Sky E.

Gross

Table of Contents

TABLE OF CONTENTS........................................................................................................................... 1
PART I: INTRODUCING THE WORK ................................................................................................. 5
THE STUDY OF THE HUMAN ANIMAL ................................................................................... 5
THE THREE PAPERS .......................................................................................................... 8
Surgeons of the Mind ............................................................................................. 8
Experts and 'Knowledge that Counts' .................................................................. 10
The World of Brain Surgery .................................................................................. 11
PART II: THE ARGUMENT AND ITS THEORETICAL COMPLEX ............................................... 13
THE MIND-BODY PROBLEM AND CARTESIAN DUALISM ......................................................... 13
Descartes and After.............................................................................................. 13
The Cartesian Fallacy ........................................................................................... 15
INTRODUCING THE GNOSTIC SPLIT .................................................................................... 17
Phenognosis and Ontognosis ............................................................................... 17
The Body and Embodiment: Closing the Great Divide ......................................... 18
Social Studies of Medicine and the Body ............................................................. 20
The Discourses of Truth: Foucault and Beyond .................................................... 22
INTRODUCING REPLICATED BOUNDARIES ........................................................................... 25
The Gnostic Split and Replicated Boundaries....................................................... 25
Replicated Boundaries: The Professional Grounds .............................................. 26
PART III: SURGEONS OF THE MIND .............................................................................................. 30
INTRODUCTION ............................................................................................................. 30
LOBOTOMY IN MIND: METHODOLOGY .............................................................................. 31
A Historical Approach to the Study of Replicated Boundaries ............................. 31
Reading Psychosurgery ........................................................................................ 32
ON PSYCHOSURGERY ..................................................................................................... 34
CREATING ONTOGNOSTIC LEGITIMACY .............................................................................. 38
'Prehistorical' Sources .......................................................................................... 38
Replicated Boundaries: The Professional and the Legitimate ............................. 40
Building the Heroic Ethos ..................................................................................... 43
The Founding Tale ................................................................................................ 44
Out of the Laboratory .......................................................................................... 46
Men of Science ..................................................................................................... 48
Locating the Mind ................................................................................................ 50
Medicalising the Mind: Symbolic Correlates of Ontognosis ................................ 53
LOSING GROUNDS: AWAY FROM ONTOGNOSIS ................................................................... 57
The Traps of Rhetorics: Facing the Debate .......................................................... 57
The Traps of Science: Methods and Rationalisations .......................................... 58
The Traps of Symbolics: Freeman and the Ice Pick .............................................. 60
FROM THE MEDICAL INTO THE SOCIAL AND BACK AGAIN....................................................... 62

1
 Black Butterflies

Social Control and the State ................................................................................. 62

Dystopic Prospects: Psychiatry in Charge ............................................................ 64
Back to Society: The Social Cure........................................................................... 65
Illegitimate Interests: The Costs of Mental Asylums ............................................ 67
THE HOMO VADUM ...................................................................................................... 69
The Homo Vadum's Brain..................................................................................... 71
Corporeality, Pain and Phenognostic Truth ......................................................... 73
Madness and Ontognosis ..................................................................................... 75
The Homo Vadum and Society ............................................................................. 76
CONCLUDING WORDS .................................................................................................... 78
PART IVA: EXPERTS AND ‘KNOWLEDGE THAT COUNTS’(BACKGROUND) ....................... 81
THE NEURO-ONCOLOGY CLINIC ........................................................................................ 81
The Clinic: Spatial Characteristics ........................................................................ 81
Schedules and Organisation of Time.................................................................... 84
The Neuro-oncology Meeting .............................................................................. 85
The Patients ......................................................................................................... 86
The Consultation .................................................................................................. 86
Family Members................................................................................................... 88
SOMETHING ABOUT BRAIN TUMOURS............................................................................... 88
Types of Tumours ................................................................................................. 88
Location of the Tumour and Functions Threatened ............................................. 89
Treatment ............................................................................................................ 91
PART IVB: EXPERTS AND ‘KNOWLEDGE THAT COUNTS’ ....................................................... 94
INTRODUCTION ............................................................................................................. 94
METHODOLOGY ............................................................................................................ 95
AT THE CLINIC: THE DIAGNOSTIC PROCESS ......................................................................... 96
MEDICOSCIENTIFIC DIAGNOSIS......................................................................................... 98
THE WEB OF EXPERTISE ................................................................................................ 101
ON THE ONTOGNOSTIC AUTHORITATIVENESS OF REPORTS .................................................. 102
The Sight of the Tumour: Radiology................................................................... 104
Sorting Things Out: Histopathology ................................................................... 109
Figuring it out: Neuropsychology ....................................................................... 111
Hands-on: The Clinical Report ............................................................................ 112
The Patient ......................................................................................................... 115
General Oncologists: Peripheral Experts ............................................................ 119
The Neurosurgeons and the Tumour Board: Peripheral Experts ....................... 121
MECHANISMS OF INTEGRATION ..................................................................................... 122
Hierarchisation ................................................................................................... 123
Sequencing ......................................................................................................... 124
Negotiation ........................................................................................................ 125
Peripheralising ................................................................................................... 127
Pragmatism ........................................................................................................ 128
CONCLUDING WORDS .................................................................................................. 132
PART V: THE BRAIN EXPOSED ...................................................................................................... 135
ON NEUROSURGERY AND THE NATURE OF OBJECTIFICATION ........................................ 135

2
 Sky E. Gross

INTRODUCTION ........................................................................................................... 135

METHODOLOGICAL NOTES ............................................................................................ 138
THE SACRED BRAIN: THE MATTER OF THE GNOSTIC SPLIT ................................................... 139
THE STORY ................................................................................................................. 141
'Prelude' ............................................................................................................. 141
The S-day ............................................................................................................ 144
Under the Skin .................................................................................................... 148
The Peak of Surgery ........................................................................................... 149
Closing up: The last stages ................................................................................. 152
Just a Story ......................................................................................................... 153
LIMINALITIES AND REPLICATED BOUNDARIES..................................................................... 154
The OR as a Space of Multiple Liminalities ........................................................ 154
The Temple of Ontognosis: The OR .................................................................... 156
Keeping Phenognosis Out: Sterility .................................................................... 157
Anaesthesia: Subduing Phenognosis.................................................................. 159
Space and Liminal States ................................................................................... 161
Going Native ...................................................................................................... 162
GNOSTIC SHIFTS AND 'THEORIES OF MIND' ...................................................................... 165
CONCLUSIONS ............................................................................................................ 167
PART VI: CONLUDING WORDS..................................................................................................... 170
The Bounded Brain ............................................................................................. 170
A Contemporary and Future Look onto the Gnostic Split .................................. 172

3
 Black Butterflies

Macbeth: How does your patient, doctor?

