specialisation. This process is not a simple labour separation process, as the epistemological bases of both of the fields were deeply affected by this psychophysic separation. One of the effects is the large group of psychiatrists leaning towards new psychoanalytical stances, growing apart from the medical model that has excluded them and marginalised their practice. Early 20th

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century saw two groups of psychiatrists beginning to emerge: while the more psychoanalytically-oriented would insist on a 'psychogenetic' (originating from psychological processes) explanation of mental illness, another substantial group will persist in its search for the organic and neurological bases of mental illness. While the former abandoned any aspirations regarding the integration into the more mainstream medical model, the latter will strengthen its efforts to differentiate itself from the 'philosophical therapy' to resemble a more scientific model of medicine. This quest will be the main drive of psychiatric research into organic-based cures to mental illness, cures that were believed to be able to form a bridge over the ever growing gulf between psychiatry and neurology. Thus, the areas of professional jurisdictions gradually aligned themselves around a distinct, though implicit, principle: the gnostic split. While neurology adhered to purely scientific ontognosis, psychiatry remained in an awkward position: treating psyche-related illness, yet holding on to an organic epistemology. Psychiatry suffered from a lack of clarity as to its basis of legitimacy, hanging in the midst between ontognostic and phenognostic grounds, leading to a severe identity crisis present to this day (Armor and Klerman, 1968; Torrey, 1975; Light, 1980; Merino, 2000). At the time, however, relentless efforts were made to medicalise (and thus 'truthicise' or 'make true') psychiatry. Psychosurgery stood at the very centre of this task.

Building the Heroic Ethos

"Doctors are different in nature. One kind adheres to the old principle: first do not 43

Black Butterflies
harm; The other one says: it is better to do something than nothing. I certainly belong to the second category". (Gottlieb Burckhardt, lobotomy pioneer) This statement raises one of the central points contrasting the Hippocratic notion of medical ethics with the kind of ethic proclaimed by psychosurgeons. The 'primum non nocere' principle cannot hold in the face of horrifying mental suffering, and Burckhardt, Moniz, and others felt they 'had to do something'. This 'something' took form in what was to become the psychosurgical intervention. While one can place some of sciences legitimacy within the ethos of a pure and disinterested search for Truth, the mere practicability and applicability of a scientific development may be of no lesser significance (Gieryn, 1983, 1999). In practice, early 20th century's psychiatry held a meagre therapeutic arsenal: asylum psychiatrists had to content with watching over the mentally ill and nursing them in their daily routine (McGovern, 1985; Witz, 1992; Shorter, 1997; Abbott and Meerabeau, 1998). Was psychosurgery to be proven beneficial, it would allow the discipline to become medicine-like, thus becoming a cure rather than a care specialisation (Sargant, 1976; Gieryn, 1983, 1999; Swayze, 1995). This demarcation would then allow the practitioners to draw upon the legitimacy placed in core medical practice: the holding of measures that were both heroic and therapeutic.

The Founding Tale

"For the physical therapy of mental

disorders they [the neuropsychiatrists] had the malaria treatment of neurosyphilis and 44

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prolonged sleep. Electroencephalography was in its infancy, shock therapy by insulin and metrazol almost coincided isotopes with were leucotomy, radioactive

unknown, and control of the autonomic system by pharmacological means was just beginning. The introduction by Moniz of cerebral angiography in 1927, and of psychosurgery in 1936 brought about a revolution in diagnosis and treatment, the eventual extension of which is not yet in sight". Freeman (1956:771). 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. Throughout the years, the tale of its burgeoning was reiterated in the work of Walter Freeman, one of its most powerful and diligent proponents. Within several important publications, Freeman persistently re-established the ethos of psychosurgery's 'discovery', by Egas Moniz: "[At the Neurological Congress of 1935, in London, during their presentation, Jacobsen and Fulton] noted a profound alteration in response to frustration in the chimpanzee with both frontal poles excised. Before the operation, mistakes, feces, if the animal it would the made with a few rage, to scream bars and

urinate and defecate in the cage, roll in the shake refuse continue in the experiments. After the operation [the excision of the frontal lobes], 45

Black Butterflies
the same animal would continue in the experimental situation long beyond the patience of the examiner, making mistake after mistake, without the least indication of being upset emotionally." (Freeman and Watts, 1947:417) Freeman, among others in the field, depicted Moniz as having stood up in admiration of Jacobsen and Fulton's presentation. He is said to have inquired as to whether the reproduction of such attempts on human would be conceivable. The murmurs of disbelief in the crowd did not discourage Moniz. In fact, he is claimed to have returned to Portugal, his home country, and to have soon begun his experiments. This founding tale is present in numerous reports, while, according to Pressman (1988), having little grounds on reality. The drawing of the events seems to serve as a constitutive myth, much less than as a historical account. In a way, the portrayal of Moniz' deductive mind offered the endeavour a halo of insightful scientific thought.

Out of the Laboratory

Psychosurgery's initial association with neurology, rather than psychiatry, would (and eventually did) provide a powerful stamp of legitimacy. Thus, not incidentally did Freeman observe that Moniz' 'Eureka' was sounded in the course of a prized academic neuro-anatomical presentation, and in response to empirical data advanced by two of the world's most prominent neurologists: John Fulton and Carlyle Jacobsen. Walter Freeman and his associate, James Watts (1947:417) begin their presentation of ten years retrospective on psychosurgeries by presenting the founding tale again, stressing psychosurgerys 46

Sky E. Gross
basis on a logical derivation from the respectable scientific laboratory work on animal anatomy: "Moniz presented many of his angiograms at the Second International Neurological Congress in London in 1935. It was at this Congress that the symposium on the frontal lobes brought forth a great deal of discussion concerning the disturbing effects upon personality that followed wounds and tumours in this region. []". (Freeman, 1956:769) The presentation of psychosurgery as evolving as part of an existing line of work in the scientific community did seem to have had an effect on its endorsement, if only by asserting its position within an ontognostic 'normal science' (Kuhn, 1970). For instance, linking the practice to the body of accumulated knowledge on brain localisation, Marchand and his colleagues reported that frontal lobotomy would allow to "enrich our anatomo-physiological knowledge of the human brain." (Marchand et al., 1949:515). Moniz himself sought to advance psychosurgery's position within his contemporarys work on the localisation of cerebral functions, thoroughly underlining his leaning on "anatomical, physiological, and clinical facts" (Moniz, 1936a:55). "In the brain there are regions that are particularly related to mental activity. If we wish to drift away from this organic orientation, we will enter domains that seem to us entirely unacceptable". (Moniz, 1936a:40) "Psychic life is exteriorized in a different 47

Black Butterflies
manner, but completely comparable to other functions of the organism". (Moniz, 1936a:41)

Indeed, the texts of the period defined the benefits of the practice not only in terms of the relief it could allow the mentally ill, but also in terms of the potential accumulation of knowledge on the brain and its functions. There, by being able to spatially define the mind, science could replace explanation by classification. Moniz will then take part in the quest for the Holy Grail of science: the mind. This presented psychosurgery as a symbol of a genuine scientific quest for 'Truth' through objective observation and methods of trial and error, as a bold empirically-oriented endeavour: "[if our experiments prove to be successful] we would have put in relation, and in a definitive manner, the mental functions, and the parts of the brain that take part in their production. It would be a great progress as a primordial fact in the study of the organic bases of the mental functions". (Moniz, 1936a:55) In sum, the underlining of this empirical basis served to reinforce the founding myth, and to support the rhetoric placing the procedure on an ontognostic-based legitimacy, as out of the laboratory, the 'factory of Truth'.

Men of Science
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Sky E. Gross
Freeman (1956:770) speaks of the basis of the resistance to the 'discovery' by the medico-psychological society in Paris, 1937. He explains: "Here was a brilliant discovery belittled through political antagonism and possible professional jealousy, but more likely through philosophical tenets that blinded Sobral Cid to the extraordinary alterations that occurred in psychotic subjects at the moment of prefrontal leucotomy". Thus, the antagonism was based on three purely "subjective" grounds: political antagonism, professional jealousy, and "philosophical tenets". Moniz himself is presented as being "extraordinarily modest": "He was never flamboyant in his speech; rather he lectured or presided with courtesy and dignity, and gave expression to his thought in measured terms. His was an inner life of thought rather than an outer one of action" (Freeman, 1956:771) or, "He was also able to present to the scientific world the results of his meditations and experiments, often in the face of considerable opposition, including attempted piracy and murderous assault. The intellectual vigor of the man, hampered by physical handicaps, indicates true genius". (Freeman, 1956:771) 49

Black Butterflies
Freeman tells us that Moniz is a 'true scientist' in his refusal to allow non-scientific groups interfere with him getting the message through to the 'real' scientific world. Interestingly enough, in 1956, the year this article was published, Freeman himself will be facing powerful antagonism. Reifying his own status as a 'true' man of science, Freeman's portrayal of his work (through Moniz') used the image of a modern day martyr of science: a man so dedicated to a purely scientific endeavour as to be willing to endure opposition, however harsh. Freeman, like Moniz, was but a misunderstood genius.

Locating the Mind

Moniz, in his book (1936a:40) states over and over again that the central nervous system (which includes the brain) is the seat of mental manifestations. The physical is the ontological basis of the explicit phenomena of the mind: "In the brain there are regions that are particularly related to mental activity. If we wish to drift away from this organic orientation, we will enter other domains that seem to us entirely unacceptable". "Psychic life is exteriorized in a different manner, but completely comparable to other functions of the organism". (Moniz, 1936a:42)

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These claims did not grow in a vacuum. The ontognostic foundations of biological psychiatry (or 'neuropsychiatry') can be traced back to Franz Joseph Galls phrenological theory, which, at the beginning of the 19th century, linked brain and skull structure to personality traits (Barker, 1995). Indeed, not unlike phrenology, the reason for the success of this popular (albeit later declared only 'pseudo' scientific) predecessor in the study of brain localisation: "The reason for this [success] was the astounding nature of its claim: that it solved at one stroke the problem of the mind; that it gave a complete and accurate picture of the nature of the mind and at the same time defined and fixed its functions" (Grant, 1968) Gall (1808:5) himself will claim to seek to: "grasp the material conditions of the immaterial principle, which manifests itself through its action, and seems to undermine our research". Later studies of brain localisation, such as Brocas and Wernickes in 1861 and 1874 respectively, persuaded many central figures -such as Meynert, Liepmann, Charcot, Kraeplin, Freud and Alzheimer - that the brain was indeed the seat of both mental functions and mental pathology (Young, 1970; Barker, 1995; MacMillan, 1996; Kolb and Whishaw, 2003). Freud's work, although developed along different lanes, was itself based on a view of the brain as the physical seat of psychic activity. In fact, in his well known "Beyond the Pleasure Principle" (Freud, 1955[1920]), he is unambiguous: one needs to apply strict 51

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empiricism, reject speculated metaphysical explanations, and keep in line with scientific methods. By progressing from observation to theory, one would find the key to understand the workings of the brain. This is precisely how psychosurgery's early proponents sought to portray their undertakings. World War I further produced clinical evidence on the various effects of head traumas, thus contributing to already the dominant trend of cerebral localisation. Studies used more and more elaborate methods, including electrical stimulation, post-mortem investigations, experiments on animals, and later, different imaging techniques. All would suggest some important correlations between function and location. Although the understanding of 'higher' brain functions (such as thought, imagination, emotion) still lingered, even in the context of mental disease, localisation was still able to replace a nebulous notion of the mind as a vague spiritual essence, and assert its fundamental form as purely material. This provided psychiatry a clear epistemological primacy over claims based on phenognosis, thus justifying a denigration of subjectivity, reducing it to mere products of brain function. Psychosurgery took on this lane of scientific studies by asserting, de facto, the spatial grounding of the mind as well as its material ontology. Porot (1947:126), for instance, describes the surgical proceedings of Freeman and Watts: The surgery is usually conducted with local anesthesia. After the surgery, X-rays are performed in order to precisely localize the plan of the section. The films are put against the trepan holes.

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Thus, by endeavouring a mapping -however primitive and restricted- of the mental, the technique drew significant attention, undoubtedly more than any other non-localised attempts to treat psychopathologies (such as shock therapy from the early 1930s, and, in the second half of the century, psychoactive drugs). A more thorough study of the literature supports this assertion. Much of the work on psychosurgery involved notions of gross anatomy, a few practitioners going as far as to weight the brain tissue excised in the course of surgery. According to Puech (1949:117), for example, 72% of the cases operated on had a "macroscopically pathological brain". This anatomical knowledge, as general and imprecise as it may have been, may have well served as a source of authoritativeness grounded on materialist ontological concepts. However, once the localisation of mental illness was largely discredited as a scientific endeavour, the idea of gross intervention into the brain to alter mental status began to seem unreasonable (Koupernik, 1977). The cutting of brain tissues, considered then as the epitome of the scientific ethos, now served as a rebuttal to the practice. Baruk (1956), for instance, will claim that psychosurgery should be morally forbidden since it would transform a functional disorder into an irreducible disease. The idea of physical intervention into the realm of the mental began to lose its association with a momentum of scientific advances.

Medicalising Ontognosis

the

Mind:

Symbolic

Correlates

of

This trend soon moved from the field of research to the field of practice. As noted, ontognosis lies within an overwhelmingly materialistic episteme where the primal focus of attention is the body (Eisenberg, 1977; Dew, 2001). This predisposition involves a 53

Black Butterflies
form of objectification by which the human body is stripped of its subjectivity and transformed into a plain object (Babbie, 1970; Csordas, 1994). An ideal form of these processes occurs in the operating room. Surgery, by definition, demands a suppression of the subjective, and the reduction of the human body from a sentient whole into a seemingly lifeless object, accessible to dissection and rearrangement. The creation and maintenance of the operating room as a well-guarded shrine of ontognostic purity are supported by a surgical ethos as well as by several symbolic elements (Katz, 1981, 1999; Fox, 1992, 1997). These include, for instance, the scrubbing rituals preceding the entry into the operating room and the elaborate draping of the patient which absorbs him/her into a small, depersonalised, objectified body-part upon which the surgeon holds complete visibility (Hirschauer, 1991; McNay, 1991). This 'symbolic theatre' thus creates a demarcated space within which ontognosis prevails4. In the case of psychosurgery, a surgical blade was employed, literally, to excise sentient experience, to subordinate it --by means of a simple sway of a knife-- to the realm of matter. Again, altering the spirit through the severing of a physical essence provided clear evidence to the spatial subsistence of the mind, as well as to its materiality. Although most biomedical practices do hold implicit reductionist bases, seldom do they constitute, in and on themselves, such powerful proclamations on the very nature of mind-matter relations. Psychosurgery, however, did not only comply with ontognosis, but also substantiated it by providing it direct and unequivocal evidence. As practiced, it was not only reductive, it also reduced: It brought the mind onto the surgical table based on it being deemed operable, but ipso facto, it also
4

This point will be further developed at a later chapter.

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created and recreated this 'operable mind', this ontognosticallyapproachable mind. This may explain why other measures, such as

psychopharmacology, did not raise nearly as much outrage as psychosurgery. The introduction of anti-psychotics in the mid1950s did have direct effects on the practice of lobotomy, and the former almost instantly substituted the latter as the treatment of choice in cases of severe agitation and hallucinations (Snaith, 1994). Clearly, psychopharmacology offered a less costly, safer alternative, with more readily visible and immediate results, as well as less serious and permanent side-effects. This brought about psychosurgerys transition from a state-of-the-art endeavour to a second-line treatment at best. More significantly, however, psychopharmacology proposed what was, at least in appearance, a more subtle paradigm of mindbrain activity. Although equally based on ontognostic views and although equally establishing a domination of brain over mind, some of its characteristics were more compatible with phenognostic views than its therapeutic predecessors. First were the symbolic aspects of its administration, involving the body as a whole, rather than a small, spatially defined area where 'the mind' would be seated. This stood in clear contrast to the protruding intervention and intrusion of an external, technical, and artificial object: the lobotomist's knife. Second was the fact that the mechanisms by which the psychoactive substances actually affect the brain are still little understood, allowing the 'mind' to retain its mystique as being too complex for science to grasp. thus, Psychopharmacologys superiority over psychosurgery,

would be more than just therapeutic: its characteristics would be more in line with epistemological assumptions on the nature of the mind. While this may not be enough to explain the replacement of 55

Black Butterflies
one treatment by another, it may well account for the lesser magnitude of the debate surrounding drug therapy. Another form of physical therapy for mental illness should perhaps be mentioned in this context: Electroconvulsive therapy (ECT), better known as 'shock therapy'. This technique, introduced in the 1930s and still of widespread use in treatment centres around the globe, involves the induction of electric stimulation5 causing the patient transient seizures. This would be highly effective in cases of severe depression, and to a lesser extent, in some cases where psychotic symptoms became unmanageable (Braslow, 1997). The mechanisms of ECT's action are still poorly understood, although two main sets of explanations were brought forward: psychological and physiological. According to the former, the shocks would be so unpleasant to the patient to have him cease his 'bad behaviour'. On a more psychoanalytic note, it would satisfy an unconscious need to be punished. In contrast, according to the physiological thesis ECT will have the brain respond to the electrical charge by altering its own electrical activity and restore it to its functionally optimal level. Not surprisingly, by now, the physical explanation is regarded as more sensible. As with psychosurgery, the usage of the technique will become less common with the apparition of psychoactive drugs, but readopted with the disenchantment from psychopharmacology, from the 1970s onwards (Friedberg, 1977; Weiner, 1984). Since, the procedure has greatly improved, reducing side effects such as memory losses, limb fracturing, and general anguish to the ECT patient. followed The debates over both its psychosurgery and psychiatry throughout

development as a legitimate 'cure' expertise (Valenstein, 1986). The latter, however, 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. The technique was relatively short lived.

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place of honour in the panoply of psychiatric treatments (Alexander and Selesnick, 1997). As with psychopharmacology, there are several symbolic characteristics which may serve as a complementary explanation for ECT's more lasting state of legitimacy. First of all, there is no actual opening of the skull, nor direct contact with the brain, the 'organ of the mind'. Secondly, the effects are believed to be (at least in the public eyes) less irreversible than psychosurgery. Furthermore, these effects would not include actual personality changes, but rather temporary losses of memory or transient states of sedation or psychocognitive 'numbness'. Another factor may be the general acceptance of the idea of brain function as based on electrical exchanges, rather than on gross anatomical processes (as claimed by proponents of psychosurgery). Finally, as in the case of psychopharmacology, non-localised, less direct, and less ontognostically ritualised procedures seem to find a more accepting attitude in the laps of a publicly scrutinised psychiatry.

Losing Grounds: Away from Ontognosis

The Traps of Rhetorics: Facing the Debate
Throughout the first stage of the debate, it was evident that psychosurgery held a strong ontognostic position of legitimacy. Science, Babbie (1970:14) tells us, is ideally amoral: its role is to judge on questions of truth and falsehood, not on questions of right and wrong (or what would be moral or immoral). Indeed, initial disapproval of the practice belonged to the realm of science, and not of ethics: Opponents insisted that the practice of psychosurgery was justified by poor research methods. More 57

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specifically, it would be claimed that a systematic, empiricallybased assessment of outcomes was unattainable, none the least because more than twenty different techniques developed over the years, a similar number of theoretical rationales proposed, and more than a dozen different sites targeted (Huyn-Dornier, 1992; Kolb and Whishaw, 1994; Pressman, 1998; Feldman et al., 2001). While initially, the disapproval of psychosurgery focused on the delicate process involving the choice of lesion as well as on the intricate selection of candidates, it became increasingly apparent that the results of psychosurgical procedures were equally difficult to assess: First was the lack of precision inherent in the technique (Andy, 1977; Lopez-Ibor and Lopez-Ibor, 1975; Ballantine, 1980). Secondly, the patients were typically under several therapeutic courses, which made the attribution of success or failure less than certain (Bockoven, 1950; Bockoven et al., 1950). Thirdly, the group of patients operated on was nosologically heterogeneous: there was no common pathology that could be given to proper experimentation (Malizia, 1997; White, 1998). In these respects, the practice proved to be in discordance with a valid scientific model by which results could lead to a falsification of the theory (Popper, 1965). The responses to some of these claims involved a drawing on the words of psychosurgery's mythical father, Egas Moniz, who reported his attempts as representing but a first success, still needing refinement (Moniz, 1936b). This portrayed the procedure as correctable and dynamic, staying in touch with empirical facts and ongoing observations. Practitioners, rather than addressing ethical and moral questions, continued to urge the development of better and more precise surgical techniques, and for a more effective choice of candidates. The discussion remained almost entirely restricted to the 'science' of the practice, keeping relatively

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insulate from the spheres of public debate. The procedure indeed grew more precise and less hazardous, thereby diminishing both frequency 1975). Although these responses did allow for some justification for psychosurgerys shortcomings, the initial questioning of the practice will result in an abrasion in its status as a pure scientific endeavour. De facto, psychosurgery surrendered itself to public scrutiny. and severity of its side-effects (Fairman, 1950; Greenblatt and Solomon, 1953; Hitchcock et al., 1972; Gildenberg,

The Traps of Science: Methods and Rationalisations

Moniz conducted the first operations with a methodical approach, both with the dosage of alcohol he injected into the brain, and with the choice of medical apparatus. Beginning with the use of a Berthelemy's syringe, he went on to design a specialised instrument: the leucotome, a device used as a way to pit (as one would do an apple) selected sections of the brain (Moniz, 1936a). The procedure was such that a hole would be drilled into the patients skull (depending on the patient, this would be performed under local or general anaesthesia), and the device would be inserted into the frontal lobes of the brain. Then, the steel thread attached to the leucotome would be manipulated to cut through the white matter (where neuron cells are linked), and dissociate 'pathological' neuronal connections. Based on Monizs reports, we could abridge the rationale behind the procedure as such: Healthy psychological functions depend on a flexible and adequate set of neuronal connections within the brain;

59

Black Butterflies
Mental disease is due to a malfunctioning of these sets of connections, the lack of flexibility leading to pathological "ides fixes"; To alter ones pathological fixed ideas, it is necessary to disconnect the underlying nervous ties; Psychological activity is mainly located in the frontal lobes of the brain, although we are still unable to precisely locate and differentiate the different functions; An ablation of the frontal lobes will not result in irreversible psychological damage; Based on those assumptions, Moniz decided to concentrate his efforts on the frontal lobes of the brain, and cut through pathological nervous connections, which are, according to him, the basis of pathological ideation. Rather faulty or not, Moniz presented an elaborate theoretical basis for his work, a basis which he would carefully associate with neuroanatomical advances of the time.

The Traps of Symbolics: Freeman and the Ice Pick

Some years later, psychosurgery's most fervent supporter, Walter Freeman -himself not qualified as a surgeon- contemplated on transferring psychosurgery from the sacrosanct operative room into the mundane world of the asylum. In fact, he went as far as to suggest psychiatrists employ the procedure within the setting of their own private practices. This brought Freeman to propose, in 1947, 'Transorbital Lobotomy', a procedure based on the insertion of an ice pick (on which the name of the ice company was still engraved) through the eye orbits, and into the frontal lobes of the brain. The psychosurgeon would then manipulate the instrument 60

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in swift vertical movements and sever groups of nervous connections. The operation barely lasted a few minutes and allowed Freeman to perform dozens of lobotomies a day. Freeman ignored much of the developing models of

neuroanatomical functioning, and suggested but a primitive rationalisation for his work: The idea behind the operation was to cut-off the frontal parts of the brain (which were believed to be associated with self consciousness, as well as rational and imaginative thought) from the more irrational, affective lower parts of the brain, and, further in the back of the skull, from 'primitive' areas. By so doing, a certain measure of affectivity would be lost, making the pathology less significant for the mentally disturbed patient. This was, at the time, an explanation that was considered weak to the very least and improbable at best. This and more, Freeman's instrument was a mundane, nonmedical object. Transorbital-Lobotomy turned the practice into a form of 'non-surgical surgery', most particularly with the introduction of a 'psychiatrist-friendly anaesthesia', based on electroconvulsive shocks. In fact, unlike Moniz, who conveyed his patients from mental asylums into his well-equipped operative room, Freeman chose to perform some of the surgeries in his own consultation office (Bernstein, et al., 1975; Valenstein, 1986). Neurosurgeons soon objected this trend. James Watts, Freeman's co-author in major psychosurgery publications, decried transorbital-lobotomy, claiming it unbearable to witness this: ".theatrical sideshow, with Freeman

administering electroconvulsive shock for anaesthesia, holding an ice pick for a surgical instrument, and taking no time to 61

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wear gloves" (quoted in Valenstein, 1986:257). The lack of medical caution in the care of the postsurgical patients was also apparent in many of the reports: "In the first hours, one has to watch the patient very carefully, as he is completely unaware of his condition and may, as we have recently reported, tear away his bandages and put his fingers into the surgical wound, and up through his brain, which can lead to unfortunate consequences". (Porot, 1947:127) The drifting away from the rituals involved in surgery, as well as its detachment from the powerful ethos and symbolic aspects of medical practice and science, undoubtedly contributed to psychosurgery's declining legitimacy as an endeavour based on scientific, ontognostic demarcation. Its introduction into the asylum and away from the control of specialised neurosurgeons denuded it of its biomedical aura and demoted it to the mundane universe of daily-life. Ironically, while supporting psychosurgery until his very last day, Freeman contributed to the vulgarisation of the practice and to its consequent decline (Pressman, 1988, 1998). The role of conquering the realm of the mind could not be left in the hands of mere 'technicians', and this is precisely what Freeman portrayed himself to be.

From the Medical into the Social and Back Again

By the 1970's, ethical issues began to surface. A powerful public scrutinising both created, and reflected upon the loosening of medicine's epistemological demarcation from the spheres of 62

Sky E. Gross
political, ideological, and professional interests. Parallel to the development of the critical debate on psychosurgery, was an erosion of the autonomy usually attributed to scientific practice, placing it on pedestal, away from political, ideological, and professional interests, hence the rise of the larger field of 'bioethics', and its association with issues of science and the social (Gieryn, 1983).In fact, scholars such as Freidson (1970) made 'autonomy' the definitive component of professionalism as a cultural authority: the involvement of any governmental regulation on science would therefore be detrimental for its distinction as a pure arena where only Truth prevails (Gieryn, 1983). Public scrutiny will lead to the practice's loss of absolute authority and a decrease in its scientific autonomy, and thus, power and prestige (Rudin and Zimmerman, 1978; Goldbeck-Wood, 1996; Snaith, 1997).

Social Control and the State

An important polemic arose in the 1970s following the publication and wide circulation of Mark and Ervin's monograph: "Violence and the Brain". In this text, the authors proposed a surgical intervention that would solve the social problem of violence: psychosurgery. A suggestion within the same range appeared a year earlier, encompassing a vision of a utopian 'psycho-civilised society', where individuals would be controlled through electrical brain stimulation (Delgado, 1969; Mark and Ervin, 1970). The outrage was immense, and reflected the changes in the assigned power of medicine, and more particularly, of a medicine of the mind: its intervention into the social, however effective, constituted now but a malice intrusion into an illegitimate area (Chorover, 1980). Equally, the very involvement of social interests in the provision of medical treatment became increasingly objectionable, in sharp contrast to the formerly 63

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accepted vision of a 'psychosocial' medicine (Breggin, 1975; Scheflin and Opton, 1978; Kaimovitz, 1980). That being said, the psychosurgical treatment of certain cases seems to have been more controversial than others, such as in instances of criminal deviance, and, to a perhaps even larger extent, where homosexuals and children were chosen to undergo the operation. This led to a perception of psychiatric treatment as a means of social normalisation, and further reinforced the view of an omnipotence of the institutionalised power over the individual. This would remain an issue of concern to this day, as Howard Dully, a lobotomy 'survivor', will open his 2008 biography with: "In 1960, when I was twelve years old, I was given a transorbital or 'ice pick' lobotomy. My stepmother arranged it. My father agreed to it. Dr. Walter Freeman, the father of the American lobotomy, told me he was going to do some 'tests'. It took ten minutes and cost two hundred dollars" (Dully and Fleming, 2008: ix) Another troubling element was amplified by the air-du-temps of a post WWII Western world: The association of the technique with attempts to apply 'Brain Control' over the general population. The period of World War II, with the eugenic notions of sterilisation and euthanasia of deviant population, brought a certain sensibility regarding issues of mind control, and questions of social control over individual differences. Freeman himself would declare that the best candidate to undergo lobotomy would be "women, black and Jews". Those were described as having a lesser degree of initiative, and therefore as expected to have lesser difficulties in adapting to their new post-operatory personality (Brisset, 1949).

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The relation with localisation, this powerful enterprise of revealing the mind through a science of the brain, associated psychosurgery with what was seen as a perhaps equally dangerous trend: control through omniscience. The ability to see through the mental would create a dangerous panopticon, at the head of which would stand neuroscientists accompanied by 'surgeons of the mind'. Psychosurgery found itself connotating with such

controversial ideas, an association not totally unfounded.

Dystopic Prospects: Psychiatry in Charge

How much could mental patients be seen as responsible for their own choices? How much control should the psychiatric institution and caretakers in general have on their decision making? Informed consent is a central issue in all questions relating to therapeutic choice. Yet, it seems to be even more complex in the context of psychosurgery. The fact is that informed consent is difficult to assert in the case of mental patients, especially those locked behind the closed doors of the world of the asylum. A second problem is based on the assumption that psychosurgery brings about basic changes in the patients self: does it not mean that the patient agreeing to go through the operation is not the same person coming out of it, in him\her having an at times radically- different constructed image of him\herself, his\her values and preferences. The 'neuropacified' patient has better chances to be compliant with the advices of his caretakers: this would hardly mean that his pre-operation person had 'genuinely' consented to be mentally transformed: this, especially considering that the effect of 'pacification' and the general agreeableness of post-operative patients may have been, after all, the very target of the procedure. 65

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This claim is also likely to be based on the fact that the first patients to undergo psychosurgery suffered from severe psychiatric symptoms. Since indeed, the intensity and duration of those symptoms were the main criteria for selection, we can see a large heterogeneity in the nosological categories of the different patients. The diagnosis as such, then, had little to do with the decision as to whether or not proceed with the operation. Moreover, although countless studies showed that the main indication was the presence of anxiety and a diagnosis of obsessive-compulsive disorders (regardless of the severity of the symptoms), the aggressiveness and agitation of the institutionalised patients still formed the main criteria for the decision to operate.

Back to Society: The Social Cure

[Interesting is] the case of a 15 year old young girl, who was going through episodes of violent rage during which she would rhythmically hit her head on the ground or on the wall, or would bit her hands and knees and scream for hours. Her parents were forced to attach her hands and legs to her bed as well as her head and chest. After the surgery, this girl could be left alone with her toys; she walks around the apartment, eats on a table. She has become capable of living in society. Such a result aids in legitimizing lobotomy. (Klein and Tardieu, 1949: 113) The patient could be back to 'society'. This idea of a 'psychosocial medicine' was evident in the context of

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psychosurgery, where the position of medicine vis--vis the social sphere formed a central issue. Practitioners were clearly unapologetic when stressing the social aspects of the 'cure'. For instance, according to the concept of post-operative re-education, lobotomy would allow patients to become candidates for active 'pedagogic intervention'. In one such 'lobotomised school', established by Joseph Farmer in 1948, therapeutic progress included three elements: "Lowering the tone gradual in delirium modification and of

hallucinations; exterior 1949:491).

behavior; and progressive adaptation to circumstances" (Brisset,

This reframed the intervention as a cynical brain erasing and rewriting, compromising the sense of self-determination of the psyche and the agency assigned to the individual- all central elements of a phenognostic discourse. Proponents acknowledged this loss from the very beginning, but considered it as a relatively small price to pay in return to the benefit of re-socialisation: "Whether the effects of frontal lobe deficit will neutralise will or be able with less the accentuate the disharmony already present, whether the individual disposal, will to think more brain relief at of his the in constructively

whether of

depression and its conversion into euphoria permit adequate adaptation society, and whether the individual so treated stands a better chance of survival in the highly competitive society of today 67

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than he would with intact frontal lobes and a potentially recoverable psychosis." (Freeman et al., 1942:214) Or, according to Porot (1947:130): "Their [the post-surgery patients]

behaviour is as a rule impeccable since, even more so than normal person, they are sensitive to the demands their education impose on them; they also know with much precision the sanctions that are involved in the transgression of moral codes". Hence the growing (but eventually little effective) demand for the legal regulation of psychosurgery (the then famous 'Habeas Cerebrum'). This demand most often referred to the question as to whether the psychiatric institution has a legitimate right to act upon the minds of institutionalised individuals, might they be conceived as mentally ill or as responsible criminals.

Illegitimate Interests: The Costs of Mental Asylums

In the beginnings of the 20th century, a patient entering a mental asylum had lean chances of ever coming out alive. In Warren Hospital in Pensylvannia, for instance, 75% of patients would die in the five years following their first hospitalisation (Duffy et al., 1997). The two World Wars brought a growing rate of

institutionalised mental patients, which turned 20th century asylums into crowded 'human warehouses', with no efficient treatment available. In is in that context that Fulton, at the time optimistic about the treatment, will declare that psychosurgery 68

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should be able to decrease the number of institutionalised patients by a fourth and save close to a million dollar a day for the taxpayer. Even patients not be able to be released after a lobotomy will at least be more manageable, not requiring as much staff and facility costs as the pre-lobotomised patient (Swayze, 1995). Other proponents will talk of 40% of mental patients being able to be released after psychosurgical treatment (Sargant, 1976). Anti-psychiatry advocates could easily use these types of texts to establish their claims: psychosurgery, as an important constituent of psychiatrys therapeutic arsenal, was but a conspirative means for social control not only at the state level where it is embedded within political and ideological interests: This 'surgical strait jacket' also served ill-intended asylum psychiatrists, seeking to make their patients more manageable, both in the asylums and in the home thereby benefiting the patients caretakers as well. For Baruk (1956), for example, these procedures would only serve to relieve some unmanageable symptoms, and will have no effect on the patients well-being as such. He himself could base his claim on the very words of psychosurgeons: "We are familiar with this lamentable picture of these children with profound imbecility who are but a long scream and whose agitation makes life impossible for their parents or any other persons who would be willing to take care of them. An intervention holding but a modest intent to cease this agitation is received as a deliverance by the family". (Klein and Tardieu, 1949:116)

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In effect, Szasz (1977), arguably the most important figure in this anti-psychiatry movement, was himself not opposed to psychosurgery per se, but regarded it as yet another instrument at the hands of a coercive institution seeking to eliminate individual autonomy of thought, experience, and action: turn individuals into 'Homi Vadum'.

The Homo Vadum

Black butterflies appear on Walter Freeman's 1942 book 'Psychosurgery', and represent the releasing of madness from its captivity, under the skull, inside the brain. By destructing their prison of material flesh and bone, these creatures of the mind will be freed back into their own universe. Black butterflies endanger the materiality, efficient causality, and orderliness of the physical, the brain. By doing away with these uncanny creatures, order could be restored, control re-established. The brain would be but a bodily organ. Ideas of free will, of an immaterial and unreachable mind, of the unobservable phenomena of subjective experience will all be cast out from a medicine of the mind: either tamed or overthrown, madness will cease to operate its threat on ontognostic reason. It is only when the price of these 'emptied' brains, i.e., the loss of a phenognostic compass, became intolerable that this surgery of the mind became a practice with victims and perpetrators, rather than patients and healers. While the outcomes of psychosurgery were of a wide range, the 'flattening' of human subjectivity is by far the most discussed in both professional and lay literature. According to these accounts, the personality of the lobotomised patient hold fairly consistent traits, including a so-called 'loss in human's superior mental capacities', such as creativity, reflexivity, and fore vision:

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

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Hallucinations may still be present, but will not necessarily be experienced as 'true' to the individual.

The Homo Vadum's Brain

According to many contemporary psychosurgeons and

neuroanatomists (e.g. Porteus, 1955; Bouchard, 1968), the effects of psychosurgery on patients' personalities would be related to the damage incurred to the frontal lobes, 'the seat of higher functions'. Moniz (1936a) linked the frontal lobes to the higher human functions of planning, controlling 'lower' needs of the organism, such as hunger or sexual drive. The frontal lobes were further claimed to be related to the ability of learning from experience, doing purposeful acts, that is, acts that are beyond reflexes and automatic responses6. This is which places them at the centre of Moniz' book: "Two categories of clinical facts can be used in this study: the different types of lesions of the frontal lobes and the results of mutilating surgical operation on these lobes" (Moniz, 1936a:30).

He reports:

These assertions are generally believed to be correct to this day

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"We have noted with those who have injuries of the frontal lobe disorders of voluntary attention skills and of mental synthesis. They are in fact incapable of the most simple of intellectual tasks; they are unable to group and orient the different elements of a given problem. [] in sum, the highest manifestations of psychic life are altered". (Moniz, 1936a:31) "It is [] certain that the frontal lobes tumors present, above tumors of other lobes, the greatest frequency of mental disorders". (Moniz, 1936a:31) Moniz (1936a:35) goes on to report studies according to which bilateral ablation of the frontal lobes will have two categories of results: First, intellectual disorders and second, lesser control over emotional responses. Interestingly, although later research will refute the presence of the first effect, the image of the frontal lobes as a form of super-ego, and a centre of 'reason' will remain central to the description of psychopathologies related to lobotomies. The gains of psychosurgery, according to Moniz (1936a:53): "It would be the solution to a clinical problem of great value: wipe out the intimate suffering of these prisoners of anxiety, of hypochondriac, melancholic and other forms of delirium: occult forces that lead patients at times to acts of despair". Frank, 1946:457: 73

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None of the patients regained full insight in the full sense of the word, or is able really to appreciate what the operation was for, or its importance. [] The specific [personality] change was a poverty, or entire lack of dreams, and a thinning, or disappearance of dereistic experience-they cannot daydream about their wishes, or be abstractly angry in a sustained fashion. They become, due to this emotional asymbolia, more plain, matter-of-fact like. Let it be noticed that Frank added in the same paper that "no cases were considered worse". Indeed, some will claim that the beneficial effects of the procedure derive precisely from those personality transformations, without which, the patient could not have reorganised his psychic scheme (Mayer-Gross, 1949). Yet, the fear of loss of the human, of the turning into a HomoVadum, did seem to intensify over the last decades. With the gradual rise in the authoritativeness of phenognosis, the position towards the Homo-Vadum began to change. Normative functioning could no longer compensate for the damage inflicted upon the Homo-Vadum's phenognostic sense of truth. Existential ideals of self-fulfilment became ever more dominant. The straightforwardness of the surgical act stood in contrast to the complexity accorded to human experience: the idea that a crude 'razing' of the brain could alter the multi-dimensional phenomenon of consciousness led to an overt discomfort. As sentience prevailed as a discursive force, this formerly amoral scientific endeavour turned immoral.

Corporeality, Pain and Phenognostic Truth

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Perhaps not unsurprisingly, over the years, a growing body of literature referred to the patient's inability not only to reflect upon his/her own condition and behaviour. Indeed, although the patients that were to undergo lobotomy seem to have had some improvement as far as their pathological symptoms (at least those related to anxiety and agitation), this would often be counterbalanced by certain personality changes. Reports describe the post-lobotomy patients (as many as 91% according to one source) as being apathetic, lacking motivation and spontaneity, childish, passive and dependant. Some will add the notion of "post-operatory personality"(or "moria") to describe the combination of symptoms observed after psychosurgery has been performed. It seems that the patients initial complaint of having to deal with overwhelming emotions was substituted by a total loss of the ability to feel any emotion at all. This was associated with the loss of a full consciousness of his/her own corporeality and emotional state: [Freeman] points out that the person whose frontal association areas have been particularly lobotomy inactivated presents a by prefrontal of number

peculiarities that distinguish him from his pre-operative self. [] he loses interest in himself, both as to his body and as to his relationship with his environment, no longer caring whether his heart beats or his stomach churns, or whether his remarks embarrass 1947:129) The Homo-Vadum, as termed here, was thus to a certain extent aware and conscious, yet incapable of sentience, the 75 his associates. (Porot,

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quality that translates mere stimuli into full-fledged qualia and by which experiences feel pleasurable or painful. These patients had a tendency to be unconcerned by subjective aspects of their being: while acknowledging drives and feelings, and internalising sensory information, they reacted as if these cues were external (based on out-there sources of Truth ontognostic knowledge), rather than internal (experience-based Truth phenognostic knowledge). [after a prefrontal lobotomy] pain may be present; but it no longer arouses a mental picture of future disability and all that this may mean in terms of disaster to the person and his family, the experience can be borne with equanimity (Freeman and Watts, 1946:445). Or: L.S. A 44 year old woman was first seen in November, 1936, at which time she had spent two years in bed because of arthritis. There was moderate lipping of the vertebrae, but no other significant changes. However, the patient complained so bitterly and was so apprehensive that it was impossible to make any headway in treatment. After being lobotomised: Within three days the patient permitted manipulation of the limbs. She winced and cried out when the knees were

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straightened, and the crepitus was very considerable, but instead of shrieking with apprehension and refusing to cooperate, she showed interest and willingness to help in the efforts that were made to aid her. [] She fell and sprained her ankle, but nevertheless kept on walking. (Freeman and Watts, 1947:427)

Madness and Ontognosis

The concept of 'madness' is intriguing in this regard. This phenognostic experience cannot, by definition, comply with an ontognostic agreed-upon Truth as to a world-out-there, hence its characterisation as deviant in thought, affect, and/or perception. "More difficult to influence satisfactorily are those persons who have drifted away from the world of reality.[] [Only when] the individual lapses completely into a dream world of psychosis with no struggle against the manifestations of disease, is he to be considered too emotionally deteriorated to be aided by psychosurgery." (Freeman, 1943 in Fleming, 1944:490). When intractable, 'madness' remains, in fact, resistant to the reasoning of ontognosis, and thus expressing an incapacity or unwillingness- to recognise what is collectively considered as True. This will, in turn, justify the use of techniques intended to secure willing or coerced subordination of what is seen to be a faulty or muddled phenognostic experience.