Doctor. Not so sick, my lord,

As she is troubled with thick coming fancies,
That keep her from her rest.

Macbeth. Cure her of that.

Canst thou not minister to a mind diseased,
Pluck from the memory a rooted sorrow,
Raze out the written troubles of the brain
And with some sweet oblivious antidote
Cleanse the stuff'd bosom of that perilous stuff
Which weighs upon the heart?

Doctor. Therein the patient

must minister to himself.

Macbeth. Throw physic to the dogs;

I'll none of it.

Shakespeare, MacBeth Act V scene iii

4
 Sky E. Gross

Part I: Introducing the Work

The Study of the Human Animal

Sociology and anthropology have forever sought to

understand the ways in which the individual relates to the world,
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 eyes 1. That
is, how does he conceive his experience in the world and how does
he conceive his experience of the world. Can he regard himself as a
thing among others, or can he only relate to himself as an
experiencing subject, distinct from a world-out-there, from which
would stem the things which he will perceive?

The question which will follow us throughout this essay is not

the question of how culture defines the 'self' – in that, this work
would hardly be original. Rather the question here is how the self
defines the self: Which can be said to serve as a basis to what is
known in the world-out-there, and in the world of the self? The
'I' (myself), the 'he' (the 'other'), or rather the 'they' ('society')?

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

know what we know. In looking at the world and at the self, which
kind of knowledge 'counts'? And if one is considered more
authoritative than another, how much is this hierarchy contingent
upon cultural settings – at both macro-level and micro-level?

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

them, at any level, is a challenge in and on itself. It is this very
achievement I sought in the years preceding the writing of this

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

5
 Black Butterflies

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

human understanding of the world and of himself within this
world.

Before entering the analysis itself, there are two issues that I
would like to address. Both relate to my choice to study the
'Western world'.

Much of anthropological attempts to understand human ways

and culture sought knowledge in social worlds other than the one
from which the discipline itself has sprouted from. This may be a
somewhat curious fact, considering it is itself the source of the
initial interest in – and conceptualisation of - the issue. While
acknowledging the value of these endeavours, I have chosen to
come back 'home', and to try to understand Western culture in its
own context, with its own dynamics, and with its own historical
development (each as defined by its own narratives).

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

one whole, and I must join these expressions of discontentment.
The Western world is indeed a mosaic of different cultures, whether
defined as based on national aspects, religious beliefs, gender
attributes, social stratification, etc. There is, however, one
important institution, which can be said to hold greater
homogeneity in respect to its epistemological and practical
grounds: Biomedicine. This has been acknowledged by endless
works in the sociology and anthropology of medicine, now well-
accepted subdisciplines, and sources of many theoretical
innovations in the social sciences in general.

The power of biomedicine in the Western world can hardly be

overrated: it may be one of the most dominant, influential, and
highly regarded profession and body of knowledge. Its

6
 Sky E. Gross

authoritativeness over the individual and the social allows it to be

the source and the culmination of values assigned to Western
culture in the most general meaning of the term. Thus, it seemed
most promising to turn to this field as an empirical arena for the
development of a general theory of knowledge as it applies to
Western society, in its modern and postmodern manifestations.

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

another vector of interest: the focal point within which the Western
modern individual defines his identity – mind and body, mind or
body. There, many complexities began to arise: am I a subject,
looking at the world from my own private perspective, defining
Truth as it is sensed, thought of, felt, by me, as an conscious
individual?; Or should I rather adopt a vision of myself as an object
among objects, in a world defined by a general (and scientific)
consensus on which is True, and which is False?

Once having ascertained biomedicine's tendency to reinforce

the second way of defining Truth (adopting a body-centred, or
objectifying epistemology), I shall look at the ways in which it is
resisted by a sense of truth as held by the experiencing subject.
These relations of power stood at the centre of my research in the
last years and will be placed at the centre of this essay as well. My
hope is to be able to convince the reader that these may form a
ground for a theory placing mind-body relations at a focal point in
the understanding of modern and postmodern Western
epistemological cultures.

7
 Black Butterflies

The Three Papers

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

substantiate, exemplify, and clarify the claims above. First, I will
propose a historical outlook on the ethical debate regarding
psychosurgery, the use of surgical, material means for treating the
mind; Second, I will bring the analysis of an in-situ work where I
observed the ways in which brain tumour diagnosis is reached,
when based on more or less objective forms of knowledge; And
third, I will lay down an analytical first-person narrative to bear on
processes of objectification associated with brain surgery, as
experienced by the field-worker.

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

reflexive – a representation of the theory itself, by which the mind-
body split infiltrates (as 'replicated boundaries') all layers of
sociocultural phenomena – from broad historical movements, to
micro-interactions, to personal thought. Accordingly, methods will
greatly vary, although remaining within the limits of qualitative
analysis. Although referred to in the coming section more careful
presentation of the methodology will be presented in each of the
three chapters, thereby avoiding redudancies and repetitions, as
well as making the compatibility between the work and the
methods explicitly evident.

Surgeons of the Mind

The first paper will serve as theoretical grounds for the overall
analysis proposed in this work. Thus, although heavily drawing on
philosophical insights, its aim will be to build a framework for a
social study of knowledge. In this, I will suggest a conceptual
framing whereby modern Western biomedical practice and research
sees two forms of knowledge coexist and fight for authoritativeness:

8
 Sky E. Gross

phenognosis (knowledge based on subjective experience) and

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

Drawing on philosophical and theoretical insights from recent

works on discourse, the body, and social studies of medicine, this
paper will propose an analysis raising cultural aspects of mind-
body dualism in modern and postmodern Western society. This
Cartesian split ('The Gnostic Split') will be pictured through a case-
study of the practice of frontal lobotomy ('psychosurgery'): the use
of brain surgery to transform the mentally-ill, yet fully sentient
individual into a complacent ‘object’, lacking the capacity for
subjective experience. An interpretative reading of the related texts
will show how certain epistemological assumptions led to the
overwhelming acceptance of the technique within modern medicine
of the 1940s-1960s, and how these have increasingly become
depicted as scandalous within a more recent post-modern
bioethical debate. The analysis will then relate this transformation
to the placing of human subjectivity above observable functioning as
more relevant goals of medical and social practices. The study of
the debate over psychosurgery will raise questions as to the ways
in which mind-body epistemologies affect conceptualisations of
humanhood and its association with self-consciousness (being a
subject) and the ability to accept ‘objective truth’ (being ‘sane’).
This historical analysis will allow a bird-eye, macro-level view of
the conceptual issues running throughout this work. It will assert
the social embodiment of the mind-body problem using a broad
perspective settled on the world of biomedicine. This will turn to be
essential to the understanding of the microdynamics associated
with the epistemological forces at hand, i.e. phenognosis and
ontognosis.