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As psychosurgery did not seem to have negative effects on one's intelligence, at least as far as studies of the time could show. Some proponents went on to claim that the inflicted personality changes allowed patients' intelligence to actually become more effective, providing them with the ability to perceive, analyse, and respond to the world more 'rationally': "After a prefrontal lobotomy, a person who was previously trained for the practice of law, engineering or scientific work, remains capable of calculation, all mental deduction operations and that accomplish 1948:497). Here, while typical patients' sensitivity to ontognosis grew, their phenognostic consciousness deteriorated: the patient would know but not experience.

concern productive activities" (Wertheimer,

The Homo Vadum and Society

Still, in line with the idea of the 'social cure', psychosurgeons who did refer to the personality dimension argued that the creation of the Homo-Vadum was a moral act par excellence, for it enabled the return of the insane into the laps of a normative society. One must consider that, based on an ontognostic conception of humanity, turning a socially incompetent individual into a Homo-Vadum was a valuable accomplishment. Rather than referring to the patients acquired condition as a regrettable albeit perhaps unavoidable - side effect, proponents of the technique used the descriptions of the Homo-Vadum as a validation of the beneficial results of psychosurgery. At the peak of its popularity, practitioners depicted psychosurgery's effects as pointing out to the success of the procedure. 78

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Questions as to normalisation and the creation of Homi Vadum are apparent in other areas of culture, notably in fictional literature. Ken Kesey's influential novel "One Flew over the Cuckoo's Nest", published in 1973, depicts its protagonist as resisting the system of the mental asylum only to be eventually lobotomised. Eager to empower a group of mental patients to trust in their own phenognostic sense of Truth, in what they believe to be right, the central character was calling for an alternative source of power: a Truth that feels true to the individual, a Truth that cannot be challenged by external authorities, a Truth that does not have to be subordinate to the gaze of the world-out-there. The 'hero' was finally defeated: lobotomised and turned into a HomoVadum, he was now both literally and symbolically at the hands of the more authoritative power: Ontognosis. Surgery left him barely conscious: a mannequin, a 'thing'. As an act of mercy, his friend would euthanise him. This classical piece of literature became one of the strongest manifests for the liberation of individual thinking from the hands of a normalising society. Its mere popularity demonstrates the claims presented throughout this analysis, namely, the idea that a rise in the discursive power of phenognostic Truth would place free subjective thought, although deviant, above the ability to accept an agreed-upon ontognostic Truth. The practice's discordance with emerging phenognostic conceptualisations of the self placed psychosurgery in the focus of debates on the significance of sentient experience. Over the years, the procedure came to symbolise "the substitution of a soulless robot for the insane patient" (Mayer-Gross, 1949:320), and the diminution of the fullfledged subject into a shallow faade of self: "exhibiting a purely objective mentality" (Golla, 1946:444). Yet, in an era where questions of value are so often approached with a phenognostic

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view in mind, to be reasonable by ceasing to be does not make sense anymore.

Concluding Words
I have attempted here to present a historical motion involving two powerful sources of Truth, phenognosis based on inner experience- and ontognosis based on observation of a world-out-there. I have then used the case of psychosurgery to substantiate a somewhat provocative claim: this sense of Truth experienced at the level of the conscious individual would play a role in the sociocultural realm, not as a prediscursive form, but rather as a full fledged discourse; not necessarily as a negative picture of an objectifying gaze, but as a positive picture in and on itself. The conceptual scheme proposed here is potentially useful in the analysis of other phenomena where ontognostic knowledge finds opposition in the form of phenognostically based claims. This seems evident in the study of New Age spiritual movements. Both practices and epistemological bases of such movements typically involve some extent of disregard of external cues (as conceived in ontognostic terms) as well as the assigning of high legitimacy to the Truth as experienced by individuals in specific states of consciousness (claims of re-incarnation for example, or sensing the presence of spiritual entities, all clearly not supported by empirical evidence). Indeed, although often contrary to ontognostic evidence, these subjective experiences will be given high status as True, as long as they 'feel' authentic, genuine, nonmediated, to the individual. Another example may involve the understanding of the credibility associated with states of trance, in the context of healers and shamanist medicine and the authoritativeness attributed to those able to experience it. All can

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benefit from the positioning of phenognosis against ontognosis on the issues of credibility, faith, and beliefs. One may find similar trends in modern psychotherapeutic discourses, where ones inner feelings are considered a priori legitimate. Along a similar line, one is often advised to seek for an 'authentic self' through deep introspection rather than through external appreciation of 'reality'. The fact that these trends are all accompanied by oppositions and by countering phenomena may point to the power ontognosis maintains, and to the complexity of the proposed forms of analyses. In effect, it is precisely these exchanges and conflicts, which may profit from an analysis based on an opposition of phenognosis and ontognosis and on a dynamic view of the exchanges between these two sources of power. I suggest here that further understanding and empirical grounding of the scheme proposed here may be of value in both anthropology and social studies in general. In the next section of this work, I will hope to show how the dynamics of more and less phenognostic sources of knowledge come about in the routine workings of a clinic. This will be based on a synchronic, rather than diachronic view of the phenomena, and on a sustained in-situ observation rather than on a more macro outlook as proposed in this paper. As I try to ascertain throughout this work, the boundaries between phenognostic and ontognostic knowledge are created, formed and reformed at several layers of the world of the sociocultural. Here, I shall provide an analysis along similar lines, albeit with a different field, different methodologies, different references to bodies of literature, and different empirical points of focus.

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Part IVa: Experts and Knowledge that Counts(background) The World of Brain Cancer Diagnosis
The Neuro-oncology Clinic
During the first half of 2006, I followed members of a neurooncology outpatient clinic situated in a large hospital in Israel. The

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team consisted of four neuro-oncologists (NROs), a head nurse, a social worker, and a neuropsychologist. The NROs were observed during routine consultations; in rounds in the inpatient ward; and in the course of three weekly professional conferences: one internal conference, one with the radiology experts, and another with the neurosurgical team. I spent some twenty hours a week at the clinic, where I gathered extensive field notes (simultaneously translated and composed in English) along with both formal interviews and casual exchanges with staff members, patients, and close-ones. A total of 103 consultations were observed, and 68 patients were informally interviewed. Although forming but a small share of the data collected, formal interviews 13 overall, 4 with NROs, 2 with family members, and 7 with 5 different patients-- were later transcribed verbatim.

The Clinic: Spatial Characteristics

The neuro-oncology clinic is an outpatient unit located in a general oncology clinic. The secretariat is shared by both groups of physicians (the latter's forming a more substantial share of the staff). The clinic includes about ten offices. Each office has, nailed on the wall next to the door, a metal name-tag-holder that can be replaced at need, according to the physician who happens to be using the room on that particular day. Thus, there is no permanent office for any of the NROs, although on the days in which the neuro-oncology clinic is active (Mondays, Wednesdays, and Thursdays), the working physicians tend to be placed in a habitual office (used by other physicians -or even nurses - on the days they do not receive patients). The neuro-oncology clinic has thus no actual spatial presence: it is a virtual set of specialised knowledge held by 'visiting' professionals.

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Each Sunday is spent around professional conferences. The conferences take place at different locations, none of which is actually secured for the NROs. The conference room at the "Moses Institute" -a building with mostly oncology-related inpatients units; ambulatory divisions; and out-patients clinics- is used for the weekly NROs' staff meeting. However, was some other group needing this room, the NROs will find a temporary office at the clinic, squeezing in into a room much too small. The Radiology conference takes place at the radiology (MRI) unit, in a small office, where the experts usually sit and go through the MRIs (and reporting, in writing, their impressions and interpretations of the images they survey). The Neurosurgery conference (referred to as the 'tumour board', hinting to its more decision-oriented character) takes place in a conference room at the radiotherapy unit. At times, when the conference room is used for other purposes, the whole team will go up to another conference room, at the neurosurgery inpatient unit, at the hospital main building. Professor Lise, the head of the Neuro-oncology team has a large, luxurious office at the Moses Institute, albeit at some distance from the actual clinic, or the inpatient unit. Her office is actually located at the one floor where the services provided are not targeted toward cancer patients i.e., where nuclear medicine tests are conducted. Her office has an interesting standing: it is both the heart of the clinic, in terms of research mostly and administration at times, but it never serves as a meeting place for the different NROs. There is, in fact, little cohesiveness or sense of 'team' between the NROs, or the rest of the staff, for that matter. The spatial arrangement may reflect that, while also contributing to this state of affairs.

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The Moses building has many floors, some of which are underground: The -2 floor includes the radiotherapy (RT) facilities and completely lacks windows or direct access to the 'outer world'. It is a dark, 'spaceship'-like floor, with instruments and names on the doors that would not shame any science fiction movie. The outpatient clinic is located on -1. One will also find there the refurbished conference room serving the NROs on Sunday mornings' meetings. As expected from a frontstage area, which serves the general public rather than patients (whose pathological state allows them some access to backstage areas), the place is bright, easily accessible, and a coffee shop is located in the general hall located on the East, leading almost directly to the hospital's mall. A small but lovely patio separates the Western and Eastern wings, i.e. the reception area and the conference room (which is, interestingly enough, surrounded by glass walls from which the conferences may be seen but not heard). Floor B is where Lise's office is located just near the corridor leading to the general hospital. Again, this is the only floor where the activity has little to do with oncology. No one could guess he had entered the "cancer building", or as another patient called it: "the death wing". The first floor is where the oncology inpatient unit is located, and where the general hospital is directly linked to the institute's building. This unit is where most neuro-oncology patients are hospitalised, alongside general oncology patients. Naturally, this is where most of the rounds take place. The second floor includes the haematology inpatient unit. At any given moment one-to-two neuro-oncology patients are to be found hospitalised, usually due to secondary complications of treatments. The third floor includes a large, quite modestly but recently refurbished ambulatory service. This is where patients are 85

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submitted to chemotherapy by perfusion and return home at the end of the day, after a short recovery and observation period. The onco-psychological unit is also located on the floor, with a consultation room of its own. The team of psychologists usually works with ambulatory patients, perhaps much more than with hospitalised patients. This might be explained by the longer life expectancy (and chances of recovery, in some cases) of the notyet- hospitalised patients as opposed to the near-death, and often unconscious, condition of many inpatients.

Schedules and Organisation of Time

On each of the days in which the clinic operates, one or two physicians receive patients. The reception hours tend to begin at around 8:00, although most physicians turn up only by 9:00. The last appointments are set for around 12:00, although this may actually last until 15:00. Sundays are organised around conferences and rounds. The morning begins with a NROs' staff meeting. This may last until 10:00, or end by 9:00. If the former is the case, the group will go straight to the next meeting (which is invariantly scheduled for 10:00) with the radiologists. If the latter happens to be the case, they will take the opportunity to finish the rounds before the radiology conference. The rounds usually do not take more than forty minutes. The meeting with the neurosurgeons (the 'tumour board'), usually begins at 14:00. There, the day ends as far as the NROs are concerned. As most of the staff members (Lise excluded) also work as general neurologists, they will spend their 'free time' as 'plain' neurologists.

The Neuro-oncology Meeting

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The first meeting includes the NROs, the head nurse, the social worker and the neuropsychologist. From time to time, fifth year medical students are allowed in. The meeting is organised around a briefing of each NRO on the cases he/she had seen over the week. Each NRO presents about ten cases, while the others listen and make suggestions as to treatment options or diagnosis. This usually happens when the presenting NRO specifically says that "this is a difficult case" or "that is an interesting case". None of the NROs consider him\herself as mere clinicians, and all are involved in research at one level or another. Thus, the meetings also include research presentations (such as dr. Levitz' presentation of findings related to "chromosomal differences between infratentorial and supratentorial ependymomas"), and reviews of state-of-the-art literature, at times by the NROs themselves, and at others by peripheral experts such as the histologist or the neuropsychologist. While the first is filled with technical terms and arise much interest, the latter is often regarded more as an opportunity to discuss patients' personal lives and personal peculiarities: as cases are presented along with the results of the neuropsychological testing, the team members would take these on to describe curious encounters they may have had with this or that patient. The neuropsychologist would typically not get involved in these discussions but neither would she try and resume them, however eager she may be to continue with her professional presentation.

The Patients
Patients adults alone, as children are referred to a paediatric unit- are referred to this clinic from all over the country, since this 87

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particular centre is considered to be providing the most professional and specialised care available (in fact, it has a reputation of being among top neuro-oncology centers in the world). There is no particular social characteristic which makes the patients' population remarkable. Most of the patients I see come to the clinic for follow-ups. Some would only come once a year (once every three months is more typical) to have their MRI done, and consider the progression of the tumour. Patients under active treatment will come up to once a week when under radiotherapy, and once a month when on chemotherapy. New patients almost invariably know about their condition beforehand. They have either been referred to the NRO after a diagnosis has been given by another physician, or did they already have an attack which rushed them into neurosurgery only then to understand they have a brain tumour. Actually, the second scenario is much more common.

The Consultation
The patient arrives at the clinic, gives his/her name to the reception clerk. His/her file is then placed on a pile which will be taken to the physician's office from time to time. The files of patients due to have an appointment are drawn from the clinic's archive the day before. The physician will find, upon his arrival to the clinic, a list of appointments for the coming day. As the NROs tend to be late, they will also find a pile of files meaning that patients are already ready to be seen. The physician would not see them in the waiting room (and they would not know whether he/she had arrived) since he/she will typically use the back door entrance to the clinic. This entrance demands making a small detour, but allows to remain unseen.

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The ways the NROs conduct the consultation is very similar: as the patient enters and take a sit, the NRO would utter a "how are you doing?" without really hearing the answer7. Using a barcode reader, the physician will then enter the patient's ID number onto the specialised software. Then, he\she will stare at the computer for a few minutes. The NROs take great care in gathering information in an orderly manner, usually as is costumed to fill in the consultation report: the gender, age and diagnosis, comorbidities, the treatment currently undertaken, the current complaints, the report of the clinical examination (if there is one, if not, the physician will suffice himself with a general impression of the patient's condition). Then come the orders: how to continue the treatment, if any test or consultation with another professional is needed, and when the next appointment should be made. One copy will be filed; another will be given to the patient. There is no formal room for questions, and the patient is expected to quick, to-the-point and assertive if he\she is determined to obtain clear responses. Even when diagnoses are communicated (often very bad news), or when complex treatment orders are given, the patient may be hasted out of the room8.

Family Members
The patients usually come with a family member. Close to the time of diagnosis and often towards the patient's death, more members of the family tend to join in. The family members are a critical part of the consultation. They usually take on an active stance, some answering the NRO's questions for the patient (even
7

At this point I would introduce myself as Sky Gross, a researcher from the Hebrew University, doing research on brain cancer and brain cancer patients. I would then ask whether I could sit in the consultation. All but one patient agreed.
8 8

Notwithstanding these comments, it has to be noted that at no point do the physicians use their time for

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in cases where the latter is well enough to answer himself). This applies to technical questions such as the dosage of drugs taken but also to more abstract questions such as the type of pain the patient suffers from.

Something About Brain Tumours

Types of Tumours
At the most elementary level, one may define two general types of brain tumours: Primary, i.e. forming in the brain itself, and secondary (or 'metastatic'), i.e. originating from another cancerous process elsewhere in the body. The types of cells involved and the form of its spreading give indication to whether the tumour is primary or secondary. Life expectancy differs dramatically, that is, once a tumour has metastasised, there is little chance in effectively controlling the process. Unlike many other forms of cancerous diseases, there are no known risk factors to primary brain cancer, and etiology is little understood. There is thus no known way to prevent the apparition of the disease. The largest group of primary brain cancers is referred to as 'Gliomas'. Gliomas involve abnormal growth of glial cells (the supporting cells of the brain) and include four main categories of tumours, based on the types of the underlying cellular formation and the location of the tumour: 'astrocytomas' (the most common), 'ependymomas', 'medulloblastomas', and 'oligodendrogliomas'. All tumours are assigned a 'grade', that is, a I-IV classification relating to the current speed of growth, the presence of necrosis (dead tissue), the number of blood vessels providing nutrients to 90

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the tumour, and the level of differentiation (pathological deformation) of the cells . Grade I-II tumours are considered benign, although may become more aggressive at a later stage of growth. They can also be located in or near a part of the brain which, if damaged, may cause serious handicaps or even death. I saw only a few of these patients, as they tend to come to the clinic for yearly follow-up only. Grades astrocytomas' III-IV or tumours are referred to as 'anaplastic Anaplastic

'glioblastomas',

respectively.

astrocytomas typically progress to become glioblastomas (GBM) at some point. GBMs are deadly, often giving the patient a life expectancy of mere weeks.

Location of the Tumour and Functions Threatened

The brain is divided into six primary regions, each controlling specific functions. The following is a brief overview of each region and their correlating functions. The Brain Stem. The area where the brain connects to the spinal cord is called 'brainstem'. It controls vital heart and lung functions such as breathing, digestion, heart rate and blood pressure, as well as the ability to remain awake and alert. It is the pathway for all nerve function through the spinal cord to the highest part of the brain. Problems in the brainstem often cause symptoms such as double vision, abnormal functioning of facial muscles, nausea, sleepiness, or weakness on one side of the body (hemiplegia). However, since so many nerves go through the brainstem, pathologies associated with this area can cause almost any form of symptoms.

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The Cerebellum. Located at the back of the brain above the brain stem, the cerebellum coordinates balance, posture, and coordination, and affects activities such as eating, walking, talking, and eye movement. The Frontal Lobes. The frontal part of the brain is responsible for organising thoughts, planning, problem solving and selective attention. It is also where higher functions, such as the control of behaviour and emotions and moral judgment. The posterior parts of the frontal lobes also houses nerve cells that produce movement. Patients suffering from tumours in or near the frontal lobes may not only have symptoms related to motor functions, but may also suffer from extreme personality changes. The Occipital Lobes. Located in the mid-back of brain, the occipital lobes are 'in charge' of vision. The neural network takes input from your eyes and turns it into the pictures that you see. Presence of pathology in this lobe can cause partial blindness or the inability to recognise shapes, colours, or faces. The Parietal Lobes. Located behind the frontal lobes, and at the top of the brain, the parietal area comprises a right and left lobe, which together, control our sense of touch, our feel and understanding of weight, size and texture, as well as much of our cognitive comprehension of the world. Pathologies of the parietal lobes can cause numbness, tingling, and other sense-related symptoms. Tumours affecting the right parietal lobe can cause a lack of spatial orientation and may hinder the ability to recognise one's own body. Tumours affecting the left parietal lobe can cause difficulty speaking or difficulty understanding speech. The Temporal Lobes. Located on the right and left side of the brain (near ear level), the two temporal lobes help us distinguish smells and sounds, and may be involved in the 92

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experience fear, and may impact short-term memory. The right lobe is primarily responsible for visual memory while the left controls verbal memory.

Treatment
The term 'treatment' is misleading. Except for a number of first grade tumours, the progress of the mass is inevitable, although it may proceed over decades. Treatment is thus meant to prolong life or to better the patient's quality of life. The NROs are unambiguous: there is no 'cure'. There are three types of treatment, provided usually in this order: Surgical resection, chemotherapy, and radiotherapy. Surgery. Surgery is usually the first step. Most of the reports I heard from patients place the beginning of the brain-cancer 'odyssey' at the point where the tumour made its first dramatic symptomatic appearance. Almost invariably do they then report on their being rushed to surgery. Surgical intervention is seldom able to remove the entirety of the mass' tissues microscopic malignant cells almost always remain to begin the growth anew. In most cases, the benefit of surgery must be weighted not only against the risk involved in any serious operation, but against the neurological deficits that may result from the assault on the brain. Chemotherapy. Brain cancer has its own set of

chemotherapeutic agents. The reason for that is that the brain keeps some of the body's material out, through what is called the 'Blood Brain Barrier'. Unfortunately, this barrier is not penetrable by the chemotherapeutic agents known to be effective for tumours across the body. One agent is, however, able to reach brain tissue is in the form of tablets: Themodal. The treatment is given for one month at a time, at the end of which blood tests and imaging 93

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are given. If the blood tests do not allow the continuation of the treatment (typically anaemia, low platelets count or neutropaenia), if the treatment turns out to be ineffective, or if two years have passed it is terminated, and the patient will be referred to radiotherapy. Themodal is self administered, at home, does not cause hair loss, and has in fact little side-effects. In all these, it will create but little a sense of "Cancer self perception". Radiotherapy. Radiotherapy is typically administered daily for a number of weeks, in the course of which the patient is to meet the NRO weekly and give blood on a regular basis. The radiotherapy causes many side-effects (which severity depends on the dosage and the areas being targeted), including hair loss, extreme fatigue, burns on the scalp, oedema and more. The series of treatments is usually given once in the entire course of the disease. It also does not have remedial powers. However, it usually does contribute to the shrinking of the tumour and does slow its growth. Symptoms Relief. Epilepsy is one of the most troubling symptoms of the presence of the mass itself and the oedema forming around it. The oedema tends to become more severe as a result of radiotherapy and surgery. Steroids are provided for the relief of oedema, thereby providing relief in epileptic seizures and intracranial pressure (a situation that may be uncomfortable at first, but will eventually cause death). Epileptic seizures are also treated with anti-epileptic drugs, some of which must be continuously accompanied with a monitoring of the active agent's level in the blood. A major sign of brain cancer is the loss of strength (paresis) or paralysis of one or more limbs and/or enervated body part. These symptoms have usually no treatment available, perhaps

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besides steroids which would relieve some of the pressure on the part of the brain involved. Steroids are eventually devastating for many body systems, especially when given in high doses. It will also give the patient a typical bloated look, making the surroundings accutely aware of their condition. Palliative and Supporting Care. When the treatment panoply has been exhausted, there is no role for the NRO but to follow from distance the palliative care provided to the patient, usually in a hospice or at home. There is relatively little pain involved in dying from a brain tumour, unlike with most other types of tumours. The end may be uncomfortable, when more basic functions begin to deteriorate, especially breathing. But, in general the process is gradual and loss of consciousness usually appears before the patient has the chance to enter the more agonising stages of dying.

Part IVb: Experts and Knowledge that Counts The World of Brain Cancer Diagnosis*
*An abridged version of this paper was published in "Social Science and Medicine" 2009 in press, and available online

The brain has much significance in broad aspects of Western culture as well as in its symbolic and physiological relations with the body. Questions of self and the brain tend, however, to be of little concern in the everyday routine of most members of society. 95

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One instance in which the brain becomes a central focus of one's life is when it becomes the site of life threatening pathology. Brain tumours brings about the neccessity to visualise the brain (through imaging tests not usually undertaken by healthy individuals), to face consequences of brain pathologies (such as motor and cognitive losses, but perhaps most significantly, changes in personality). What I expected to find was thus a more intensive questioning of the place of matter (brain tissue) in individuals' own psychic life and sensation of self ('mind'). Yet, I would be soon taken aback: almost no patient sought an understanding of the mind/body conundrum as it applied for him\herself - This, even with the most philosophically-akin subjects. As is often the case in fieldwork, however, I unwittingly revealed other interesting phenomena, i.e. those related to the creation of a web of knowledge hierarchised and utilised in high accordance with the gnostic split. This will be the focus of this next study.

Introduction
The majority of medical texts represent brain tumours as involving fairly clear-cut entities and categories of entities, amenable to 'discovery' through different ontognostically-based practices. A closer look into the life of a neuro-oncology clinic proves, however, that the solidification of neuro-oncological objects is less than straightforward, in both epistemological and practical terms. This study sought to provide such an in situ understanding of the ways in which diagnoses are handled in medical experts daily routine via a deep insertion into the everyday practice of a wide range of experts. The aim of this paper is double: first, to underline the technological and epistemological grounds of 'expertise' in the medicoscientific practice of diagnosis, and their roles in the assertion of expert

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authoritativeness; and second, to propose analytical tools to approach the complexity involved in the creation of knowledge,the potential frictions it may create, and the mechanisms of their resolution.

Methodology
Over the last decades, a new approach to the study of medicoscientific work has arisen, seeking closer attention to the everyday practices of 'making science' (e.g. Latour and Woolgar, 1986; Lynch, 1988; Pickering, 1992; Rabinow, 1996). Drawing on this now considerable body of research, this paper will present an ethnographic study which allowed for a sustained in situ look into the daily micropolitics of the diagnostic practice. Being, in a way, the physician's home ground, the hospital constitutes a precious setting for understanding the world of medical experts (e.g. Anspach, 1993; van der Geest and Finkler, 2004; Mizrachi, Shuval and Gross, 2005). In this case, a lengthy and laborious work of negotiation and clarification, namely with the head of the clinic led to the gradual gaining of the staff's confidence. Finally, a formal permission from the hospital's board of ethics (the 'Helsinki Committee') allowed me to begin my work. By the end of this process, I was accorded access to the most inner stages of the clinic, naturally conditional on the informed consent of both the professional and the patients taking part in the research project. Anonymity is ensured by the use of pseudonyms throughout, again, for both patients and staff. Considering the level of intimacy I developed with the patients, I felt more comfortable using first names as pseudonyms, while referring to staff members in a manner that would reflect their professional roles, rather than on ad-hominem aspects of their work (i.e. Dr. X.). 97

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In view of the intricate nature of the field of neuro-oncology and the complex terminology used in interactions, I spent months prior to my insertion in the field studying related medical texts. In fact, it seems one can hardly communicate the 'real life' work of the professionals without referring, however critically, to these schemes. That being said, I had to repetitively make clear to patients that I retained neither medical nor counselling role in the clinic. This was particularly salient as I did, to the request of the staff, wear the traditional white robe. Still, provided that proper ethical directives were followed, and as cooperation was ensured, this did not seem to eventually form any significant obstacle.

At the Clinic: The Diagnostic Process

According to textbook medical knowledge, a brain tumour arises out of the proliferation and multiplication of a single cell, which, for reasons little understood, undergoes molecular mutation. At the histological level, these will reproduce, create their own blood supply, and eventually become numerous enough to apply pressure on adjacent nervous tissues. The tumour presents itself through a neurological realm of signs and symptoms, which may include epileptic seizures, total or partial paralysis, speech malformations, visual disturbances, loss of sensation in the limbs or, in some cases, personality changes. Reporting diagnostic information such as biopsy and MRI studies, along with clinical impressions allow NROs to determine the locality of the tumour, its size, the types of cells involved, and its degree of malignancy. At the clinic, this process begins with the first encounter with the patient. There is a fairly ritualistic intake of new patients, where the NRO assesses previous findings, gathers clinical history, and performs a physical examination. If judged necessary,

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immediate intervention is considered, albeit only once options are discussed in conjunction with other experts, such as radiologists and neurosurgeons, and, if applicable (viz. the tumour is metastatic), with the primary oncologist. In either case, treatment options (including, among typically a in this wide order: array neurosurgery, of biomedical chemotherapy, radiotherapy, clinical trials, and palliative care) are deliberated relatively professionals. Routine assessments of cases are typically performed in the course of three weekly conferences. First, during the NROs staff meeting: there, each physician is expected to present the files of the patients he/she has seen throughout the week, his/her colleagues offering their opinions and evaluations. The second meeting proceeds at the MRI unit, where the radiologists go through recent imaging tests while the NROs provide clinical information on their patients. The formers then report their impressions, first orally to the staff (things look bad, tut tut tut), and later in writing (a slight compression of midbrain structures was observed). The third meeting, the 'tumour board' which includes the NROs, neurosurgeons, and radiotherapists- seeks a collective appraisal of the applicability of different surgical or radiotherapeutic protocols ('treatment algorithms'). Its place within the diagnostic complex is limited, and the approach is largely task-oriented. The only common participants in these three sessions are the NROs, a fact that reinforces their centrality in the diagnostical process. Indeed, as the integration of reports into a compiling diagnosis requires the adoption of a common way to speak of' the disease, the participants (i.e. the reporting experts) are expected to conflate their way to 'speak of' the disease to the NROs, thus placing the latter in a junction of significant power (Mol, 2002).

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The interaction between professionals is critical both before and after initial diagnosis. Patients attend the clinic up to once a week while under a radiotherapeutic regime, and once a month when under chemotherapy typically referred to imaging tests every few weeks. In fact, for a brain cancer patient, diagnosis is literally a lifelong process; For the NRO, each diagnostic function defines a point on a temporal line which presumably depicts a logical evolution of the disease, usually towards a worsening in all diagnostic values. The 'case', thus, remains in a certain state of fluidity, where each re-assessment demands further exchanges of reports through the web of expertise.

Medicoscientific Diagnosis
"In order to be able to offer each of our patients a course of treatment perfectly adapted to his illness and to himself, we try to obtain a complete, objective idea of his case; we gather together in a file of his own all the information we have about him. We observe him in the same way that we observe the stars or a laboratory experiment". (Foucault, 1963: XV) With the proliferation of diagnostic technologies, the practice of medicine has become increasingly dependent on expert medicoscientific observation, adding to the intricacy of medical work (Howell, 1995; Dew, 2001; Clarke et al., 2003). This is accompanied by the need for a constant reshaping of the definition and conceptualisation of disease, most prominently in fields where diagnosis remains complex and critical (Reiser, 1978; Clark and Mishler, 1992; Casper and Koenig, 1996).

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Facing sets of signs and symptoms, physicians are expected to 'reveal' the one underlying ontognostically-reachable element: the Disease. This quest aims at a reconciliation of accumulated diagnostic data (e.g. clinical examinations, blood test results) and the preconceived nosological scheme of knowledge regarding diseases characteristics, expected course, and likelihood to respond to certain treatments (Foucault, 1963; Lynch, 1988; Moreira, 2000). This integration of pathology and nosology requires a ramified process of creating, changing, communicating, and alternating definitions of 'the Disease' as one epistemological object (e.g. Berg and Mol, 1998; Mol, 2002; Moreira, 2004). In many biomedical settings, this process involves a

multiplicity of experts: within each expertise, diagnostic elements are observed, explained, assigned attributes and boundaries within its specific 'styles of reasoning' entrenched within formal and tacit knowledge (e.g. Good, 1994; Bos, 2004). As Polanyi (1998) and others (e.g. Hacking, 1982; Collins, 2001) have shown, expert conceptualisation of pathologies is further mediated by technology (e.g. an MRI machine), a form of attention (e.g. the analysis of the spatial characteristics of a tumour) and a hermeneutic agent (i.e. what does this finding mean?) (Foucault, 1963; Berg and Harterink, 2004). This gaze then provides further interpretation of reality within these styles of reasoning (Latour and Woolgar, 1986; Latour, 1993; Haraway, 1997), and mediates the definition of the disease as a thing-out-there, an object (e.g. Koenig, 1988; Rabinow, 1996; Boumans, 2004). Different expertises are sustained within their own technological, rhetorical, and epistemic systems (Goodwin, 1994; Knorr-Cetina, 1999), each creating what shall be referred here as 'expert-mediated objects'. These will then be made comparable and manipulable within an established nosological order, where they can be 'spoken of' in a common language. They will they be placed within a 101

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delineated, organised conceptual chart of identified pathologies (Lynch, 1985; Hacking, 1992), and amenable to integration or alignment with other objects. Both the ontological status and communicable qualities of these mediated-objects are maintained by professional rhetoric in the form of reports, i.e. the artefactual products of processes of observation and translation (Young, 1981; Anspach, 1987; Latour, 1996; Bos, 2004). Reports may be as numerous as the number of expertises involved, and create as many objects as the number of gazes laid upon it (Berg and Mol, 1998; Mol, 2002; Beaulieu, 2002). While mediated-reports may 'make sense' in the context of the single expertise, epistemological inconsistencies may arise once these are juxtaposed, often demanding an implicit evaluation of the forms of authoritativeness associated with each of its sources. As this work will seek to demonstrate, NROs --being ultimately in charge of diagnosis making-- tended to strive towards the assertion of the nosopathological uniqueness and integrity of the 'brain tumour' object. With this aim, they were seen to apply often implicitly and always subtly several mechanisms, which will be discussed later in the text.

The Web of Expertise

In order to create the neuro-oncological object as a coherent 'ontologically asserted' (or 'ontognostically-based') referent (Bos, 2004), the NRO has to draw beyond his or her own field of expertise well into the neighbouring provinces of knowledge and technology. Within the scheme proposed here, this involved

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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 Marfas 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 patients 103

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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

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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, Alyoshas 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 105

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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

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interpretations. Therefore, in practice, whenever possible, Soren worked with the team, while his colleague continued working on 'general patient's reports. When Martin did replace Soren, the meetings were tenser, and most of the final judgements on the meaning of the image on the screen were given by the neurooncologists rather than by the radiologist. Clinical information was more often sought and drawn from when the picture seemed inconclusive (i.e., if unsure of whether the tumour has grown or not, a worsening in the patient's symptoms was used to settle the interpretation the tumour must have grown as well). All four NROs were present at each of the weekly meetings, as well as the head nurse. Joining them was Lise's secretary, Gila. Gila sat with Lise's laptop, plugged onto the hospital's intranet, and equipped with the software especially designed for keeping and documenting patients' cases, albeit for the neuro-oncology team's use only. Gila entered the evaluations she received from the group, usually as summarised by Lise. She often did not understand the jargon, thus not knowing what she was writing. She never made any comment on patients, nor shown emotions when news were particularly diffficult. In fact, she never expressed any interest beyond what was directly dictated to her. In this sense, she served more like a mediating device than an actual 'professional'. The more formal report was composed by the radiologists themselves before (forming the grounds for the discussion with the NROs) or after the meeting (then formed around the reading suggested in the course of the exchange). It included several carefully operationalised components, each conceivably contributing to the diagnostic effort: the location of the tumour, the colouring of its centre and borders, the number of foci, the regularity of its margins, etc. This, along with the clinical and 107

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histopathology reports, enabled a grading of the tumour, and a characterisation of its cellular bases. This report played an important role in the continual examination and re-examination of the state of the disease; so much as to have patients sent home --without being examined-- if their MRI had not been yet deciphered by the expert. As far as the team was concerned, it was arguably the most straightforward and informative means of assessing the tumour's progression: I see now or It's right there were typical ways of referring to the radiology-mediated object during MRI meetings. This has grounds on several broader cultural stances, including the medicoscientifical tendency to regard sight as evidence, with 'seeing' being almost inseparable from 'knowing' (Lynch and Woolgar, 1990; Jenks, 1995; Draper, 2002; Dumit, 2004; Joyce, 2006) and vision as an unmediated perceptual source of knowledge: the images themselves purportedly allowing an ontognostic, non-interventional access to the truth (Foucault, 1963; Knorr-Cetina and Amann, 1990; Daston and Galison, 1992; Cartwright, 1995), and ruling out phenognostic interferrences and interpretations not intended by the reader (Bastide, 1990; Ala, 2004). Although the MRI is by definition a mediated view of the patient, there is a process by which the technicians seek eliminate this very mediation by creating an object: the 'thing' that they look upon becomes the ontognostic 'real thing' that needs to be approached. This materiality is what enables them to approach the thing, and make the subject of this thing transparrent (Duden, 1993; Boumans, 2004). It is easy for MRI technicians to forget that there is a 'body' there (Rohrer, 2007), that is: that the screen shows an abstraction of something, a mediated 'something' rather than the 'real thing'.

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Once the visual is alleged to provide the most authoritative access to the object of disease, radiology would undoubtedly represent the epitome of diagnostic science (Gunderman, 2005; Burri, 2008; Joyce, 2008). In fact, some will claim that radiology may make things 'more real than real' or 'hyperreal' (Baudrillard, 1988; Frank, 1992), that is, more accurate than would any direct assessment of the 'object itself', including phenognostic assessments by the object itself (i.e. the patient). 'Space' is another crucial element in the assertion of the authoritativeness of radiological knowledge (Leigh Star, 1989): "Wow, it is indeed large, now I get it [why the symptoms are as serious]!" or: "How can he even walk around with a tumour that big?!" These are types of phrases I would regularly hear in radiology meetings. The diagnosis of a brain tumour, in the NROs' own terms 'a space occupying process', indeed involved an emphasis on spatialisation: brain-cancer is a local, non-systemic disease, unlikely to metastasise to other parts of the body; The symptoms tend to be in correlation with the surfaces of the brain affected by the disease; The site of the symptoms often directly reflects the location of the tumour, its spatial characteristics, and to the rate of its spreading. Often, however, when speaking of a patient's pathology, the physicians would rather use gestures that point to the area of the brain involved rather than to the location of the symptomatic revelation of the tumour. For instance, when Lise left Simon's 109

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room and discussed his condition with her colleagues, she naturally placed her hand on the left side of her skull, rather than where the (very visible) paralysis was, i.e. on the right side of the face. The spatial attributes of the tumour are strongly tied to every aspect of the physicians' work, including in the clinic. Radiology, thus, as a space-oriented measure, has powerful epistemological affinity and mimetic relations with the disease as it is conceived: a spatial diagnostic technique, for a spatially defined pathology. This is well examplified in the case of Simone, a 25 year old woman, with advanced cancer. Her husband, Albert, accompanied her along with her mother to Franz' office. Simone sat on a wheelchair, completely lethargic, keeping an empty smile when spoken to, only to go back and doze off again. Franz read the file: Simone had just completed a round of radiotherapy, and yet, she looked considerably worse. He looked at the MRI and without uttering a word, turned the screen towards Albert: "Look", he said. Yassar remained unsure of the thing he was supposed to 'look' at, but understood that something must be wrong. This is when Franz solemnly announced: "The radiotherapy had no effect. In fact, the tumour has grown, and surgery is now impossible: the tumour takes on half of the brain". "This", Franz pointed at the screen, now more clearly drawing around the edges of the tumour, "explains how she is", as if the visualisation of the tumour actually explained anything. Albert: "Couldn't you suck it up, like in a biopsy?". Franz bluntly answered,

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annoyed by the nave question: "This is not a liquid! You would suck up all the brain out!!". This is when the mother burst into tears, now joined by Yassar. I was interested as to whether actually seeing the tumour made any difference: Just a few minutes before, Albert proudly showed me how her hair had begun to grow again, asking a rhetorical question: "she'll be alright, now, right?" to which I answered with a smile. After the consultation, I asked him whether he was surprised to see the MRI: "Yes, after 30 days of radiotherapy, it isn't supposed to grow. I don't understand". "You didn't think she looked tired?" "I thought it was the radiotherapy that made her tired". He was by now completely deflated. It was as if he finally 'got it', did the picture make the disease more 'real'?

Sorting Things Out: Histopathology

The work of the histopathologists is perhaps one of the more central in the diagnosis of brain cancer, as it is the most accurate source of defining both the grade and the cellular basis of a tumour. Thus, one of the first steps taken after the initial diagnosis is to have a portion (or, in some cases, the entirety) of the mass removed and sent to the laboratory expert. Within days, the laboratory will produce a report on the assessment of two main parameters: the tumour's grade (I-IV) and the tumour's cellular basis (the type of cells involved). This assessment is extremely complex, especially in terms of correlating pathology with existing 111

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(and continuously growing) nosological schemes. To mention only a few criteria of histopathological categorisation: one form of gliomas, astrocytomas, may be either well-differentiated or anaplastic, either fibrillary, pilocytic, or gemistocytic, with low or high degrees of cellularity, low or high degrees of pleomorphism, etc. Patients, one must note, were seldom aware of such minute details regarding their tumours they would rather turn to plain binary terms: about the mass being either cancerous or not, or about their cancer being either malignant or benign. These sophisticated schemes of identification and classification are, however, central to the creation and preservation of the ontognostic medicoscientific ethos (Foucault, 1963; Cicourel, 1964; Reiser, 1991a; Keating and Cambrosio, 2003). Histopathologys ever-growing categories of mediated-objects, its high tech procedures, and its position at the cutting edge of research contribute to its prestige as providing an exclusive corpus of knowledge. Another characteristic appears to be involved in this assertion of authoritativeness. In sharp contrast to the 'hands-on' clinical evaluation, the removal of biological tissue and its analysis outside of its human context allows 'social distancing'. The living person becomes literally out-of-sight, out-of-site, and, in a way, out-of-time, isolated from subjective time and space (and thus from subjectivity itself) to create alternative sterile, motionless, and well-defined areas where scientific work can proceed. This, in turn, provides the laboratory a distinction drawn on a halo of pure science, clear of the 'fuzziness of reality' (Foucault, 1963; Bourdieu, 1977; Thompson, 1995; Rosenberg, 1999). Removing the personal particularities of the patient enables a more clear-cut alignment with existing nosological categories, both within the

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realm of histopathology and within the broader neuro-oncological compiling diagnosis.