9
 Black Butterflies

Experts and 'Knowledge that Counts'

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

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

10
 Sky E. Gross
The World of Brain Surgery

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

can be discussed from the viewpoint of the objectifying party.
Resisting a dichotomy between physician-objectifying and
ethnographer-humanising, I will portray objectification as being of
a fluctuating nature, rather than a necessary by-product of
professional tendencies, epistemological bases, practical
necessities, and processes of socialisation. With this in mind, I will
propose a further look into the settings within which these
discursive dynamics take place and come about through artefacts,
space, symbols, etc. I will first briefly portray my relationship with
Ivan, a brain cancer patient whom I have followed over a period of
eighteen months, and then focus my attention on my observation
of the brain surgery he had to undergo. As it is presented from a
first-person perspective, this account will provide a glance into the
ways in which clinical or clinically-situated exchanges are not only
observed but also experienced.

Considering the breadth of the methodological and empirical

bases for this work, each chapter will be structured as relatively
independent unit, with its own body of literature and
methodological sections. This is, in many ways, the presentation of
three stand alone journal articles, as customarily composed and
structured in the professional academic press. First, references are
used only as far as they are directly relevant to the essays; and
secondly, the textual content is refined and condensed to create a
succinct and to-the-point exploration of the issues at hand.
Nevertheless, the integration of these papers into a unified scheme
allows a broader and more compelling development of the
theoretical framework which will serve the analysis throughout: the
idea of the 'gnostic split' and the suggested concept of 'replicated
boundaries'. I believe that neither of the papers, in and of

11
 Black Butterflies

themselves can provide sufficient ground for the conceptual

schemes proposed here.

12
 Sky E. Gross

Part II: The Argument and its Theoretical Complex

The Mind-Body Problem and Cartesian Dualism222

Descartes and After

"Cogito ergo Sum"

(I think therefore I am)

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

definition of the mind as an entity outside of the realm of matter.
More specifically, he would define how mind and matter were
distinct: Matter has a spatial extension, i.e., it has a place and a
dimension; Matter has proper characteristics and attributes, such
as colour and shape; Matter is public and accessible to all,
including to scientific observation. The mind, in contrast, will have
no spatial extension, no attributes, and exists in the private world
of the subject (Garber, 1992; Kendler, 2001).

Along the same lines, Descartes will claim that a human

being is not one entity, but rather has different parts: some
mechanical and some non-mechanical. The mind, in belonging to
the latter form, will thus constitute a form of 'ghost in the machine'
(Ryle, 1949; Koestler, 1967). The question of the nature of the
relations (or lack thereof) between 'the ghost' and 'the machine' will
become one of the more important foci of post-Cartesian Western
philosophy (Leibowitz, 1982). The most prominent philosophers
would argue for this or that view of the problem, giving birth to an
immense body of works.

Among the ways in which the problem was tackled, one may
find some that may be viewed as dualist and others as monist.
2
Note: some of the material presented here is borrowed from my own Master's Thesis

13
 Black Butterflies

Much like Descartes himself, philosophers adhering to dualist

views conceive of the problem as based on the relations between
two distinct ontological entities (entities that 'are' in the world).
Monists, however, will speak of one dominant substance: this being
either material (materialists) or spiritual (idealists) (Schimmel,
2001).

Dualist explanations, in turn, can be subdivided into

interactionist or non-interactionist ('parallelism'). As Descartes saw
mind and body as interacting entities (more specifically through
the 'pineal gland', an organ located deep within the brain), one
could define him as an interactionalist (Schimmel, 2001). Leibnitz
(1646-1716), in contrast, would see mind and body existing in
parallel, without having one affecting the other (non-causal
dualism, or non-interactionism). This 'identity theory' will have
mind and body as two manifestations of the same phenomenon –
thereby not claiming for a duality of substances but for a duality of
properties. 'Mind will appear when the question is approached from
a subjective angle, and 'matter' when approached objectively.
Trying, like monists and 'substance dualists' do, to ask whether
water is water or H2O, makes no sense to the 'property dualist':
these are not two phenomena, but rather two ways of looking at
one phenomenon (Kendler, 2001).

'Functionalism' will hold a somewhat related concept: the

mind-brain relationship would be comparable to drive-car
relationship, that is, rather than one being a by-product of the
other, there would be between the two a relation of function to
matter (Ben Zeev, 1996). An additional important dualist theory is
referred to as 'epiphenomenalism'. According to this view, mental
phenomena will be but a by-product of material substance, a
Hegelian 'foam on the wave' of brain activity. With the rising power

14
 Sky E. Gross

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

have become ever more pervasive.

The Cartesian Fallacy

The mind-body conundrum can be defined around the logical

fallacy arguably entailed by Cartesian dualism. Benjamin (1988),
for instance, brings us four prepositions, each considered 'true'
prima facie, yet logically incompatible with the others:

The human body is material.

The mind is spiritual.

Mind and body interact.

Spirit cannot affect matter and matter cannot affect spirit.

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

relinquish at least one of these assertions. This is, in the broadest
terms, the basis for the different philosophical approaches
described earlier:

The body would not be material (idealism);

The mind would be material (materialism);

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

identity theory, or ephiphenomenalism);

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

With the development of modern science, idealism has lost

most of its vigour. With the evolution of experimentalism and the
focus on pragmatism in the development of technologies,

15
 Black Butterflies

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

less or more extreme version – seemed to have led 20th century's
Western thought. This until recently, when modern physics
(notably quantum theory) raised questions as to the ontological
exclusivity of 'matter'. Along with more general trends of New Age
culture, this seems to have revitalised concepts regarding 'mind' as
a powerful entity, or to the very least, as a consequential actor in
the 'world', were it the world of 'nature' or the world of the 'social'.
This process will stand at the very centre of much of this current
work.

The accumulation of scientific knowledge leaves little doubt:

there is to the very least some correlation between the mental and
the cerebral. The question remains as to the idea of a causal
relationship: is brain activity a result of mental activity or vice-
versa? Science keeps reinforcing the concept of correlation, yet
does not take us closer to resolving the problem of causation
(Midgley, 1996). The answer must thus be found in the realm of
the cultural, of the social, where conceptualisations on the nature
of 'the world' originate and manifest themselves.

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

modern society's marked cultural character, as expressed in one of
its most powerful discourses: biomedicine. I will show it to be
based on movements between two distinct forms of knowledge,
each holding claims to the ultimate Truth: ontological (what IS in
this world, what are its fundamental essences); and
phenomenological (what is it like to BE, how is the world
experienced). For the sake of conciseness, and in order to avoid
ambiguities with related terms, I will term the former ontognosis
(gnosis – Greek for 'knowledge') and the latter, phenognosis. After
proposing an essential definition for each, I will turn to picture the
evolution and manifestations of these two epistemological forms

16
 Sky E. Gross

within broader contexts, affirming their relevance and

consequentiality in the sphere of the sociocultural.