Figuring it out: Neuropsychology

Unlike the psycho-oncologists, whose task was to provide patients emotional support, the neuropsychologist (Keren) was regarded as a diagnostic source. Keren was assigned patients that seemed to suffer from cognitive or emotional deficiencies related to the organic effects of the tumour, or to side-effects of the treatment provided for the tumour. She administered psychological tests and interpreted them; but also guided psychology students who are obligated to practice giving these tests to patients. Yet, Keren's job was no less practical than diagnostical: She suggested technics by which the patient might find a way around his/her neurological deficits and still maintain some quality of life. Her contacts with the staff were very limited, and her reports were usually filed, never to be read by the NROs. She was consulted in rare cases to consider a patient's capacity to give proper consent to medical interventions or his/her need of being referred to psychiatric or psychological care. That being said, neuropsychology played little or no part in the actual medical decision process. Arguably with the aim of establishing medicoscientific status, neuropsychological evaluations tended to be presented as highlydetailed statistical reports. Still, such knowledge however justified and materialised in the form of standardised and empirically confirmed scales and numbers - remained illustrative rather than demonstrative. If the neuropsychologist was so seldom consulted, it was probably based on the low authoritativeness and epistemological profile of psychological methods (and 'psy113

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knowledges') in the medicoscientific complex (Rose, 1985; Reiser, 1991b; Hacking, 1992; Porter, 1995). Relying greatly on statistics, numbers and standardisation allowed a rising of psy-knowledges towards the level of authoritativeness assigned to more conventional biomedical sources. This allowed it to be distinct from other forms of knowledge that would have been brought forward but which may not have had the same communicative value. It would perhaps not have been regarded as worth mentioning just like a patient's astrological map or his reading of his hands would not. The knowledge was allowed in, as advertently or not, it was presented through a filter of 'epistemotechnics' that would 'truthicise'9 it in the context of scientific medicine Indeed, if psychology wants to take full part in a purely medical practice (here: neuro-oncology), it must relates to 'epistemotechnical' aspects of its work that put it in the same (or close) epistemological level as medical science. Keren was open about that: she insisted on sitting in team conferences because she wanted her work to be treated as a meaningful and "serious" contribution to the more medical clinical 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, comprises a direct, usually non-instrumented, assessment of a number of parametres. According to textbook directions, although rarely meticulously followed in practice, these include the tone of each muscle group, muscle power, and reflexes. Changes in sensation will be identified by means of a probing of different parts of the body, and coordination by observing body movements. Also central to the examination is the
9

'make true'

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evaluation of gait, during which the patient will be asked to walk back and forth. The clinician is expected to provide expert deduction and gather relevant information from the patient, while drawing on haptic skills and limited technological aids (Foucault, 1963; Porter, 1993; Moreira, 2006). This 'low-tech' practice is believed to be highly susceptible to errors and inaccuracies: the patient's body viewed as disordered and 'messy' in conveying valuable data, and the method itself based on phenognosis and overall 'primitive' (Joyce, 2005). The second component of clinical practice, history-taking, demands a systematic gathering of information (e.g. headaches, seizures, visual disturbances, motor or sensory dysfunctions, pain, nausea) which must be characterised by time of onset, duration, location, frequency, severity, progression or remission, precipitating circumstances, and associated complaints. A history of administered treatments must also be sought, as well as should a more general background of co-morbidities, past medical interventions, and cases of severe illness in the family. The lack of neutrality, objectivity, and preciseness attributed to this practice is critical in the evaluation of the validity and thus authoritativeness of knowledge portrayed in such reports. Arguably, patients have a 'privileged access' to their own inner world of experience, and are able to reach a phenognostic 'truth' that is beyond scientific exploration (Heil, 1988; Gertler, 2001). This impinges upon the ethos associated with ontognostic thought, whereby the physician would necessarily have epistemological supremacy as holding total and absolute knowledge of the phenomenon of disease. In order to retain ontognostic authoritativeness, the expert must bind his/her perspective to observable and accessible aspects of the 'reality' he/she faces, rather than to the patient's life-world: his/her belief system, 115

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background, personality, particularities, emotional issues, etc (Cicourel, 1983; Mishler, 1984; Anspach, 1988; Gunderman, 2005). The patients themselves cannot be assigned 'expertise', a clear form of power, even in the context of reporting their own subjective experience: doing so would challenge the hierarchical physician/patient relations in the sacred biomedical space of the clinic and would allow in a non grata phenognostic knowledge. While the patients may influence the actual process of diagnosis (e.g., overemphasise some minor symptoms in order to assure full attention and treatment), they are denied any status of expertise: the expert is the 'reader' of the body, the deciphering agent of the narrative, both of which are more or less-- reliable givens At the clinic, written reports showed patients' accounts preceded by a sort of 'disclaimer', noting their relative unreliability. Typically, the reports included clauses such as: according to the patient... or, quoting from one clinical report: "[The patient] describes events of

abnormal smells, tastes, and panic feeling up to 10 times a day" or, "He complains of some difficulty getting his words out in conversations". A similar trend was found in oral exchanges: the 'had' as in "the patient had headaches"- was presented during meetings as if of higher authoritative status than the 'described', and to a lesser degree-- than the 'complained of'. The first was assigned some legitimacy as the reporting physician ipso facto provided a seal of approval to the actuality of the symptom. The second portrayed

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the patient as able to observe, reflect on, and effectively communicate the nature of the symptom by offering a description, rather than speak of a vague, emotionally-laden complaint. These, however subtle, variations provided clues not only as to the authoritativeness assigned to clinical knowledge, but also to the conceived credibility of different forms of clinical information: from the more phenognostic sources to the more ontognostic.

The Patient
A clinical evaluation, as defined above, does not solely rest on the examination of the patient's body, but also on the accounts he\she critical. Observations of the field suggest that a classification of patients into reliable ('good patients') and unreliable ('bad patients') is most sensible. This classification has its basis on a range of characteristics. In general terms, the ideal patient is cooperative and compliant. Yet compliance does not merely involve following 'doctor's orders'. The term, I shall argue, also applies to the patient's ability or willingness to internalise the biomedical gaze and its ontognostic claims for epistemological authoritativeness (Gross, 2009a). He does not have to be knowledgeable on the subject of his illness, and in fact, being too knowledgeable may be seen as an annoyance. He still needs to be able to ask intelligent questions, or to refrain from asking questions at all, thereby re-affirming the physician's skills in providing all relevant information. In general, the patient is expected to be straight and to-the-point in reporting his complaints, asking the right questions and responding in an appropriate way to the the physician's inquiries. 117 may provide. This makes the definition of the authoritativeness of phenognostic, first-person information highly

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For instance, Adi turned from 'a bad patient' to a 'good patient' when her reports, at first not taken seriously by the oncologist, were truthicised with ontognostic measures. Shortly after the oncologist declared her "better": "There was one weekend Thursday, Friday, and Saturday, when I had insane headaches. I've been living for thirty years, I never had such headaches you know, you bow your head to brush your teeth or something I felt my head will explode and drop to the floor". The oncologist told her she was overmaking it, yet: "After [I applied] very intense pressure, he sent me to do a head CT. I had several brain tumours. They sent me for radiation right away and gave me steroids [] I felt like telling them: 'You see, I'm not faking it!!!' " The 'good patient' reports symptoms that are compatible with the physical profile of the assigned pathology. The reported symptoms' alignment with the determined diagnosis is a clear sign of the internalisation of the 'medical truth'. Was a patient to report on symptoms that were not compatible with the diagnosis, he would be expected to accept the superior epistemological status of the physical sources, i.e. the authoritativeness of the 'observed' (ontognosis) over the 'felt' (phenognosis). Such a patient will tend to think some symptoms more relevant than others or some symptoms being simply 'psychosomatic'- if they would not fit into the scheme proposed by the physician. He\she would then quickly adjust his\her account accordingly. 118

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The 'good patient' must also report symptoms that 'make sense': problematic accounts may include "feeling as if crossedeyes, but in the ears". The good patient also never argues with neither the diagnosis nor the advised course of treatment. Lise's account of an exchange she had with a patient: "His wife doesn't understand the drug thing. She argues with me and won't agree with me. She is retarded, I think". [In my view, the woman did not show any sign of mental retardation] Although some information may only be sough from the patient's account, such as feelings of numbness or pain, one may distrust these first-person mediated, phenognostic accounts. This has two major reasons: one, the person may simply be not truthful (lie), and second, the person may not be aware of his own condition. The field teaches us that the patient must provide specific forms of accounts that eliminate, or diminish these two considerations: he must speak of symptoms in a credible way talking about witnesses, referring to the 'right' symptoms according to the 'book': this may include a "my head is on fire" as an unsophisticated but accurate account of what a patient may feel like after radiotherapy. In fact, it is considered most credible when the patient seems to 'incidentally' report symptoms that, without him holding true knowledge of it, would be compatible with the textbook account of the disease. A good patient will provide just the right amount of reporting, being succint but informative. He must also not be "overly anxious" (this being a typical term used), although, where brain cancer is involved, one may wonder whether there is such a thing as being 'overly' anxious. There is also a right timing when the 119

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symptoms must be mentioned: an eagerness to report symptoms may have one lose credibility, he may seem 'hypochondriac' or as more often used 'suffering from anxiety'. The staff members are well aware of the suggestibility of patients, and will at time refer to it with some sense of humor. Riba, the headnurse, told the team a story about one of the female (deemed 'hysterical') patients: "She won't admit it but she's getting better, so I told her, if you don't feel well [as if trying to catch her bluff]: go to radiotherapy." She refused. Riba has the morale of the story: "A month later she said she felt much better and stopped telling these overly dramatic stories. When we looked at the MRI, there was no real improvement". The team was amused, again reifying the epistemological inferiority of patients' accounts over MRI results. 'Bad patients' will get raised eyebrows in exasperation when leaving the room, some NROs going as far as sharing of the experience with the team: "this patient is psycho" or "I hate these wives that are sticky and pushy". 'Bad patients' tend to come from less educated backgrounds, and often from lower socio-economic status. They may arrive to consultations with too many family members ("they must think it's a party!" said the headnurse about one such family). Ultra-orthodox are quickly assigned to this group, also because they are seen as making choices that give rise to clear indignation: having too many children, too early, marrying the wrong partners, turning to a Rabbi for advices and so on (Gross and Shuval, 2008). 120

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One memorable case of such 'bad patienthood' is Benjamin Abitbul's. Benjamin was recently diagnosed with a brain tumour, and sent to more elaborate testing. Invited to receive the results of his biopsy (and the qualification of the tumour's grade), he arrived (from the provincial area of Tiberiade, more than 100 miles away from Jerusalem) accompanied with no less than five family members, including his wife, two sisters, a brother, and a sister-inlaw. He himself seemed embarrased to be followed by what the staff will disdainfully refer to his 'Tiberiade' family. The group was quite assertive with their presence, speaking outloud, passing snacks and water from one to another. Lise, in charge of breaking the news of Benjamin's impending death, applied her authority by asking the crowd to keep away from the area of her office and by refusing to accept more than one family member in the room, this, although she would often have consultations with three or more persons present. What made her furious was Benjamin's sister turning to her in the corridor asking whether she could "on the way" give her "just one calming pill, just so to make him [Benjamin] less upset". Lise responded with a dry "no" and went on ("Does she think it's like giving out candies?" she would later say). She would later scornfully describe the incident to her colleagues: "These people" were "impossible to work with" and "didn't know how to behave". Little did she know the sister soon approached me with the exact same request.

General Oncologists: Peripheral Experts

The oncologist that worked most closely with the NROs is Doctor Sari, a middle aged woman. She is relatively assertive and confident (although always cordial and gentle) with her patients as well as with the clinic's clerical staff. In her exchanges with the NROS, however, and not unlike other specialists, she tends to take on a subordinate, passive, position. 121

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The physical basis of the clinic is in a general oncology clinic, which facilities the NROs use three days a week. The rooms do not hold any specific characteristics that would point to any particular specialty (such as drug posters, anatomical illustrations and so on), thus a simple change of the name tags on the doors is sufficient to have the room become a neuro-oncologist's rather than an oncologist's office. This is particularly interesting, since neuro-oncologists are not trained as oncology specialists. Rather, they are general neurologists (who, besides the head of the clinic, Lise, all work as neurologists either in the hospital or in the community), with some on-the-job experience in neuro-oncology. Knowledge in general oncology is rarely required where brain cancer is concerned. The brain responds to only a few chemotherapeutic interventions, the diagnostic tools are well defined, and seldom does the tumour spread to other organs. The structure of the specialisation may also point to the complexity and level of specificity assigned to knowledge of the nervous system against knowledge relating to general understanding of cancer pathology and treatment. This is in line with the general trend of regarding brain-related disciplines as most distinguished. Indeed, Levitz, on why he chose neurology as a field of expertise succintly put it: "It's a field that is most challenging in terms of having to think. It's an intelligent field". Thus, in many ways, the neuro-oncological clinic and its related interdisciplinary web is organised along a nosological concept, which also points top the importance of the nosological difference between brain cancer and body-cancer. The clinic is an environment which accepts specific nosological categories but also

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finds the chosen cases most instructive, perhaps as a by-product of the nosologically-based criteria of inclusion: "By operating a process of selection, it alters in its very nature the way in which the disease 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. 123

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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'tre 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

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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.

Hierarchisation
Forms of knowledge, as well as the objects produced by this knowledge, are created and sustained by having its different forms become authoritative, and others subjugated, marginalised, or excluded from the sphere of legitimacy (Foucault, 1980; Latour and Woolgar, 1986; Latour, 1996). As shown throughout the text, the forms of expertise associated with neuro-oncologic diagnosis differed not only in terms of instruments and types of knowledge applied to the mediated-object, but also in terms of their perceived authoritativeness, and, consequently, hierarchical position. The NRO, confronted with the task of incorporating the disparate reports, could (and often did) choose to constrict the 125

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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, "Its 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 patients experience subordinate to the images on the monitor." Lise declared a worsening in Ilyas state: now judged ineffective, Tals chemotherapeutic treatment was discontinued.

Sequencing
Brain tumours are conceived as having a dynamic

constitution. First, it is granted that the tumour may progress from one grade to another, may respond to therapy --at times long after the treatment itself has been interrupted or concluded-- or may simply remain unchanged. Moreover, symptoms tend to accumulate and aggravate, and their response to medication may decrease over time. Sequencing uses this set of temporal factors to account for diagnostic changes without challenging the unity of 126

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'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, Karls wife called Franz to report that her husband had a new symptom: he felt 'tingling' in his left arm. She was surprised as the MRI, taken two weeks earlier, suggested a shrinking of the tumour. Considering the authoritativeness assigned to medical images, Franz did not readily discard the imaging report as unreliable. Rather, she answered that the disease had probably worsened since. As MRI images were never compared unless taken at least one to two months apart, this was an assertion that, while sensible, was impossible to be put to the test, and thus also impossible to challenge. Yet, as it allowed the initial diagnosis to remain valid, it was accepted, to the very least until other evidence came along (the next MRI suggested that the tumour was indeed growing). In general, in case presentations, the sequencing of the events is very much put at the centre, and the temporal dimension is central to the characterisation of the disease. Only with little exceptions does it not make complete narrative 'sense' as the development of one (or several concomitant) diseases.

Negotiation
It is during the weekly radiology meeting that 'negotiated processes' (Moreira, 2006) could be observed. There, the four NROs would sit behind a radiologist who gave 'live' interpretations of the images. Led by the NROs' instructions, he focused on particular sites, paid attention to specific patterns, all the while well aware of 'what it is we are looking for'. The clinical and the radiological were often again, never deliberately - adjusted 'on the spot', that is, well before the written report was issued. 127

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

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histopathologists interpretations. Finally, the importance of the histopathology report was often only tangential to decisions on treatment, and was conducted significantly less frequently than radiology tests. Negotiation was also present in clinical exchanges with the patients. For instance, when Misha came to hear about his latest MRI and discuss his condition, he was almost literally told what he 'should' be feeling, and conseqently abided to this normative statement. The MRI showed that the tumour had slightly grown over the last two months. Looking carefully at the MRI, Lise asserted: "I don't believe you should feel any change" Misha: "Well, I do have some headaches". Lise: "It's I don't think it's really

something". Misha, mumbling: "OKright..." The headaches, a symptom now completely discredited, were never brought up again.

Peripheralising
Sofya, a 52 year old woman with a highly malignant cancer, was told by Franz that "the latest MRI shows [she is] doing better". Now almost completely blind, holding her face in her two hands, she mumbled in response: "but my head aches so much that I cant even touch the tips of my hair without feeling like 129

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screaming!". Franz interrupted her short monologue: "That, I cant explain". As she attempted to persuade him that her pain was real, he referred her to a dermatologist: "it could be a different problem", he concluded. Here, as in other cases, the independent expert was sought once a diagnostic element could not be accounted for within the neuro-oncological sphere: the dermatologist could, however, explain away the 'hair ache' without openly dismissing the patients complaints on the one hand, or challenge the already well-established diagnosis on the other. This dermatology-mediated object could then be

incorporated into the view of the neuro-oncological disease, albeit in its periphery. Such objects could then serve either as contextualisations of the meta-diagnosis or as evidence of its accuracy. As these objects belonged to a sphere of expertise defined as 'independent'- i.e., extrinsic rather than intrinsic the NRO held considerable leisure in their re-interpretation or, alternatively, their thrusting aside. Overall, the place of independent-expert-mediated objects was to a large extent assigned by the compiling expert, providing the NROs a certain degree of slack in their meta-diagnostic work.

Pragmatism
In neuro-oncology, treatment options are comparatively scarce. They include a few forms of chemotherapy, a limited array of surgical interventions, and relatively little room for intense radiotherapy. The primary brain tumour will almost invariably be fatal to the patient: more than half will succumb to the disease within the twelve months following diagnosis. Only one fifth will be expected to survive for more than five years (Coldman, Phillips and Reid, 2004). In practice, once treatment options run out, the

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NRO usually ceases to be involved. The patient will then be offered supportive and palliative care, typically in a hospice or among his/her relatives. This being the case, elaborate and minute diagnosis may, in some cases, seem somewhat less crucial. This was the case with Grushka, a 84 year old woman, whose precise type and grade of tumour were unknown. The group was unanymous: she will not have her tumour biopsied, rather, she will be given something for her symptoms, i.e. a large dose of the most common steroid used in brain cancer: dexamethazole. In effect, patients themselves were little interested in precise diagnosis. Treatment prospects seemed more salient: "Will I have to go through chemo?" "Will I lose my hair?". Simon, for example, spent months visiting the clinic without showing any interest as to whether his tumour was graded III or IV. Although undoubtedly aware of the grading system, he "never thought of asking". Indeed, for many patients, beyond general notions of improvement or degradation ("Has it grown?", "Am I doing better?"), formal diagnosis remained futile. As a rule, the neuro-oncology clinic saw patients only once a brain-tumour diagnosis was reasonably established. At this point, however, the diagnosis remained vague: "There is a finding in your brain, we are still unsure of its exact nature" was a classical opening. Patients rarely demanded much more details, and, more often than not, avoided using the term 'cancer', to rather refer to hazy notions such as 'my condition', or 'the lump'. Oren, for example, was surprised to hear me refer to the 'oncology clinic' when we set a location for an interview. He said he never noticed it was a clinic that "also deals with cancer"- this after five years of follow-up.

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Recently diagnosed patients tended to use the more hesitant "I was diagnosed with" than the definite "I have". Both patients and physicians entered a sort of unspoken pact, where the precise diagnosis was regarded by both as merely tentative. In line with the "pact", the physician would respond with such uninformative remarks as: "Lets not jump our horses" "Lets talk after we have some further tests done" or, "Were never sure of anything, but we have to do what needs to be done". In the course of more than one hundred such consultations observed, only a few patients inquired into expected consequences of their diagnoses: the "how long do I have, doc?" question was never raised, under any variation. When at all, prognostic information was only vaguely sought, with a "can this be treated?", rather than "will I live?". Physicians themselves never went beyond a general: "its all just statistics", or "each case its own". While family members did occasionally sought online information on the expected lifespan of their loved-ones ("for practical reasons", they would typically claim), as far as patient-physician interaction was concerned, precise diagnosis did not serve any prognostic aim. In fact, one of the younger patients, a computer programmer well acquainted with the web, told me he read "a lot" about his condition. As to his life expectancy: "Really?! Do they [the websites] say

anything about that?! It must be in small

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letters, or I must have missed this line [where life expectancy was mentioned]". In the case of Alexey, an 18 year old boy, he would go on and on about becoming a physician. Although aware of many aspects of his condition, he seemed completely oblivious to the fact that his life expectancy was of a year or so, during which he will probably be increasingly handicapped. The prospect of medical school was poor, as was his life prospects in general. However, like many other patients, he would simply deny this reality. This trend was also evident among another significant group of patients. These were referred to the clinic after the treating oncologist (being, here, the compiling expert) suspected the presence of cerebral metastases. At this point, the neurooncologist (here, serving as an independent expert) tended to provide an assessment that was more quantitative than qualitative: the tumours were either present or absent, single or multiple, active or stable. Patients were then less concerned about the precise nature of the neuro-oncological aspect of their disease. Gabriel, a 66 year old man, just heard about his melanoma (skin cancer) having metastasised to his lungs and brain. He "doesn't want to know too much": "The only information I have is what my sons tell me. As far as I'm concerned, I don't need to know anything beyond the tip of my nose [places his finger on his nose]". Also, as the presence of metastases remained an almost definite death sentence, as far as the NRO was concerned, a more pragmatic approach was be adopted, focusing on treatment options and palliative care rather than on elaborate diagnostic

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undertakings. The disease may itself be loosely defined as belonging to a more general diagnostical category. In these cases, NROs often favoured the use of as little information as needed for the determination of the most advantageous course of therapy. In practice, this stance of pragmatism typically involved tacit avoidance of definite and elaborate diagnosis. Still, while unspoken, an official diagnosis invariably appeared on the reports, stating, for example, whether the tumour was defined as a grade-IV or III, whether a glioblastoma multiforme or an anaplastic astrocytoma. This was in many cases, however, little more than a bureaucratic formality, which the NROs regarded as of weak empirical validity. In these cases, the NROs accepted the fluidity of this definition and proceeded to consider treatment options. Perhaps most interestingly, pragmatic considerations could eventually have some bearing on the overall diagnostic process: once a tentative object of disease was defined, other forms of diagnosis could align. This process of alignment little usually of involved the reporting of and its independent experts: these would typically treat this diagnosis as ascertained, being aware looseness epistemological grounds.

Concluding Words
As part of a larger attempt to consider issues of dynamics of knowledge and their relation to social phenomena, this study demonstrated the significance of the web of expertise in the production of diagnosis, most particularly where the latter tends to be ubiquitous, and involve highly heterogeneous epistemological forms.

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While widely acknowledged in past literature, little research was based on thick descriptions of expert exchanges in the backstages of a hospital setting. The ability to witness the processes of diagnosis from various angles, including different actors and different settings, allowed for a thorough and detailed presentation and schematisation of the microdynamics of a central aspect of medical work, i.e. the undertaking of diagnosis. As and defined a above, expert gaze incorporates into one sets of

epistemologies and technologies, both of which mediate diagnosis reduce multileveled phenomenon single manageable object. The replicated flows of artefacts, concepts, and interpretations among experts were shown to have an important role in asserting both reporting and independent expert authoritativeness, but also in reifying the legitimacy of neurooncology as a compiling expertise. Participant observation of the in-situ workings of the clinic suggested that this reification involved, on the part of the compiling experts, the use of five mechanisms of consolidation: hierarchisation, sequencing, negotiation, peripheralising, and pragmatism. These mechanisms were shown to involve different cases at different conjunctures, and with different sets of expert relations, emphasising the complexity of diagnostic work. Many of the patients discussed here died before this manuscript was finalised. Others will soon die, some more in comfort than others. All being said about the ontognostic 'reality' of these 'objects of disease', it eventually comes down to the effort to save patients lives, to give them more time with their family and loved ones, to make their last moments more bearable. I propose concluding with an afterthought. The analysis presented here may seem abstract. In an ironic, yet mesmerising 135

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way, by reflecting biomedicines utopian vision of diagnosis as sterile from non-scientific spheres (e.g. phenognostic forms of knowledge), this work was narrated in a way that suggests the presence of a similar bias. Yet, it is through exchanges between experts, through mechanisms of diagnosis and decision-making, that actual, experienced lives are altered, prolonged, or less painfully ended. It is through dynamics of knowledge exchange, of human exchange that the enterprise sustains itself. One cannot, and indeed should not, lose sight of the fact that ethos, symbols, technology, epistemology, and eventually the experts themselves, do not live in an abstract world of theory, or objective insularity. They are encroached in the flesh, in the suffering, in the existence of actual men and women. A discussion of these very issues will stand at the centre of a latter section of this work, when the individuality and subjective depth of one particular patient will be brought to the fore. This section will be based on a notion of the brain as an intermediary between matter and consciousness; brain is both the assigned locus of phenognostic knowledge, and an ontognostically observable 'thing'; it thus only makes sense to place the brain at a most significant juncture of this work.

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Part V: The Brain Exposed On Neurosurgery and the Nature of Objectification

Introduction
"The presence of disease in the body, with its tensions and its burnings, the silent world of the entrails, the whole dark underside of the body lined with endless unseeing dreams, are challenged as to their objectivity by the reductive discourse of the doctor, as well as established as multiple objects meeting his positive gaze.thus the articulation of medical language and its object will appear as a single figure". (Foucault, 1975: XI) As described earlier in this work, modern Western culture has always held an intricate view of the body: while still being considered as an object among others, the body will keep its singular phenognostic status as the locus of a subjective consciousness (Sartre, 1956; Merleau-Ponty, 1962; Lanigan, 1995a, 1995b). Focusing upon this dualist epistemology, social studies have repeatedly shown how biomedicine, as a dominant discourse of modernity, tends to refer to the body in terms of the 137

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former, discarding the latter (e.g. Martin, 1994; Cartwright, 1995; Lock, 1997). Indeed, over the last decades, a significant range of research has accumulated, associating biomedicines practices and epistemological bases with stances of depersonalisation and objectification of the patient (e.g. Scheper-Hughes and Lock, 1987; Thornquist, 1997; Scambler and Higgs, 1998). Arguably, this tendency toward objectification will have biomedicine centre its attention upon the body as a material, ontognostic entity (e.g. Eisenberg 1977; Mishler et al. 1981; Dew 2001), where it would be treated as a machine, observable through expanding scientific technologies and knowledge (e.g. Arney and Bergen 1984; Synott, 1992; Walters, 2004). According to this claim, the observable and ontognostically-graspable body will take precedence over which remains beyond biomedical epistemological reach, i.e. subjective experience (Babbie 1970; Armstrong, 1983, 1984; Csordas, 1994; Good, 1994), and thus favouring the ontognostic over the phenognostic. These lines of argument have become the dominant voice in broad areas of social study of biomedicine, and the portrayal of biomedical epistemology as reductionist and materialistic is by now little questioned. The split between experience and the body is perhaps most salient in studies of patient-physician interactions (Murphy, 1990; Toombs, 1990; Wiltshire, 1999), where these interactions are typically portrayed as consisting of a dialectical exchange between two voices: the voice of medicine and the voice of the life-world. As the former will relate to the body in abstract decontextualising terms, the latter will see to the patients experiences as grounded on his/her social and personal life as it is narrated from a subjective position, and based on phenognosis as a source of knowledge (Mishler, 1984; Young, 1997; Barry et al., 2001). An overbearing claim albeit often implicit in these texts is that since medicine seems to disregard

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this life-world, it remains to the researcher to be attentive to it and to relate to it in a more empathetic manner: either by pointing to what he/she considers as an excessive attention to its supposedly symmetrical opposite (the body), or by applying more sensitivity toward the complex, subjective, personal aspects of human existence. Indeed, in important works studying the body as a site of conjunction between the two spheres (e.g. Turner, 1992; Csordas, 1990, 1993, 1994), the researcher is typically portrayed as more aware to the phenognostic, lived aspect of the body, as if a necessary consequence of his/her position (e.g. Featherstone et al., 1991; Haraway, 1991; Berg and Akrich, 2004). Phenognosis, however is not a mere pre-discusive form, necessarily applied unless 'disciplined' by ontognosis. It is, as I have argued before, a consequential discursive force, which requires fit contexts upon which to attach itself in order to gather and retain- power. This means that a phenognostic-based attitude toward the 'other' is not a mere default position, held in nonmedicalised settings by not medically-socialised individuals. It is a discursive power in and on itself. Although biomedicine might indeed use a dualist, or materialistic view of the person, it is neither a constant position, nor is it a necessary by-product of epistemological, historical, technological, or even political characteristics of the profession. Rather, the patient is defined and redefined in interactions, alternating subject and object positions, passive and active stances, and definitions as either patient or person (Berg and Akrich, 2004). Taking this a step forward, I will argue that one cannot, and must not, exclude the researcher from these microdynamics. The researcher, however reflexive and empathetic, is hardly immune to objectification tendencies. If the body is imbedded in contexts within which it appears, and if 139

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dependent on its characteristics and positions, both ethnographer and biomedical practitioner will find themselves in transition between stances of objectification and empathy. Any participant observation in the social studies of medicine will have to address this issue prior to the actual insertion into the field.

Methodological Notes
I will present this movement using a first-person narrative of my own relationship with Ivan10, an informant encountered in the course of my fieldwork at the neuro-oncology clinic. Six months of intensive participant observation pursued by a year-long follow-up allowed a close rapport to develop. As I accompanied this 32 year old man throughout his battle with brain cancer, I attended the many clinical exchanges he had along the way, and eventually accompanied him into the surgery room where I would witness his brain exposed. There, where a last attempt to prolong his life was undertaken, it seems the complexities of our relationship would be taken to their extreme. An interesting feature of this case is that, while becoming increasingly intimate with both him and his close ones, I also had continual access to the purely biomedical aspects of his condition this by attending staff meetings where his case, among others, was discussed. Along parallel, yet at times intersecting lines, I followed his disease as an ontologically-asserted physical entity but also as it was experienced by a person with full subjectivity, as an illness (Kleinman, 1988). Tied with the development of his
10

As with all names mentioned throughout this work, this is a pseudonym

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illness trajectory, I gradually took on the role of a confident and provided some of the mental and emotional support he desperately sought. Ivan became a principal research subject and, to some extent, a friend. In an attempt to understand this fluctuation in my stance toward him, I use this essay to reveal my internalisation of different roles, at times as part of the clinical team, at others, as a lay (i.e. non-medical) researcher with strong personal relationships with the subject. I depict the ways in which my own experience was altered by replicated11 ritualistic and symbolic elements, often said to serve as facilitating medical objectification. These elements may be discerned in many arenas where the body prevails. However, and as made ever more evident in this work, I shall claim that one organ holds particular features, features which make the analysis around it more complex, but also more promising: The Brain.

The Sacred Brain: The Matter of the Gnostic Split

The brain is not just another body part. It is the site in which all bodily activities, sensual perceptions, cognitive and emotional processing take place. If, according to some theories, the social is imbedded in the body (e.g. Frank, 1990; Turner, 1992) and the body is what is situated in the world (Merleau-Ponty, 1962) the brain is where 'the world', 'the other', 'the self' all meet. It is where subjectivity and objectivity ultimately link: a conceptual pineal gland. Western medical thought is largely based on an organoriented view. 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.

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linked together as sequences of cause and effect. The brain plays a central part in this anatomical-causal complex, in being both the causal source of every bodily process (from blood circulation to muscle coordination), and the point which every bodily process eventually affects. It is the source of action and the endpoint of both internal and external sensory input. Social science literature has brought us several illustrations for the centrality of the brain in biomedicine. First may be the conviction that, although biologically viable, brain-dead individuals have lost their personhood or humanhood, and can be referred to as beating heart cadavers or neomorts (Youngner, 1989; OkhuniTierny et al., 1994; Kaufman, 2000; Lock, 2002). The central position of the brain in Western society can also be seen in its cultural emphasis on reflexivity, and "the paramount cultural and material importance of the mind" (Webb, 1998:1). Webb, for instance, analyses cases of brain injured individual and explains their expulsion from modern society by referring to the particular features of the brain as an organ rich in meanings that are central to Western society (Webb, 1998). Another example can be found in Popper and Eccles' work (1977:177), according to which it would be clear that a transplantation of a brain onto another's body would amount to the complete "transference of the mind, of the self" into the latter. Then, the brain, rather than the body as a whole, holds paramount significance in the definition of selfhood and subjectivity. At a different level, the brain can have primacy over the body, such as in cases of phantom limb syndrome, when the brain creates a seeming perception of one's body. This leads amputees to experience sensations (e.g. pain, tingling) as having their source in the limb removed. This phenomenon may be explained by the presence of neuronal representation of the arm or leg at

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the level of the brain, which, when cerebrally activated, can 'feel' as the 'real thing', external to the brain. A related (and, in a way, reverse) condition is of 'asomatognosia'. This takes place when a person's limb 'feels' like an external object 'glued' onto one's body, having nothing to do with his/her perceived 'self' (i.e. Tsementzis, 2000; Greenberg et al., 2002). In these cases, patients may go as far as calling this limb by a name, such as 'Joe' or 'Mary' (Sacks, 1985; Feinberg, 2006). This phenomenon has its source on disorders of brain activity, again providing a vivid instance of brain's domination over the body. This idea of the brain as the apex of subjective/objective liminality, will have clear ritualistic expressions in the surgery room. It will create multiple dimensions within which the subjective will be dealt with, replicating the liminality and the boundaries created as a result of this liminality. Based on the following ethnographic description, I shall turn to the analysis of these dimensions.

The Story
'Prelude'
I had barely begun my fieldwork when I met Ivan. The last patient had left Lises office and Ivan's dossier laid on the top of the pile. I looked at his name and remembered his case, which was just brought up during the last staff meeting: my field notes read "Ivan Katz is a 31 year old patient with a grade II oligodendroglioma", a type of brain cancer with a life expectancy of seven to ten years. He was diagnosed in 1999. We were now at the end of 2006. The day of our first interview, set at a coffee house near the hospital, was incidentally the day when Ivan experienced the first 143

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epileptic seizure he had in the last two years. As far as I could gather from the situation, he was probably emotionally drained from having to recall his seven years experience with brain cancer and, ten minutes into the interview he left the table to freshen up in the bathroom. On his way back, however, he collapsed. Lying on the floor of the staircases, he regained consciousness surrounded by strangers, mostly nurses and other hospital employees. As I was later told, he immediately asked for me, calling out my name and describing me to the security man. The latter reached the coffee house and almost out of breath, asked me whether I knew a 'Ivan Katz'. "He doesn't feel well" was all he said as he was leading me to the staircases. I naturally found myself helping him to the Emergency Room (ER) the access to which was much facilitated by the fact that I was wearing my white gown. We were able to use unquestioned the back entrance, usually reserved for staff members. There, we were to spend the next seven hours together. I knew that the seizure was a clear sign of relapse. I was told a few days later that the chemotherapy ceased to be efficient and that his tumour was growing. The following year would be his last. On the day of this dramatic interview, Ivan had an MRI taken. Later this week, I would be the first to see the image, as I regularly participated in staff meetings. There was little need for professional deciphering: the tumour grew considerably, a fact which explained the seizure. As to my question on the specific episode and its timing, the physicians all categorically ruled out any causal relation between the seizure and Ivan's emotional tension at the time the subjective was not allowed into the loop of causation. It was the tumour "having its will when it had its will". Ivan would continue to see this as a direct reaction to his emotional experience, while I remained indecisive, although

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continuously troubled by the question: was this a purely bodily phenomenon with its own causes and effects - or was I to take Ivan's account as a fact, as The Truth? In medical terms, however, there was little doubt that Ivan's condition was deteriorating. As a behind-the-scene, backstage observer, I was well aware of that. However, as my research placed Ivan rather than the medical team- at the centre, I had to wait for him to reveal this unfortunate development: for me to convey the results to him directly would not only be a breach of ethics. It would have merged which has become the two spheres within which I operated: the professional, biomedical (and thus ontognosis-oriented), and the personal, experience-focused (thus perhaps more phenognosis-inclined). At another level, it was the clinical (his seizure) and pathological (the MRI), which spoke of the disease, even while Ivan still did not (as he was not, at least consciously, aware of his condition). The disjunction became ever clearer: Ivan was both a talking corpse, sending cues in the forms of signs and symptoms, and an embodied subject, eventually mediating the knowledge of his disease via his conscious self. This double, and very much dualistic, perspective became omnipresent in all exchanges related to him: Ivan was both person and patient, subject and body. As the months went by, more aggressive treatment became inescapable: Ivan went through radiotherapy; his hair fell out; he gradually lost his ability to communicate properly, to focus his sight, to remember phone numbers. His seizures grew both in intensity and frequency, now up to a five times a day. Toward the end of the year, he became hemiparetic12 and suffered an almost complete loss of sensory and motor capacities on the right side of his body. After the last chemotherapy round turned out to be
12

A neural weakness on one side of the body, typically leaving the other completely functioning

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almost lethal, the Jerusalem team gave up on treatment. They had nothing else to offer. Palliative care was all that remained. Ivan, however, refused to give up without what he considered as a fair fight. He and his family turned to another hospital, now in Tel Aviv, seeking advice. There, the team offered one additional surgical intervention in order to remove a part of the tumour. That, they thought, might possibly allow for the chemotherapy to be more effective. The surgery was to take place a month later. Ivan was amused when I first asked him whether I could join in on the operation. He dared me to go through this, and swore me to talk to him afterwards about "what [he] looks like inside". I wondered whether knowing what his brain looked like would add anything to his understanding of himself, or to my understanding of him, and as to whether he would have had the same request was another organ the target of surgery. When I inquired about it, he responded that "it wouldn't have been that cool". As far as I was concerned, the baring of the 'organ of the self' bared nothing of his 'self'. I could only speak figuratively, and tong in cheek, on how large his brain was, as if it reflected his intelligence. Sadly, the size of his brain had more to do with the space-occupying presence of the tumour. His brain said nothing. The story of our relationship and the difficulties I had in positioning myself in relation to Ivan found their epitome during the day of the operation: all seemed to be encapsulated in those hours before, during, and right after Ivans brain surgery.

The S-day
The morning of the surgery, the pressure Ivans swollen brain applied on the inner walls of his skull was so severe that he had to keep his eyes shut in agony. The increasing doses of steroids had 146

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his face so puffed-up that he looked like a giant squirrel. I looked curiously, a bit detached, at this grotesque figure being wheeled to the OR, his hands nervously petting his skull. On the top of his head were scattered a few chick hairs, huge bold blemishes, and a long purplish scar at the centre of which stood a bulging bump of fatty tissue both remainders of his first surgery, eight years ago. I myself could now hardly recall the way he looked 'before', when his body did not declare that it was a cancer patient's. In fact, as Ivan bought his first hat, after having lost most of his hair, he proudly told me how he "gave the man [the salesperson] a heart attack" when telling him he was buying it "for the radiations". He now did not only feel like a cancer patient, he looked like a cancer patient. Throughout, I had to remember to hold Ivan's left hand rather than his right, where he was completely insensitive to touch, but somehow, in these moments, all clinical details of his case seemed to evade my mind I was with him, at times detached, at others immersed in his experience. He looked at me and made a slight attempt to smile from time to time, but raising his heavy eyelids seemed extremely painful. Not able to make genuine eye contact with him, I kept asking myself who this body was, and whether it was at all somebody's. I followed the wheeled bed down the elevator along with his parents and sister. We reminded ourselves of the evening Ivan, his mother, and I spent at the hospital inn (where he was staying for the course of his radiotherapy). There, as we were chatting about this and that, Ivan ran to the window: Jerusalem was covered with a white blanket of snow. So little snow ever falls in Israel, that we were all three captivated by the scene. Reaching the door to the surgical area symbolised the breaking of our serene silence and 147

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sense of 'normality'. As if suddenly awakening us all, the nurse abruptly halted, firmly instructing us to be careful not to cross this boundary and to say our goodbyes now, here. The family kissed Ivan, and asked me, in tears, to take care of him, as if reminding me to treat him as a friend, rather than as a patient, even now, as I was about to cross into the biomedical realm. I followed the nurse to the Intensive Care Unit (ICU), where patients were kept and monitored right before and after surgery. After a short inquiry as to my relation with Ivan ("who are you to him?" was the typical phrasing to which I responded by presenting myself as a researcher from the Jerusalem clinic), I was requested to wear disposable shoe covers and a non-formal yellow coat loosely tied on the back an attire available to all family members and close ones who happened to be allowed into the ICU. Ivans bed was positioned between two other patients. His eyes still painfully shut, I quietly arranged his pillow this familiar (albeit futile), gesture of concern. As I rubbed his good arm, the anaesthesiologist approached his bed and began asking questions. Since Ivan found it difficult to answer -his speech being highly hindered at this point I intervened and answered myself. I used the medical jargon I knew so well by now, and provided clear, short, efficiently phrased information. My answers surprised the anaesthesiologist who, only at this point, asked me who I was. I explained my position as an anthropologist, and my affiliation to the Jerusalem neuro-oncology team. The scarce attention he gave to my response seemed to reflect his lack of interest in 'gatekeeping', a fact compatible with the analysis of his position in relation to the the replicated boundaries as provided later in this text.