Introducing the Gnostic Split

Phenognosis and Ontognosis

My analysis will follow a philosophical division of the mind-

body conundrum into two set of predicaments: the easy problem,
and the hard problem. The 'easy' problem involves a view of mind
and body as different kinds of fundamental essences of a 'world
out-there' (there is matter and there is mind, whether experienced
or not). The 'hard' problem emphasises an epistemological gap
between first-hand experience (‘felt’) and public, scientific
knowledge (‘observed’), or between subjective and objective
knowledge (Ornstein, 1972; Young, 1990). This 'hard' problem
rightfully earned its appellation. The subjective/objective split
presupposes a form of consciousness encompassing a set of
'truths' (often referred to as qualia) inaccessible to scientific
inquiry: the sight of the colour red, the sensation of an itching toe,
or a tooth ache whose actuality could never be disputed by a
dentist. Arguably, no progress of science will ever allow being,
feeling, or aching in the place of another, and no map of the brain,
however elaborate, will be able to convey subjective experience
(Damasio, 1994; Edelman, 2000; Searle et al., 1997). As Nagel
(1974), in his famous article "What is it like to be a Bat?"
eloquently notes, true knowledge of 'what it is like' is an
epistemological privilege reserved to the sentient subject, i.e., to the
bat itself: Only a bat would know 'what it feels like' to see with
sounds, and only a particular bat would know what it feels like to
be this particular bat (Jackson, 1982; Heil, 1988; Gertler, 2001).

17
 Black Butterflies

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

site where one turns acquired knowledge (of the world, of oneself)
into which he/she will define and often declare to constitute the
'Truth'. This, regardless of whether the source is the world-out-
there agreed upon by several individuals or one’s own
hallucinatory world. This first-person’s position is also the focal
point where facts become meanings and where data become
experience, this again, regardless of whether the meaning assigned
to a phenomenon seems ‘objectively’ acceptable or based on some
sort of psychological distortion (Edelman and Tononi, 2001;
Metzinger, 2003). This locus of 'Truth', based on 'I know', 'I think',
'I feel' (phenomenological Truth), will often be challenged and
questioned by a claim for Truth based on 'There is', or 'This is'
(ontological Truth), a claim most often originating from the world of
science and biomedicine.

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

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

The Body and Embodiment: Closing the Great Divide

Phenomenology has its basis in philosophy and finds itself at

the centre of much contemporary work in the philosophy of mind,
namely in the field of neurosciences. For instance, one may find
such a view in Bennett and Hacker's famous essay, "Philosophical
Foundations of Neurosciences":

"A human being is a psychophysical unity, an animal

that can perceive, act intentionally, reason, and feel

18
 Sky E. Gross

emotion, a language-using animal that is not

merely conscious, but also self-conscious – not a
brain embedded in the skull of a body" (Bennett
and Hacker, 2003:3) [my emphasis, S.G.]

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

philosophical attempts to either deny its existence or dissolve its
problematic aspects. One such important – and relatively recent –
attempt can be found in French philosophy and human sciences
(Lanigan, 1991): Maurice Merleau-Ponty (e.g. 1962) sought the
resolution, or rather, the conceptual annihilation of the Cartesian
split. According to him and to many of his existentialist and
phenomenologist predecessors, although the body could be seen as
an mere object, 'experience' or 'mind' cannot. The latter will only
exist as far as it is embodied: the mind is not the 'ghost in the
machine' – it is rather the experiencing, first-person, façade of the
machine. While the body may be without mind, the mind cannot be
without body: both empirically and philosophically, perception,
action, cognition, emotion are all 'embodied phenomena'.

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

organism: it keeps the visible spectacle constantly
alive, it breathes life into it and sustains it inwardly,
and with it forms a system" (Merleau-Ponty, 1945 in
Lanigan, 1995a: 203).

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

while the body may be regarded as a mere physiological and
natural entity (an 'objective body'), it will, once experienced, turn
into a 'phenomenal body'- unified with (rather than distinct from)
this physiological entity. The phenomenal body, thus, must be
viewed as one with the objective body: experience is experience of
the body, rather than an entity IN the body.

19
 Black Butterflies

Social Studies of Medicine and the Body

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

have taken up these leads and engendered considerable research
on the existential and phenomenological groundings of the self and
its relation to 'the body'. This was associated with an ongoing effort
to account for possible gaps between 'sentience' and 'science' at the
level of the self, a self problematised as dual (mind vs. body) by
external expert knowledge (most notably by medical practitioners,
dealing directly with the 'body in pain', or the 'experiencing flesh').
These works generally sought to merge the body’s objective façade
with the less tangible subjective experience of which it serves as
the locus. This would lead to the understanding of culture and
experience "insofar as these can be understood from the
standpoint of bodily being-in-the-world." (Csordas, 1994:143).

Along tangential lines, feminist literature took on the task of

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

20
 Sky E. Gross

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

1995; Turner, 1996; Lupton, 1994; Williams, 1996) have shown
how much 'we are our bodies' and how much of the mind-body
split remains unchallenged by current sociological work (Nettleton,
2006). Thomas Csordas, one of the leading scholars in the field,
explains that the shift from looking into the body to considering the
phenomenon of embodiment:

"…corresponds directly to a shift from viewing the

body as a nongendered, prediscursive phenomenon
that plays a central role in perception, cognition,
action and nature to a way of living or inhabiting
the world through one's acculturated body."
(Csordas, 1994: xiv).

Overall, while ascertaining the presence of epistemological

conflicts in micro-settings where third-person and first-person
views collide (IT vs. I), even these 'embodiment'-oriented
undertakings show little concern for the changing hierarchies
between the two forms of Truth (subjectively experienced vs.
objectively accountable) as broad discursive forces. For instance,
while Turner (1992) brings up the distinction between leib (the
lived body) and korper (the physiological body), he uses it as to
show the preciousness of the leib over the korper as a source and
grounds for culture. Still, the relationship between the two as
'Truths' is never analysed as such.

Throughout this work, I will seek to provide such a

complementary outlook, using Foucault’s (1986) notion of
discursive practices as entailing human desire for 'Truth' about the
world and about the self. In an attempt to do so, I will first propose
a theoretical framing and then attempt to work the theory into the
canvas of the social settings from which individual cases were

21
 Black Butterflies

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

The Discourses of Truth: Foucault and Beyond

Biomedical and scientific discourses generally comply with

ontognostic views whereby Truth would be accessible through the
unravelling of the world of material essences. Medical knowledge is
essentially of a reductionist nature, paying little or no attention to
the subjective aspects of disease. This ontognostic epistemology is,
in turn, associated with the foundation of a powerful ethos, the
establishment of an authoritative system of rhetorics, and the
drawing on highly evocative symbolic elements - all of which
serving to support its discursive supremacy.