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Shortly after Ivan had signed the consent forms (which he could obviously not see at all), the surgeon then arrived, a young, impressive man wearing his 'scrubs'. As he approached the bed, he announced Ivan that he will shortly be brought to surgery. Much more careful as a gatekeeper, his gaze pierced my eyes: "and who are you?", I answered that I was a doctoral student conducting anthropological research at the neuro-oncology clinic in Jerusalem. I immediately stressed that I was given permission by Professor Zosima (the head surgeon) to attend to surgery. He smiled and replied "of course, no problem at all". Treating me as courteously as one would a guest in his own home; he called on who turned out to be the OR head nurse: "This is what is your name again?...". Once I have reminded him of my name, he turned to the nurse again: "... [This is] Sky Gross, she is from neurooncology in [the name of the clinic in Jerusalem], she will be joining us. Can you show her where she can get ready?" The nurse reluctantly showed me to the changing area. She searched for her employee card (only a few of the personal were allowed access to this high-status outfit) and used it on an automatic machine from which sterile uniforms, carefully bagged in plastic, were dispensed. The nurse handing me the blue nylon pants and shirt found me a bit embarrassed: was I to wear the uniform on top of my current clothes? No. I must take off my casual clothing and wear it directly on my bare skin. Entering the changing room dressed as a lay person, I remained there virtually naked for a few moments, my identity in Dantean limbo until I wore the uniform, now my uniform. I could feel it on my skin as I unwittingly adopted a 149

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slightly different walk (faster than usual) and handled my body differently (less eye contact and a more upright position). As I passed through the ICU, I was told by one of the surgeons not to forget to put the hair cap and mask on before entering the OR. These were available only very near the entrance to the OR, an even more restricted area, and consist of the last piece of garment promising me a place in this in-group. My position as an outsider would be hidden behind these clothes: fully camouflaged, I could then identify myself and be identified as a member of the biomedical team.

Under the Skin

As I was struggling with the hair cap reminding me how little I 'really' belonged there, Ivan's bed was wheeled up into the OR and 'prepped' for surgery. Upon joining the staff, I found him unconscious, draped from head to toe, his large blue eyes shut with tape, his puffy face concealed, his body scrapped clean and sterilised. All I could see was an idle body. Ivan lost all awareness as the staff completed his transformation into a living corpse. His body was at the centre of attention, but Ivan was nonetheless completely absent, unaware his brain was being picked and probed. As Ivan increasingly waned as a subject I shifted roles, from accompanying him to accompanying the surgeons. From where I was now standing, I could see the back of his head, his open skull and his brain, the material, graspable loci of his subjectivity. Was he to open his eyes at this moment, he would not have seen me, nor would he have recognised me behind my mask. Deep into the realm of idle objects, I could not pet neither of his arms now, as both were insensitive, anaesthetised. The room was relatively free of tension. The staff (which at this point included a junior surgeon, a surgical intern, an assistant

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nurse, a head-nurse, a practical nurse, an anaesthesiologist, and a neurophysiologist accompanied by his assistant) moved freely around the room, talking, organising their gear in relative leisure. When the first stage of the actual operation began, the room gradually turned silent. I applied myself as I followed the knife going over the long crescent-shaped scar and two centimetres further down. I remained standing over the orifice, feeling surprisingly little awe or disgust -as one would perhaps expect from an 'outsider'- but was rather directed by an acute sense of curiosity. The skin was pinned to the sides, allowing the opening of a fist-wide cavity at the centre of the wound. The cutting revealed five pieces of bone stapled as to form a sort of jigsaw puzzle, a remainder of the previous intervention. As the two junior surgeons removed the white eggshell pieces and dropped them into the stainless steel bowl, only a thin layer of tissue, the dura, kept the majestic organ in. Swollen and eager to escape its captivity, the brain herniated and literally broke out into the open air. The staff showed interest in the unusual extent of the phenomenon. For me, it was as if I could now see why he was under so much pain: His brain was about to burst out of his eyes' orbits, literally. I could empathise with his pain as he moaned and groaned, yet something about the sight of this bulging lump of flesh made it more 'real'. When I heard his mother tell me, a year before that her son's head was a closed box, and she was afraid his brain will 'leak out', I found this portrayal curious. Although I never questioned the subjective truth he communicated, still, the physical, the ontognostic, the visible seemed to provide me more 'evidence', and seemed thus more authoritative. In the surgery room, I held on to a model that is classically claimed to pertain to the world of physicians: valuing visible, material phenomena over patients' reports.

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The Peak of Surgery
As the team was getting closer to the handling of the actual brain and entering deeper into the body, the ritualistic aspects of surgery became more dominant. For instance, only once objectification reached its peak did the head surgeon make his appearance. After intensive and extensive scrubbing, he sat on a high chair, carefully prepared in advance, covered with a sterilised sheet, curiously resembling a king's throne. The junior surgeon also took a sitting position at this time. He sat on a similar chair, albeit at a less central position, beside (rather than directly behind) Ivan's head. Other members of the team remained standing, with some level of freedom of movement which was only rarely taken advantage of. At this point, the OR became silent, still, and tensed. The lights were turned off, except for a beam of pale light illuminating Ivan's Skull. The LCD screens, from which the site of the operation was 'broadcasted' to the OR audience, were turned on. From one of the screens, the head surgeon could observe a live MRI picture of Ivan's brain as he inserted his instruments. He then set 'coordinates' which will serve him in the spatial handling of this complex organ. As I was to realise later on, I found myself disenchanted. I knew how the brain looked like, but I did not know how Ivan's brain would look like. At some level, I expected it to look like him, like Ivan. It did not. Seeing the brain without seeing the mind, observing its actuality, its fleshiness, one has to admit: in the OR, the mind is nowhere to be found. Time went by as the surgeons were methodically vacuuming tumour tissue and were carefully closing blood vessels, and I became increasingly focused on the physical biological presentation of the tumour. I felt I had developed a relationship

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with Ivan's brain, a relationship that was in many ways independent of its carrier, Ivan the person. After all, in the course of the last eighteen months, I had almost as many direct encounters with Ivan's brain as with Ivan himself. This was perhaps most striking when the surgeon showed the latest MRI image on the screen: its shape, its shades of grey were all-too familiar as I recalled the many staff meetings it had appeared in. I remember the remark, which made the team giggle: Impressed by the tumour's current size, I said I knew it13 "since it was this little!", as if I had been speaking of a child. Was I taking lightly the sight of this immense lump slowly killing a beloved person? Was I talking about Ivan at all? As discussed earlier in this work, prognosis is a form of knowledge which is habitually held away from patients, and this for various reasons, including the detrimental health impact receiving bad prognosis can have, the inadequacy of medical skill and knowledge to deal with issues related to emotional challenges and lifestyle choices associated with a patient's management of prognostic information. In cases of life-threatening brain cancer, prognostic information (and at times, even diagnosis) is clearly, although often not explicitly, unwelcomed by the patient. The latter expects his physician to act as a 'responsible adult', and manage his condition without burdening him with details he is not able to deal with (such as one's impending death). This trust is a form of 'you know best' reflecting upon a surrender of full and complete conscious involvement in the matter under exchange: the knowledge of one's own state of affairs. Brain surgery is often performed with the patient fully awake: This serves the surgeon as he\she is able to hear reports from the patient, and thus localise functions in the areas neighbouring the site of intervention. Ivan's surgery was planned to be performed
13

In Hebrew, the 'it' and the 'he' are interchangeable

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thus, since his tumour layed in the midst of critical senso-motor function areas. His condition, however, was decisively too deteriorated and the idea was abandoned hours before the intervention. As his phenognostic account became of little value, Ivan had to be treated as an ontognostic source: a more 'objective' and objectifyingmeasure was used, and a neurophysiologist was asked to join the team. Wires were attached to Ivan's legs, and, as the surgeon moved an electrode on the surface of Ivan's brain, the neurophysiologist reported on movements detected meaning essential motor tissue was stimulated. Ivan's body was electronically probed and mapped, making the mediation of a subject redundant. The clinical gaze involves the creation of a spatial dimension which will create the disease as an entity, the body as an ontognostic-based 'thing': " a space whose lines, volumes, surfaces, and routes are laid down, in accordance with a now familiar geometry, by the anatomical atlas". (Foucault, 1975:8). These postoperative hours spent in the ICU were perhaps the most tensed to the family this was when I found myself most torn between my two roles: I came in and out, reporting to the family whether Ivan was awake, since only once he regained consciousness were family members (one at a time) allowed in, and supervision was loosen. Once alll would have access to Ivan as a tangible, palpable, source of knowledge into his own wellbeing, my mediation was little needed. While perhaps not unusual in the field of medical diagnosis, the fact that the organ involved in this latitude-longitude definition was the brain, that the functions observed were speech and movement (both typically associated with purposeful volition), and

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that the process took place in 'real-time' made this event particularly intriguing.

Closing up: The last stages

Once the thrust of the surgical intervention (i.e. the removal of tumour tissue) over, the head surgeon told the juniors to "close him up" and left the room. As the pieces of bone were placed back and the skin stapled, lights were turned on again, and movement became freer. As if now having gone through an initiation ritual, the younger surgeons included me in their small talk. Overall, the tension was released, masks were taken off, cables and electronic devices were removed, and Ivan's face and body were again visible. I followed the head surgeon as he went over to discuss the operation with Ivan's parents. The despair with the intractability of his condition and "the impossible mess the tumour made in his brain" was reserved to backstage discussions. Not entering into details, the surgeon gave a relatively reassuring impression: Ivan survived and the surgery did buy him some more time. Only when directly questioned did he admit that, considering what they observed in surgery, they will not be able to offer him any more chemotherapy. Again, I knew what my informants did not: the surgery was in vain this serious and dangerous intervention only gave Ivan a few more weeks, which he will spend in nursing and palliative care. The operation lasted more than five hours, during which I remained standing directly looking into Ivan's skull. However, it was only a few hours later, once having taken off 'my scrubs', leaving the hospital, and searching for my car in the parking lot that I began to feel a throbbing pain in my legs and a general feeling of physical exhaustion. It was as if I now returned to myself 155

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as a lay person, i.e. not only mentally but also in terms of how my body felt to me.

Just a Story
The account of the past is almost inevitably tainted with current interpretative schemes, focusing on concerns that are particularly meaningful to the teller. Thus, one important aspect of narratives is that they are typically told in hindsight, which makes past events appear as if naturally leading to the 'now' as it is understood (Mattingly, 2008; Williams, 2008; Gross, 2009b). The narrative form allowed me here to create coherence and continuity in the sequencing of events and the unfolding of what I believed to be their significations (Ewing, 1990; Becker and Kaufman, 1995). It also allowed me to create a common thread of meaning around a series of noteworthy moments or 'events' (Polanyi, 1985; Mattingly, 1998), and to thereby justify current claims: First, that my experiencing and perceiving of Ivan as a subject and object was of a fluctuating nature; Second, that this reflected on and was reflected by contextual elements within which our interactions took place; And finally, that these contexts all involved some extent of boundary definition (replicated in the conceptual, spatial, professional, symbolic layers) between two seemingly opposite sources of Truth: phenognosis and ontognosis. I shall now like to unfold some of these points as they arose in the field, and as they relate to recent and contemporary work in adjacent subjects.

Liminalities and Replicated Boundaries

The OR as a Space of Multiple Liminalities

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The OR might be regarded as the epitome of biomedical practice, as restricted both physically and symbolically from everyday life, and secluded from the less distinct areas of the hospital (e.g. Wilson, 1954; Goffman, 1961b; Foucault, 1975; Moreira, 2004). This is where the invisible becomes visible, the inaccessible accessible. The OR is also a space where states of liminalities are omnipresent, and most particularly liminalities where scientific thinking ceases to exert its conceptual control (Van-Gennep, 1960; Douglas, 1966; Turner, 1969). This includes the patient oscillating between life and death, and between forms of 'presence': i.e. a state of simultaneous presence (as a body) and absence (as a person). This liminality and confusion of categories demand a clear ordering of things through elaborate rituals. As has been well shown in previous studies (e.g. Katz, 1981; Katz and Kirkland, 1988), OR rituals are associated with the need to facilitate the transition between categories of things by clarifying their distinction, more particularly the distinction between things that belong and things that do not belong in the OR, the sacrosanct of biomedicine. Rituals, however, can do more than create boundaries. They may also convert mundane objects into entities that belong to the 'sacred' and are thus less likely to form objects of liminality. For instance, when transformed from a sentient whole into an operable body, the patient can be allowed into the OR (Katz, 1981; Fox, 1992). The medical personnel itself also goes through processes of transformation: these might include scrubbing rituals preceding the entry into the operating room and special attires worn by the staff (Moerman, 1979; Felker, 1983; van der Geest, 2005). Along with specific rules and practices, these allow a conversion of the life-world into an object that can be dissected 157

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and manipulated in the setting of the OR (Gaines and Hahn, 1982; Hahn and Gaines, 1985; Hirschauer, 1991). I shall claim that rituals serve to restrain and manage subjectivity in a way that would minimise the soiling of the purity associated with the ontognostic realm of 'things'. While the discussion of objectification in medical contexts is omnipresent in the social sciences of medicine, and while the issues of purity and danger (and their relations to social practices and categories) constitute one of the pillars of cultural anthropology, the wedding of the two subject of interest has never, to my own knowledge, been directly attempted. Here, I shall advance the idea according to which the gnostic split is symbolically, practically, and epistemologically replicated as comprising a 'dirty' element (phenognosis) and which can be regarded as its mirror reflection: the 'pure' element of biomedical ontognosis. If phenognosis is the matter out of place (Douglas, 1966), it is not only categories of life and death, of inside and outside which boundaries must be reinforced and safeguarded, but also categories of subjectivity and objectivity: of sentient person vs. present body. In this shrine of objectivity, the subject must be either subdued (anaesthetised), hidden (draped), or made sterile (disinfected). In other words, in settings such as the OR, ontognosis will be seen to annihilate, dominate, or restrain phenognostic presence. This is in fact much similar to the type of boundaries shown to be drawn and replicated in other layers of the gnostic split, e.g. between an 'ontognostic neurology' and a 'phenognostic psychiatry', and as shown by Mizrachi, Shuval and Gross (2005), between an ontognostic biomedicine and a holistic, at times 'spiritual', approach to the patient. In all three cases, the subjective will need to be conquered, as its epistemological resistance contests ontognostic authoritativeness.

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In the case of surgery, however, boundaries cannot and will not remain blurred: surgical intervention is the pure manipulation of matter. Whichever is not clearly assigned to this sphere must be either eradicated, constrained, or subordinated.

The Temple of Ontognosis: The OR

Questions of objectification arose in the field around several elements. These worked in unison to replicate a movement from the subjective to the objective and from the personal to the biomedical. First, with anaesthesia, which transforms the sentient self into a passive body; Second, with sterilising practices, which separate the OR from a 'messy' outside world where body and mind are meshed up (and where forms of knowledge can be confused as well); Third, with spatial definitions, which create clear boundaries between areas of objectification; Finally, with components such as clothing, language and technology associated with this stance. I shall now discuss each of these.

Keeping Phenognosis Out: Sterility

"Rituals exaggerate the discontinuity in the operating room and they proclaim definite categories. An instrument is either sterile or nonsterile; it is never almost sterile or mostly sterile. A person is either scrubbed, gowned, and gloved, and, therefore, sterile, or he is not scrubbed, gowned, or gloved, and, therefore, not sterile." (Katz 1981:345346)[my emphasis, S.G.] According to Katz (1981) and others (e.g. Cassel, 1987), the lengthened minutes of scrubbing immerse the professional into a state-of-mind by which the patient turns into a physical entity 159

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interacting with and endangered by other physical entities: germs. Along these lines of arguments, Listerism and sterility would play no role other than promoting practical aims of preventing infections. My observations, however, suggest that these rituals cannot be explained away by simply turning to this 'germ theory'. More specifically, I will claim for an association between levels of objectification (by different professionals, at different stages) and the demand for elaborate scrubbing. The "precise and beautifully choreographed ritual" of scrubbing (Cassel, 1991:91) involves transformative practices in regard to the experience of surgery (Landzelius, 2003), namely in keeping a view of the body as belonging to the world of matter, whether germs are involved or not. In more concrete terms: the more one would treat the patient as an object, the more one would be required to be sterile, that is, to abide to this "stylisied, arbitrary, repetitive, and exaggerated" behaviour (Katz, 1981:349). Throughout securely the course and of his Ivan's vital operation, stable, the the

anaesthesiologist kept holding his mask rather loosely. Ivan anaesthetised signs anaesthesiologist sat at one corner of the room and engaged in online crossword puzzles, occasionally joining me and offering me trivial information on this or that procedure. As a rule, his active presence was required only at the temporal edges of surgery, i.e. the entering of Ivan into the anaesthetised condition and his gradual emergence into full consciousness: Then, he would take on a more religious attitude towards his scrubbing attire. It is then that he would have most contact with Ivan's body, but it is also then that the boundaries between conscious and unconscious, between dying or viable would be most challenged. Interestingly, I was the least sterile. Although I did wear a sterilised surgical robe and did put on a mask and cap, I was not

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asked to wash my hands ("that's OK, you don't have to" the junior surgeon declared). This was especially curious as I was, at one point, asked (by the looser gatekeeper: the anaesthesiologist) to touch Ivan by holding a cotton ball over his perfusion wound. The fact that I was only partially scrubbed placed me in an in-between state where I was allowed to concomitantly hold an outsider's state of mind, as well as an insider's. This again suggests that sterility guidelines are not followed in a mere attempt to physically keep things clean of germs. They are intimately associated with patterns of observance of the place of subjectivity in the OR.

Anaesthesia: Subduing Phenognosis

The effect of anaesthesia on objectification is undoubtedly powerful. When sedated, a person's state of wellness becomes defined in terms of pulse rates or levels of oxigenisation as shown on a computer screen (Collins, 1994a). By eliminating the patient's subjective presence, anaesthesia creates a lifeless body to be manipulated, as if in the absence of its owner. In submitting him/herself to sedation, the latter will convey his faith in the expertise of the surgeon as a 'worker of the body' into whose hands one can literaly place one's existence. Yet, this faith is not granted ad hominem i.e. trust is not bestowed upon a particular person or persons, but to a basin of knowledge and an embodiment of skills: to the praxis as well as to the epistemological soundness of biomedicine. The consent forms are typically signed to never be read, the summary the surgeon14 may give the patient, never to be really seriously considered. The patient often willingly accepts but always ceases to resist the overpowering of his/her own subjective experience (Mizrachi Shuval and Gross, 2005). In the surgery room,
14

Or, as in Ivan's case, the anaesthesiologist

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the patient surrenders any claims for epistemological supremacy: phenognostic claims cannot be made if subjective knowledge is not generated, i.e., when one is unconscious. This is in fact precisely at this point, when the critical spectator turns absent, that the team is able to make the transition to a backstage form of interaction (Goffman, 1961a; Pilnick and Hindmarsh, 1999; Hindmarsch and Pilnick, 2002). They do provide powerful grounding to the change in the patients 'presence' (or rather 'absence') in the social interaction taking place in the surgery room. Still, they focused rather on the team than on the patient, and did not offer an analysis based on the observers position.), which could not have been enacted in the presence of an outsider: the patient. Backstage, the language becomes more technical and inside information is more freely communicated15 including, as in this case, alarming news on the patient's prognosis. For instance, while Ivan was deeply sedated, the head surgeon called me over and showed me, right on the surface of the exposed brain, the extent of the damage, announcing as if of a matter-of-fact that the tumour was enormous and that Ivan's prospects of survival were grim. This is a statement that could hardly be made in the presence of a patient or his/her loved ones. Perhaps most strikingly, Ivan himself was absent (i.e. anaesthetised) as his death sentence was declared. As discussed earlier in this work, prognosis is a form of knowledge which is habitually held away from patients, and this for various reasons, including the detrimental health impact receiving bad prognosis can have, the inadequacy of medical skill and knowledge to deal with issues related to emotional challenges and lifestyle choices associated with a patient's management of prognostic information. In cases of life-threatening brain cancer,
15

This is also when the team's sense of humor was more readily exercised. However, I must admit, that never in reference to Ivan. I was not impressed that this was merely due to my presence.