Biomedicine has had indeed notable success in achieving this

demarcation as highly respectable, trustworthy, and distinctive
from other social spheres, such as religion, politics, and economics
(Gieryn, 1983, 1999; Mizrachi et al., 2005). This distinction
persists within a particular power structure where a hegemonic
regime of truth is established, defining the forms of knowledge
considered admissible while dismissing competing claims for Truth
(Foucault, 1972, 1980, 1986; Armstrong, 1983). This will ipso-facto
place non-scientifically based knowledge – including phenognosis -
in a subordinate position (Foucault, 1982). Phenognosis, however,
should not be seen as comprising mere 'leftovers' of this biomedical
ontognosis. When considering the development of post-modernism,
the linking of subjectivity with power relations will reveal that it
may indeed constitute a rising discursive force.

In the 1979 Stanford Lectures, Foucault stated that what

troubled him since his first book was:

"In what way are those fundamental experiences of

22
 Sky E. Gross

madness, suffering, death, crime, individuality

connected, even if we are not aware of it, with
knowledge and with power? I am sure I'll never get
the answer; but that does not mean that we don't
have to get the question".

Foucault's analyses distinguish between discursive events

and prediscursive events – i.e., 'things' that are not based on
discourse, and that have not been produced by the social. These
include pain, madness, and experience of self. I shall claim here
that Foucault may have had the question misspelled: what if these
experiences were not prediscursive, but rather discursive? After all,
following his claim that 'Man' is but a discursive event, a "new
wrinkle in our knowledge" (Foucault, 1972; Goldstein, 1994), why
not consider 'Man' as a discursive event based on the phenognostic
authoritativeness of human experience?

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

own lifework can be defined as revolving around this issue of
discursive subordination, both his writing and more recent
literature has, by and large, omitted the option of a symmetrical
opposite, by which phenognosis itself would serve as grounds for
legitimacy and, therefore, for power. When at all acknowledging
subjective forms of knowledge, these works rather deal with them
in oppositum to the hegemonic power/knowledge, that is, through
the challenges it may present to the material-ontological bases of
biomedicine, science, and modern Western social order (e.g.
Eisenberg, 1977; Rosenberg and Golden, 1992; Rosenberg, 1999;
Mizrachi et al., 2005).

Traditionally then, phenognosis, as a consequent discursive

formation in and on itself, rarely seems to be deserving particular
interest, again making the relationships of power between

23
 Black Butterflies

phenomenological and ontological forms of knowledge critically

understudied. This lack of attention remains somewhat enigmatic
considering recent historical developments.

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

the form of hierarchical changes in the statuses of the two forms of
knowledge. This shift had both roots and repercussions within
what social sciences have traditionally referred to as the rise of the
postmodern (Lyotard, 1984; Harvey, 1989). This postmodern era
would see critiques of science joining existential,
phenomenological, and relativist influences in the social sciences
(and in general culture, most particularly in art and literature), to
pave the way toward a destabilisation of the grounds upon which
ontognosis drew its force. Grand ontological and metaphysical
accounts lost grace to local, negotiated, and provisional forms of
knowledge, thereby allowing experience to ascend as a legitimate
source of Truth.

Still, although overwhelmingly rooted in phenomenological

thought, more radical postmodernism will reject the whole idea of
Truth, including – if ever considered- phenognosis (Bourdieu, 1992;
Dickens and Fontana, 1994). Thus, while postmodernist thought
may have notable affinities with ideas associated with the concept
of phenognosis, one cannot stress enough the distinctiveness of the
two worlds of notions, whereby stands the value of the proposed
reconceptualisation. This issue shall be clarified as this analysis
develops.

24
 Sky E. Gross

Introducing Replicated Boundaries

The reconceptualisation of the mind-body conundrum will

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

The Gnostic Split and Replicated Boundaries

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

social phenomena, how can one discern, detect, or recognise its
manifestations? How are phenognosis\ontognosis reflected in the
institutional, symbolic, interactional, spatial, professional,
epistemological spheres?

The systems of classification we hold ordinate the creation of

boundaries at many layers of cultural phenomena (Abbott, 1995),
thus forming 'replicated boundaries'. In broad terms, replicated
boundaries refer to the presence of epistemological groundings –
here, as a relation between two forms of knowledge- which will
replicate themselves in several spheres concurrently, and still keep
structural similarities. These spheres may include both lay and
professional epistemologies and practices, and may encompass
beliefs, classifications, actions, symbols, etc. If, for instance, one
finds a process of subordination of one form of knowledge to
another, this will come about in the subordination of one
professional sphere to another (e.g. one group of professionals
losing their status), in changes in the ways in which space is
distributed (e.g. forming a panoptical advantage in spaces where
the more powerful form of knowledge is exercised), and so on.

25
 Black Butterflies

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

assert that ontognosis' failure to conquer and subordinate
phenognosis led to a rejection of the latter from the territories of
the former; and that this was followed by the creation of robust
limits to forestall any 'leaking' of the phenognosis into ontognosis'
terrains. I shall further claim that these bounding limits will not
remain within the layer of the abstract, and will have powerful
manifestations at several layers simultaneously: the splitting of
brain and mind in the professional layer (e.g. neurology vs.
psychiatry), in the layer of the spatial organisation of biomedical
areas (e.g. where the operation room becomes a well-bounded
ontognostic shrine), in the symbolic layer (e.g. the apparatus used
to keep each form of knowledge distinct in social settings), the
conceptual layer (e.g. in the case of brain tumours - the conceiving
of oneself as either body or mind) and in the more general
discursive layer, where definitions of authoritativeness remain
crucial (e.g. hierarchies of sources of information in the forming of
diagnosis).

The phenomenon of replicated boundaries will accompany us

throughout the analysis, in which I hope to be able to establish it
as a valuable theoretical concept.

Replicated Boundaries: The Professional Grounds

Professions constitute social fields where particular

organisations of knowledge are often manifested in a most palpable
way. In the course of this study, I have thus chosen to lay special
attention to the professional developments of the fields where the
mind\body split would come about most noticeably, that is,
biomedicine, and most particularly, neurology ('the profession of
the brain') and psychiatry ('the profession of the mind').

26
 Sky E. Gross

The rise of the professions is related to the processes of

secularisation in Western society around the late eighteenth and
nineteenth centuries (Parsons, 1971; Goldstein, 1994). Parsons
(1971:145) sees the professionalisation as a "criteria of cultural
legitimacy", and sees it as the "single most important component in
the structure of modern societies". Foucault (1982) joins him in
pointing to the importance of the professions in Western modern
societies. Associated with the interest in professions and the
attempts to define the phenomenon has always been the study of
knowledge and of epistemological subordination. As claimed by
McDonald (1995: 160), “professions are knowledge-based
occupations and therefore the nature of their knowledge and the
occupations strategies in handling their knowledge base are of
central importance”. For Foucault, for instance, the unbreakable
link between abstract knowledge and the profession would be
based on the idea of the 'gaze', most often present in discourses
related to the practice and epistemological grounds of medicine
(Goldstein, 1994).

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

that enable it to be referred to as a profession, rather than a mere
occupation. First, it holds a body of abstract knowledge which
must be mastered by its members; Second, it holds a degree of
exclusivity in the relevant field of practice and knowledge; Third, it
is autonomous in the definition of its practice; And finally, it holds
a 'service ideal', that is a disinterested practice that is based on
altruistic rather than self-centred objectives (Wilensky, 1964;
Goldstein, 2001).

The need for professions to isolate themselves from other

forms of culture and to gain power through knowledge involves
processes of 'boundary-work'. There are several ways in which
biomedicine, as an ideal type of profession may 'do' boundary-work

27
 Black Butterflies

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

authority or expertise into domains claimed by other professions or
occupations; Secondly, by creating a clearer contrast between itself
and its rivals; Thirdly, by monopolisation of professional authority
and resources; Finally, by labelling rivals as pseudo or amateurish
and exclude them from its turf.

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

resolution of jurisdictional (and knowledge-related) conflicts
between professions may entail three possible forms: the control of
one profession over a field of jurisdiction; split jurisdiction; and
subordination. These relations find themselves replicated on
several layers, hence my proposed definition of replicated
boundaries. This involves symbolic, rhetorical and professional
modes of boundary formation around and in parallel to these forms
of knowledge.

From a more recent perspective, Gieryn (1999) defined

'science' –the basis for biomedicine's authoritativeness - as placed
on 'a map of culture', bounded off from other territories such as
common sense, politics, or mysticism. In my view, these 'non-
science' territories can all be seen as belonging to the subjective
realm, as the interest of science is to remain the home of
objectivity, reason, and truth. In this case, drawing a map of
science is but replicating a map of a gnostic split.

This essay presents particular cases of professional

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

28
 Sky E. Gross

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

two kinds of truths.

29
 Black Butterflies

Part III: Surgeons of the Mind

Frontal Lobotomy and the Mind-Body Problem

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

serve as a case-study where the key concepts of 'ontognosis' and
'phenognosis' are taken to their extreme. The boundaries between
the two forms of knowledge will come about at the level of temporal
developments as well as at the level of professional dynamics. Its
value as a basis for analysis is manifold: First, the case reflects a
daring attempt to bridge Cartesian dualism –acting upon matter to
alter the realm of the mind-- making this chasm remarkably
explicit. Furthermore, it relates to the cultural significance of the
brain in biomedical thought. Finally, one cannot overrate what is
at stake here: i.e., notions of humanhood, experience, existence,
and consciousness (Kleinman, 1997). This may account, at least
partially, for the fact that, while over the years many medical
procedures were eagerly embraced only to be consequently
rejected, few arose as lively debates and as much moral outrage as
psychosurgery's.

Introduction

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

of elementary acts than an intellect where there
reigns disorder of subtle synthesis. Society can
accommodate itself to the most humble laborer, but
it justifiably distrusts the mad thinker". Walter
Freeman, psychosurgeon, 1942 (cited in Kucharski,
1984:766)

I will suggest here an integrative analysis of the cultural and

philosophical aspects of mind-body dualism in modern and
postmodern Western society. I will picture this chasm, now broadly

30
 Sky E. Gross

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

frontal lobotomy 3 (‘psychosurgery’): a modern endeavour using
brain surgery to transform the mentally-ill -- yet fully sentient--
individual into a self-content ‘object’ only partially able to sense
subjective experiences. I will demonstrate, with the aid of an
interpretative reading of texts related to the debate, how
epistemological assumptions associated with the Gnostic Split have
led to the overwhelming acceptance of the technique within modern
medicine of the 1940s-1960s, and how these have increasingly
become depicted as 'outrageous' within a more recent post-modern
bioethical debate. More specifically, I will relate this transformation
to the placing of human subjectivity above observable functioning as
the ultimate goals of medical and social practices.

Lobotomy in Mind: Methodology

A Historical Approach to the Study of Replicated Boundaries

"Sociological explanation is necessarily historical.

Historical sociology is thus not some kind of
sociology; rather it is the essence of the discipline"
(Abrams, 1982:2).

Historical analysis is often most resourceful when tackling

central interests of sociology (Abrams, 1982). It enables a drawing
of infinite changes and shifts in the relations of the subject matter
with other contexts. Boundaries can be understood as a belonging
to a process through time: their locations are drawn and redrawn,
at times strengthened, at others weakened. This and more, the two
sides of the borders are ever changing, both defining and being
defined by the boundary, or the relationship with the 'other'. This
is why a proper study of boundaries should involve a temporal
3
Lobotomy is but one psychosurgical technique – yet, as it is of common usage to refer to the latter by
the former, and as it was the most practiced form of psychosurgery, I will use both terms alternately.

31
 Black Butterflies

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

between two entities, were it professional, sociocultural, or
epistemological entities.

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

seek the theoretical drawing on a historical case, and not a detailed
description, or critical reconstruction of an event. Psychosurgery is
brought here as a "historical individual" in Weber's sense, that is,
as a form of historical ideal type of the phenomenon at hand, or:

"…a complex of elements associated in historical

reality which we unite into a conceptual whole from
the standpoint of their cultural significance".
(Weber, [1930] 2001:47).

And it is the cultural significance associated with the dealing

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

Reading Psychosurgery

The insights presented here find support in an empirical

groundwork study of texts pertaining to the portrayal of
psychosurgery and to the debate it generated. The focus on
professional publications –mainly medical, but also from the social
sciences-- provided a relatively continuous frame of analysis, that
was, as a rule, devoid of dramatisation tendencies often present in
lay reports. Primary sources included books and journal articles
published since the 1930's, the selection criterion being their
referring to terms related to psychosurgery or to its main
practitioners. I have included both French and English sources
collected in two central libraries in Paris, and four in Israel. This
revealed 384 articles and 14 major book publications. I interpreted
the texts along a chronological thread, as well as through several

32
 Sky E. Gross

overarching themes: the criteria for the evaluation of the

procedure; the rhetorical devices employed; positive/negative
stances; and finally, the drawing on symbolic aspects of medical
practice. I then defined the debate as rotating around a number of
issues.

First was the inadequateness of theoretical and empirical

bases- using a method of trial and error on groups of patients
diagnosed with etiologically, nosologically, and symptomatically
diverse mental pathologies.