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prognostic information (and at times, even diagnosis) is clearly, although often not explicitly, unwelcomed by the patient. The latter expects his physician to act as a 'responsible adult', and manage his condition without burdening him with details he is not able to deal with (such as one's impending death). This trust is a form of 'you know best' reflecting upon a surrender of full and complete conscious involvement in the matter under exchange: the knowledge of one's own state of affairs. It was thus little surprising to see myself perplexed when confronted with instances where my own knowledge regarding Ivan's diagnosis greatly surpassed his. Not certain if the patientphysician 'pact' regarding prognosis applied to me, I was again to wonder as to the nature of our relationship: As I knowingly withdrew information from him, I found myself in the role of the 'I know, but I know better than to have you know what I know' an expression of epistemological power I did not wish to hold against whom I wished to remain a subject rather than a 'patient'. This backstage stance was increasingly difficult from my position as an ethnographer. Another issue arose when, as Ivan's subjectivity has been made to disappear, or made irrelevant, it refused to enter the stream of my own. This stood in contrast to what Alfred Shutz (1970:31) termed the 'we-experience': experiencing the other experiencing. I could not create an intersubjective relation with what seemed as a 'thing'. Intersubjectivity is present only when two subjects experience a common situation. If one of the parties become absent, my attitude becomes simply phenomenological that is, based on my own experience of a world of matter.

Space and Liminal States

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As Young (1999) asserted in her work, the spatial organisation of the hospital reflects conceptual elements central to biomedicine's epistemological bases. In my study, the ICU, for example, clearly served as a space of transition between the outside and the inside, and as described above, between the sacred and the mundane. The ICU was where a taxonomic order that has been loosen and endangered in the OR could be reconstructed (Turner, 1969; Turner and Turner, 1978; Landzelius, 2001). Still in a state of limbo between life and death, and most vulnerable to unforeseeable and rapid deterioration, the patient is there followed with elaborate rituals and monitoring, until fully awake, 'stable' and 'out of danger', i.e., when re-becoming a 'normal body' (Kaufman, 2000). At the point where there is less danger to the ordering of the orthodox state-of-being (Van Gennep, 1960; Landzelius, 2001), intensive surveillance is relieved. As life-world modes of interactions become available (the patient regains consciousness and is able to report on his/her subjective experience), and biomedical, ontognostic monitoring becomes less essential, the patient may be released to the outer circle of the 'sacred' space: into the ward. These postoperative hours spent in the ICU were perhaps the most tensed to the family this was when I found myself most torn between my two roles: I came in and out, reporting to the family whether Ivan was awake, since only once he regained consciousness were family members (one at a time) allowed in, and supervision was loosen. Once alll would have access to Ivan as a tangible, palpable, source of knowledge into his own wellbeing, my mediation was little needed.

Going Native
There are other elements affecting my own stance of objectification, elements belonging to one of the oldest concerns of anthropology: the adoption of the research subjects' ('emic')

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viewpoint, and the keeping of an outsider's ('etic') distanced position. One way to attain a deep understanding of the natives perspective is to find oneself within this perspective, or go native. Whereas this argument seems well developed in other fields of anthropology and ethnography, it seems little attended to in mainstream social studies of biomedicine. According to Collins (1994a, 1994b), this lack of understanding of the physicians lifeworld (or verstehen) leads to significant biases in ethnographies of medical settings. Achieving, to the best extent possible, an emic look into the surgeon's world would then allow a more elaborate and accurate depiction of the field. In an attempt to achieve such an understanding and become an expert observer (Bolton, 1995), I undertook an elaborate preparation which included the study of the technical and more theoretical aspects of the profession. I acquainted myself with the different aspects of neuroanatomy and clinical neurology and was able, through the internet, to watch sequences of both general brain surgery and tumour resection operations. I achieved some fluency in the native language and acquired somewhat more tacit knowledge such as the ability to distinguish between brain tissue and tumour tissue and the ability to visualise the actual wound with the MRI images laid up on the screen. This knowledge allowed me to avoid, at least partially, what Bolton (1995) defined as the inherent bias of non-medically informed anthropologists: The incapability to really understand medicine, thus to really enter the physicians state of mind. In biomedical settings the expert observer will perform as a nativeethnographer, and will provide valid contributions, which might not be available unless abandoning this lay navet which is often overbearing in anthropological accounts of medical practice (Collin, 1994b). For instance, non-physician anthropologists tend to romanticise the physician, to underrate instrumental aspects of 165

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medical practice, and overrate the reductionism of medical texts. Considering the methodological advantages of expert observation, this enculturation has also affected my view of Ivan as a subject, and my readiness to adopt a biomedical perspective when approaching him in the OR: this eventually allowed me to understand the shifting nature of objectification from a less disciplinary distanced perspective. Medical education includes the teaching of the ability to keep role distancing, or hold clinical detachment from patients as human beings (Goffman, 1961; Fox, 1979; Smith and Kleinman, 1989; Good, 1994; Walters, 2004). It allows physicians not only to treat the case more objectively or to be less sensitive to awkward and at time repelling tasks, but also to refrain from developing emotional attachment to patients, an attachment that is often emotionally straining (Hafferty, 1988; Leder, 1992; Good, 1994; Frank, 1995; Francis and Lewis 2001). Without having gone through clear medical socialisation to distancing, I was still able to sustain the surgery observation without extreme emotional response. For me, distancing was a fluid state-of-being highly contingent upon the setting. Thus, as this case shows, distancing is not only a skill taught in medical school, nor is it simply a form of tacit knowledge acquired through practice. When undertaking the task of surgical intervention, the specific rituals and symbolic elements work to suppress feelings of identification and compassion. It worked not only upon the 'medically taught' participants, but upon the lay observer as well. Still, as elaborated in Anspach and Mizrachi's work (2006), and as seen in this particular field, the researcher might experience a tension between his16 position in his disciplinary field and his position in the ethnographic setting. Most particularly, in the social studies of medicine, one may find oneself holding
16

I again use the masculine stance here, so as not to impair the readability of the text

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incompatible ethical imperatives, depending upon the field he regards himself as being a part of (Dingwall, 1980; Goodwin et al., 2003; Dickson-Swift et al., 2006). There is little doubt as to the effects of professionalisation and disciplinary field (Anspach and Mizrachi, 2006) on the positioning in the field of a researcher. Here, however, I have focused on the setting itself, rather than on the disciplinary or professional background of the different actors. The ways in which the field itself influenced my mode of attention to the patient suggest that the setting holds immense power in affecting the view of the patient as a subject, but not only that. It also showed that relating to phenognostic forms of knowledge is not a 'natural' unquestionable given: it requires, like any other discursive formation, a ground upon which to assert its power and act to apply itself in the field.

Gnostic Shifts and 'Theories of Mind'

Objectification can be seen as either 'medicine's biggest fault or, in terms of daily interactions, as a natural, perhaps unavoidable, part of one's exchanges with the world. While the former view relates to the more detrimental effects of referring to another as an object, the latter returns to the philosophical fundamentals: can 'the other' really be seen, experienced, understood as a subject? From his17 very own birth and throughout his infancy, the human being learns to regard himself as distinct from the surrounding world. This is when he realises himself as a subject facing objects, including his own body (Mead, 1934). This type of objectification is an inevitable consequence of the gnostic split, as it binds attempt to understand the 'other' as a subject. According to Western tradition, there would be two ways of 'knowing the
17

Here again, based on considerations of style and readability, I will use the masculine form

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world': the phenognostic first-person perspective which provides subjective certainty, or the ontognostic third-person perspective which has been made secure by scientific method. In either way, whether experienced first-hand or scientifically ascertained, the other will seem as an object, as well may be one's own body (Gallagher, 2000). This problem has been addressed by philosophers, namely around notions of solipsism and the presence of a 'theory of mind'. The first relates to the fact that one can only be confident of his own subjective presence: as far as can be ascertained, others can be automatons claiming to 'feel' and experience an inner world of their own. 'Others' can alternatively be characters in a dream one would be the protagonist of. The idea of a 'theory of mind' turns to the understanding of the mechanisms by which human beings DO ascribe 'minds' to others. According to many philosophers, thus, one would hold a 'theory of mind' according to which others are subjects if they happen to have characteristics deemed to belong to a 'minded' thing. Some will have broader theories of mind to include animals (which may squeak in pain when tortured, thereby seeming to have a subjective presence). Others will have more limited theories of mind, leading to the objectification (considered more or less 'morally just' or 'scientifically justifiable' among different cultures and societies) of entire categories of human (and non-human) forms of existence, including comatose patients (or 'vegetables' conflicts, etc. Considering the inclusion of non-human categories such as animals, and in some religions, 'things' others may consider as objects (i.e. objectify) in to theories the of mind, I find the 'objectification' preferable 'dehumanisation' outlook. accordingly), foetuses (or 'unborn babies', accordingly), ethnic minorities, women, the aged, opponents in

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However, as in the modern Western World 'things' considered as holding subjectivity tend to be anthropomorphised, and as, in the modern Western World, human deemed subjective beings tend to be referred to as 'persons', I will have to treat objectification, depersonification, dehumanisation as strongly linked notions. In the setting of the clinic, and perhaps to a larger extent in the OR, these can almost be used interchangeably. More than that: as more 'object'-looking one is (e.g. being still, being insensitive and non-reactive to pain), the more he would be dehumanised; The less 'person'-looking one is (e.g. wearing uniforms, having masks over one's face, blending in the crowd) the more he would be objectified (treated like one piece of a faceless whole); The less human one acts (being cruel, disregarding basic taboos, acting 'like an animal'), the more he will be depersonalised (and can thus become a target to violent acts of indignation). The instances where Ivan most resisted objectification were when he looked, acted, and was treated like a person. This included his increasingly grotesque appearance as his disease advanced, and his draped inertness in the OR, as he was attached to non-biological electronic, digital, and mechanical devices (creating a sort of cyborg as the mechanical extended to his own body). It also included the sense in which he was 'reachable', or respondent to communicative stimulations, such as touch, sounds, words, and so on: e.g. his hemiparetic state outside the OR and the effects of anaesthesia inside the OR. Not only was his ability to perceive affected by this, but his ability to respond was as well. This had to do with the level of pain he was suffering from, as well as his cognitive and language processive deteriorating skills. Again, his responsiveness to communication was gradually altered throughout the general course of his disease and in the more specific setting of the OR. In all cases, he acted and appeared as less than a full ideal-type person, and this had deep effects on 169

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stances of objectification, on both my part and the biomedical staff's.

Conclusions
In the case presented here, both the biomedical team and myself, as a researcher, eventually found ourselves within a complex, yet basically dualistic attitude, as if in a dynamic flip-flop between the patient as object and patient as subject. With Ivan, the boundaries between absolute objectifying distancing and complete personal identification seemed to be in a continual flux, and replicated over different layers: This was true on this first day, when I only knew him as a medical case, and remained no less salient as our relationship developed. In fact, I created Ivan's body as much as my own presence is created by the network of objects and relationships: both are of a fluctuating nature, contingent upon the setting and my own role-taking. Indeed, the tendency toward objectification is affected by ritualistic practices and symbolic elements. The ethnographer is not immune to these influences and might find herself involved in the objectification of her research subjects, perhaps no less than biomedical practitioners are claimed to. The OR has its own rituals and is in many ways an extension and intensification of biomedical epistemologies, practices, and symbolic elements. This involves the transformation of a life-world into an object which can be manipulated. The patient is then absorbed into a small, depersonalised, objectified body-part (Hirschauer, 1991; McNay, 1991). Often defined in terms of a loss of human concern over another, objectification is overwhelmingly used in a pejorative tense. Here, however, I sought to show how it might be a necessary, undeniable, and unavoidable part of biomedical work. Neither is objectification a process limited to

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biomedical settings, nor is it exclusive to physicians: anyone can objectify anyone. Ethnographers, in particular, often sway from objectification to empathising positions (Fabian, 1983; Clifford and Marcus, 1986; Pratt, 1986; Wiltshire, 1999). Using insights from my own ethnographic work in a neuro-oncological clinic and a neurosurgical unit, I raised the need for a multi-faceted approach to questions of objectification, taking on the concept of epistemological fluctuation in ethnographic studies of biomedical exchanges. This interpretation of exchanges in biomedical spheres points to the inherent tension between these two tendencies (objectification-empathy), two roles (physician-ethnographer), two perspectives (biomedical-personal), and two phenomenological states. I claimed that, on occasion, and highly dependent upon the symbolic and ritualistic setting, the most empathetic actor may take on a position oscillating between these two attitudes, experiences, and forms of rapport. The ethnographer does not merely observe, nor does she merely participate in transformative rituals- she also experiences them, and is phenomenologically affected by them. There is no 'pre-discursive' experience of the 'other' as a sentient entity: objectification is present as it is encroached in a form of knowledge\power, yet so can be said about the adoption of phenognostically-based attitudes. The not medically-disciplined actor does not necessarily adopt a phenognostic discourse as default: It iself needs to be encroached in a form of knowledge\power in order to sustain itself.

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Part VI: Conluding Words

The Bounded Brain
The brain is the apparatus through which we experience the world and relate to it, and is the ultimate locus of our selves. This makes it both organ and concept, both biological and hermeneutical, both object and site of meaning. Hence, knowledge about the brain can never be universal, or fundamentally 'true', but only interpretational and culturally contingent. I suggest, thus, that a deep and attentive study of the notion of 'brain' is likely to offer unique, meaningful insight into the fundamental questions troubling the sociocultural world of modern Western society, and the world of academics seeking the understanding of Western society. Still, the association of the mind-body split with broader social terms such as professions, science, history, bioethics, discourse, is not nearly as problematised as one would hope, and theoretical work on the issue has too seldom been undertaken. My

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contribution wishes to stand precisely within these nascent fields of studies. As shown here, the brain can be regarded as an interim, a colossal pineal gland, the site of the clashing of two ultimate realms: the world-out-there, and the inner world of experience. This clash, I have claimed, would be reconceptualised in a way to assert clearly bounded categories: science and non-science, reason and emotion, objective and subjective, at both ontological and phenomenological levels. This work presents instances where these boundaries are encountered, challenged, and replicated. The understanding of these processes, I hope, allowed a refinement and elaboration of concepts of scientific vs. subjective forms of convictions, and the role these forms of knowledge may take in both diachronic and synchronic perspectives on the sociocultural world of biomedicine. Somewhat unorthodoxly, I chose to present this analysis in the form of three relatively independent essays - each with its own body of literature and theory, each with its own empirical foundations. This also demanded an intense focusing on which I considered as the most essential aspects of the phenomena at hand, as required in professional academic publishing. I believe that this served not only to portray research in advanced scholarly language, but also to distil my ideas, to carefully extract the most powerful points I chose to advance, and to most thoroughly consider their actual contribution to selected bodies of literature and areas of concern. The significance of the association of the papers stands at their similarities rather no less than at their diversity. Indeed, it is almost a truism to say that the consequentiality of theoretical advances cannot be tested upon its elucidating one phenomenon 173

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or another it is its applicability and relevance throughout a full array of empirical worlds that endow it with promise. In this, three fields were chosen as epitomising the theoretical suggestions made throughout this text, while still holding a substantial empirical range. First, I proposed a detailed picturing of the adoption and then relegation of psychosurgery as a decreasingly 'purely scientific' ontognostic medical procedure. This was shown to represent a case of 'replicated boundaries': an occurrence in which boundaries are drawn and concurrently replicated at several levels. This work then took us to the in situ understanding of the assignment of authoritativeness to different diagnostic forms of knowledge as more or less purely ontognostic. Finally, I offered here a first person narrating of the effects replicated symbolic and ritualistic Cartesian boundaries had on the objectification of a research subject in the context of the operating room. In all three cases, phenognosis was sought-after as a site of knowledge to be tamed and conquered by science and biomedicine, rather than a mere pre-discursive default. As it remained still beyond the reach and control of the ontognostic endeavour, it was to be kept strictly outside of the practical, epistemological, rhetorical and symbolical of the ontognostic realm. Phenognostic resistance to this reduction to the realm of matter created a clear threat to the discourse of objectivism as potentially omniscient, hence the great attention given to the creation and sustainment of these boundaries. I here sought to show how the boundaries are created in several layers: The patterns of boundaries were drawn by epistemology and reflect the rejection of the polluted, as was the case in and around Ivan's brain surgery, in and around the debate

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on psychosurgery and in and around complex processes of diagnosis. Cartesian boundaries were presented not as a philosophical but as a cultural phenomenon: a phenomenon where both professions and rituals, where both macro-levels and micro-levels, where both institutions and personal thoughts were looked upon to identify the replicated boundaries of 'Truth' around an obstinate gnostic split.

A Contemporary and Future Look onto the Gnostic Split

Conceptions of the body are socially contingent and reflect the critical elements of the culture in which they are formed and kept alive (Kleinman, 1988; Martin, 1994). As mentioned, my aim here was to refer to the mind-body problem as one such conceptual complex. In terms of its social revelation, one thing seems to be clear: Western culture has not yet overcome the gnostic split, and still holds on to the two forms of 'truth'. This dualism continues to create areas of contest where symbolic actions as well as rhetorics are used to reassert an uncertain, notcommonly shared, unstable, idea of 'what the world is'. Over the years, the mind-body problem has indeed enticed endless contemplations, and has been overwhelmingly portrayed as the most perplexing epistemological chasm of postenlightenment society (e.g. Crick and Koch, 1990; Rosenberg, 1992; Chalmers, 1995, 1996; Searle, 1998). Withstanding all efforts of reconciliation notably in the field of neurosciences, artificial intelligence, and functional imaging studies - this explanatory gap remains insoluble, and is still of critical consequence in broad domains of research (e.g. Levine, 1983; Nagel, 1986; Dennett, 1999). Still, and despite some exceptions (e.g. Williams, 1996; Martin, 2000), a clear disparity hangs 175

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between philosophical advances on the matter and efforts made by social sciences to recognise, define, and study its sociocultural grounds and implications. I shall claim, however, that a number of recent developments have created a more urging need to attend to this conundrum, These include the exponential growth of neurosciences and the rising power of post-modern and New Age epistemologies. Long before the 1990's 'decade of the brain', long before the neuroscientific revolution of the 1960s, the cerebral organ has raised considerable interest from both medical and scientific endeavours (Hyman, 2000). As has been well addressed throughout this essay, the brain indeed holds peculiar attributes which makes it such a fascinating object of study: It is, after all, the apparatus through which we experience the world and relate to it, and is the ultimate locus of our selves. The last decades saw a growing interest in the physiological, chemical, biological, and electrical bases of mental activity, as well as an exponential growth in neuroscientific technological developments. Over the years, research has gain tremendous successes in identifying the physical correlates of thought, emotions, personality, and sensomotor activity. Today, it would be nonsensical to deny the presence of some form of correlation between mind and brain. Yet, it would seem almost as nonsensical to claim that our sense of existence can be utterly reduced to the brain. In other words, it seems unlikely that scientific advances in the understanding of the brain will ever be fully able to reduce subjective experience to the mere realm of matter. Subjectivity and our sense of 'being-in-the-world', 'what it feels like' to be, to see the sunshine, to experience pain, is doomed, if only by definition, to remain in the private world of inner sensation and beyond the reach of objective query. Science finds there its

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ultimate boundary, and the most important threat to its ultimate authoritativeness. As well put by Horgan (1999:4): "Inner space may be science's final and eternal -frontier". Other sociocultural developments raise a need to deal more substantively with the mind-body problem. Most significantly perhaps would be the rise of the post-modern. The post-modern movement provides definitions of 'Truth' which have by now become widely accepted: Whilst the 'modern' had truth as a 'thing out-there' ready to be unveiled by scientific efforts (ontognosis), the 'post-modern' claims for a multitude of 'truths' contingent upon perspectives, cultural biases, and relations of power. This calls for a more accepting stance towards claims to truth based on subjective impressions and inner experience, i.e. phenognosis. Many New Age movements will take this stance even farther. These may go as far as to portray 'experience' as not only a legitimate source of Truth and as holding strong authoritativeness. Phenognostic sources may have predictive elements, may be able to alter an ontognostically-known 'reality' and work beyond the forces of the world-out-there (in ways considered 'supernatural', i.e. beyond ontognostical metaphysics). In many cases, when scientific evidence will not support a claim based on subjective experience, the latter will be considered superior. Science, for example, may have a strong case against the probability of the divination of the dead. The believer, however, will claim that, as it felt true to an experiencing individual it IS true. Here again, two sources of truth will interact and fight for authoritativeness, and now both will share a common battle ground: Modern Western epistemological culture. This social and cultural phenomenon should stand among other areas of concern in which contemporary social scientists are engaged.

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In sight of a possible contribution to these works, this study sought to assert a claim by which the mind-body problem deserves to be seen as more than a philosophical problem. It also presented a theoretical framework on which to ground future studies in the field. I will hope to see social sciences relying upon philosophical advances in the understanding of the mind-body problem and go beyond to apply them to the understanding of related social phenomena.

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