Second were the procedure's mutilating aspects and the

irreversibility of its effects as it inflicted great damage to both
affective, cognitive, and physical functioning by the severance of
brain tissue not targeted by the procedure.

Third were issues of obtaining informed consent from mental

patients, some going as far as claiming the latter to be infeasible in
the case of such extreme mental transformation: in terms of
personality, the patient giving his consent may not be the same
person going through the postoperative phase.

A fourth matter included questions of human

experimentation, with practitioners having limited tools to predict
the outcomes and calculate the risks of such an intervention.

Another issue was the immense power accorded to the

psychosurgeon in social and political spheres: Critics, in fact, often
associated the procedure with contemporary Hitlerian concepts of
euthanasia and eugenics.

And finally was the theme of abuses and aberrations observed

through the implementation of the different procedures, including
interventions on children as young as four year old (Valenstein,

33
 Black Butterflies

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

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

Browsing through the literature, one typically finds depictions

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

On Psychosurgery

34
 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 co-
founder of the American Board of Psychiatry and Neurology),
Edward Strecker (vice-president of the American Neurological
Association and president of the American Psychiatric Association),
and Harold Solomon (president of the Association of Nervous and
Mental Disease). Some promised a full recovery to a significant
share of patients. In 1949, Moniz was granted the most prestigious
scientific acknowledgement: the Nobel Prize (Berrios, 1997; Ligon,
1998). Three years later, the Pope himself accorded psychosurgery
his blessing (Rouvroy, 1954). In the words of one of the
practitioners:

“[Prefrontal lobotomy is] the realization of a new

stage in neurosurgery […]. The introduction of
surgery in the treatment of affective disorders is a
momentous event.” (Wertheimer, 1948:497)

or,

"Psychiatrists, neurologists, and neurological

surgeons may well look back upon the period before
the discoveries of Egas Moniz as equivalent to the
Dark Ages." (Freeman, 1956:771).

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

one of medicine's greatest promises: In the US of the 1940s, many
would consider it unethical not to propose lobotomy to some

35
 Black Butterflies

patients. In fact, both asylum psychiatrists and neurosurgeons

viewed it as no less than a breakthrough in the scientific
understanding of the mind. By 1960, tens of thousands of
psychosurgical interventions were conducted worldwide, most
particularly in the US, but also in Continental Europe, the UK, and
Japan (Hirose, 1972; Donnelly, 1978; Kucharski, 1984). Between
1942 and 1954, 10,365 were counted in the UK. Until mid 1941,
more than 18,600 operations were performed in the US (Swayze,
1995). Globally, according to Silverman (2001), since 1945 the
number of lobotomies doubled each year: from 240 in 1945, to
more than 5,000 in 1949.

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

between 1942 and 1954 shows that 41% were fully cured or greatly
improved, 28% had little improvement, 25% seemed not to be
affected by the operation, 2% saw their symptoms aggravated and
4% would die as a result of the procedure. Indeed, a great part of
the studied literature shows a distribution of approximately a third
of 'favourable' results (where symptoms disappeared altogether or
at least greatly improved), a third of 'medium' results (where some
improvement can be observed) and a third of failures (no change,
or the patient's condition has worsen). Still, and although already
in the 1930s most professional widely and openly acknowledged
the ill effects of the operation, both physicians and family members
tended to consider the postoperative patient as better off, or even
cured.

Essentially, psychosurgery offered a source of hope for the

deliverance of the mentally ill from the misery of their existence.
This enthusiastic embrace, however, soon waned. By 1960,
psychosurgery did not only lose grace, but also acquired a
gruesome image as one of medicine's darkest episodes. Fewer and
fewer neurologists showed interest in the technique, research grew

36
 Sky E. Gross

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

mental asylums. From a symbol of scientific progress,
psychosurgery came to be regarded as the craft of mad scientists
with ill-defined intentions of mind-control at best, and of pure
sadism at worse.

In the popular press, changes in the attitude towards

psychosurgery were evident (Diefenbach et al., 1999). The first
publications, initiated in 1936, were brief medical reports,
becoming increasingly detailed by 1941. The tone was largely
positive, the descriptions overstating the practice’s miraculous
effects. Between 1945 and 1954, the press became progressively
more critical, with a rising number of negative reports. It is only in
the late fifties that a strong polarisation occurred, with a typical
depiction of the practice as a form of “menticide” or “mental
euthanasia” (e.g. Baruk, 1953, 1956; Umbach, 1976; Chorover,
1974, 1979). With the rise of anti-institutional and anti-
governmental movements in the late sixties and early seventies,
many texts, mainly in the lay press, began to associate
psychosurgery with other forms of governmental excesses of power,
including malicious brain-control techniques. 'Brain-washing' was
so entrenched in the public imagination, that psychosurgery
immediately joined the list of techniques thought to be in the
arsenal of the opponent, whether in the form of agents of secret
services, or as radical communists seeking control over the
American mind.

Today, the concept of frontal lobotomy has some grim

connotations. Although by now, with the introduction of anti-
psychotics, the use of the technique has become extremely rare
(and much more advanced in both target, technology, diagnosis
etc.), an aversion towards the very concept of psychosurgery,
invariably seen as destructive and abusive, is still clearly present

37
 Black Butterflies

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

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

Creating Ontognostic Legitimacy

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

'Prehistorical' Sources

Although often ignored in historical accounts of the

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

38
 Sky E. Gross

This report led to the more ambitious (and controversial)

experiments of Gottlieb Burckhardt, the head of a large Swiss
mental asylum. He put forward the idea that the creation of a
barrier -in the form of a surgical cutting through nervous tissue -
between the cortex (conceived as responsible for the reception and
processing of sensory information) and the lower areas of the brain
(the 'motor areas') will relieve some of the pathological behaviour of
mental patients: and most particularly, behaviour that involved the
patients’ lack of control over themselves (Stone, 2001).

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

dangerous and difficult" patient of the asylum. This 51 year old
woman, diagnosed with schizophrenia, was impulsive and violent.
She has been hospitalised for the last 16 years, mainly in isolation.
She once almost strangled to death one of the nurses, and did not
seem to be responsive to any kind of treatment known at the time.
Suffering from chronic diarrhoea and of a lack of proper hygienic
manners, she had to be assigned with two nurses around the
clock. She was particularly difficult to maintain under control as
she spent many of her days screaming in the halls of the asylum.
Burckhardt (1890, in Stone, 2001:83) then began to wonder
whether it would make any sense to:

"…extract this impulsive emotional element from her

brain mechanism, transforming her from an excited
patient to a calmer dement schizophrenic”.

Four surgical operations were conducted on Frau B. in the

course of the next fourteen months. Almost 15 grams of her brain
tissue were removed. Each operation seemed to have had a calming
effect on the patient. As Burckhardt himself put it:

“Though her intelligence seems to have been lost,

39
 Black Butterflies

she is now calmer and less dangerous”. (Burckhardt

1890, in Stone, 2001:83)

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

will not survive the operation, and another will commit suicide
shortly after. The positive effects on the subjects' hallucinations
and agitated behaviour did not, however, convince the psychiatric
community of the beneficial potential of this avant-garde
procedure. Burckhardt suffered from harsh criticism and was
forced to bring his experiments to an end, although claiming:

“I will not let myself be discouraged and I hope

neither will my colleagues, but rather, they will use
my experiences and go the way of cortical
extirpations and achieve continued better and
improved results”. (in Stone, 2001: 85)

Burckhardt died convinced of the potential hiding behind this

new technique, stating he could have turned asylum’s chronic
population into calm and satisfied mental patients.

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

resurge. Yet, its origins in Burckhardt's work were, perhaps most
conveniently, forgotten. Considered as utterly unscientific, none of
the more modern psychosurgeons wished to have their practice
associated with it.

Replicated Boundaries: The Professional and the Legitimate

I shall claim here that the boundaries created between

neurology and psychiatry represent replicates of layers of broader
sociocultural boundaries in Western thought: the boundaries
between objective and subjective. They reassert an ethos, a way of
thinking the world. Thus pure reason becomes pure objectivity,

40
 Sky E. Gross

pure science: neurology as a mainstream biomedical and scientific

endeavour on the one end; and the fuzzy, the emotional, the soiled,
the subjective psychiatry on the other. Inside the category of pure
reason reigns order and inner classification, and outside: chaos.

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

and fast-growing academic fields (Abbott, 1988; Pressman, 1988).
Comprising a rather small group of physicians, neurology sought
an alliance with psychiatry, a more commonly practiced, albeit less
prestigious, form of medicine (Abbott, 1988; Gelfand, 2000). By the
1920s, a unification of the fields was undertaken, to the benefit of
both professions. As knowledge on the anatomy and structure of
the brain began to accumulate, 'neuropsychiatry' of the early 20th
century became dominant in research on the cerebral basis for
mental illness (Marti-Ibanez et al., 1954; Lishman, 1992). However,
while 'pure' neurology pursued the incorporation of functional (or
'mental') diseases into the medical field, psychiatry remained
associated with psychological – i.e. non-medical— disciplines, such
as psychoanalysis (Fadda, 1988; Eisenberg, 1995; Shorter, 1997).

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

passed over from psychiatry’s managing know-how, to neurology as
an expertise founded on complex and abstract knowledge
(Alexander and Selesnick, 1997; Seli and Shapiro, 1997).
Psychiatry was to rely on subjective, introspective accounts, or
symptoms. Neurology, on the other hand, could attain diagnoses
through quantifiable, communicable, and scientifically reliable
signs (Audisio, 1968; Price et al., 2000). The disciplinary separation
of what will become the fields of psychiatry and neurology is
strongly correlated with the distinction made between physical and
mental pathology. As more and more once believed to be mental
disease, have found their physical basis in brain pathology,
neurology has grown to encompass an enlarging group of brain

41
 Black Butterflies

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

diseases such as aphasia and epilepsy have been relocated from
the blurry field of psychiatry to the more medical-like field of
neurology. The physical nature of disease will be attributed to any
brain-related pathology which physical basis can be understood
and clearly tagged. The psychic nature of disease will be attributed
to any mental syndrome for which no apparent 'physical' cause
could be found. The former group of diseases will belong to
neurology as a medical expertise, while the latter will be left in the
hands of psychiatrists, then conceived as mental asylum
practitioners, mainly directing day-to-day life conditions for mental
patients (more 'technicians' than 'experts'). Medical treatment for
actual 'psyche-related' disease will be inconceivable, since the
basic definition of such a disease is related to the absence of
known brain-pathology.

In other words, the separation between mental – and therefore

non-medical – disease, and physical – and therefore treatable
within medicine – disease, shaped the separation of psychiatry
from neurology, turning psychiatry into a mere nursing
specialisation. This process is not a simple labour separation
process, as the epistemological bases of both of the fields were
deeply affected by this psychophysic separation. One of the effects
is the large group of psychiatrists leaning towards new
psychoanalytical stances, growing apart from the medical model
that has excluded them and marginalised their practice. Early 20th
century saw two groups of psychiatrists beginning to emerge: while
the more psychoanalytically-oriented would insist on a
'psychogenetic' (originating from psychological processes)
explanation of mental illness, another substantial group will
persist in its search for the organic and neurological bases of
mental illness. While the former abandoned any aspirations
regarding the integration into the more mainstream medical model,

42
 Sky E. Gross

the latter will strengthen its efforts to differentiate itself from the
'philosophical therapy' to resemble a more scientific model of
medicine. This quest will be the main drive of psychiatric research
into organic-based cures to mental illness, cures that were believed
to be able to form a bridge over the ever growing gulf between
psychiatry and neurology.

Thus, the areas of professional jurisdictions gradually aligned

themselves around a distinct, though implicit, principle: the
gnostic split. While neurology adhered to purely scientific
ontognosis, psychiatry remained in an awkward position: treating
psyche-related illness, yet holding on to an organic epistemology.
Psychiatry suffered from a lack of clarity as to its basis of
legitimacy, hanging in the midst between ontognostic and
phenognostic grounds, leading to a severe identity crisis present to
this day (Armor and Klerman, 1968; Torrey, 1975; Light, 1980;
Merino, 2000). At the time, however, relentless efforts were made to
medicalise (and thus 'truthicise' or 'make true') psychiatry.
Psychosurgery stood at the very centre of this task.

Building the Heroic Ethos

"Doctors are different in nature. One kind adheres to

the old principle: first do not harm; The other one
says: it is better to do something than nothing. I
certainly belong to the second category". (Gottlieb
Burckhardt, lobotomy pioneer)

This statement raises one of the central points contrasting the

Hippocratic notion of medical ethics with the kind of ethic
proclaimed by psychosurgeons. The 'primum non nocere' principle
cannot hold in the face of horrifying mental suffering, and
43
 Black Butterflies

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

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

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

ethos of a pure and disinterested search for Truth, the mere
practicability and applicability of a scientific development may be
of no lesser significance (Gieryn, 1983, 1999). In practice, early
20th century's psychiatry held a meagre therapeutic arsenal:
asylum psychiatrists had to content with watching over the
mentally ill and nursing them in their daily routine (McGovern,
1985; Witz, 1992; Shorter, 1997; Abbott and Meerabeau, 1998).
Was psychosurgery to be proven beneficial, it would allow the
discipline to become medicine-like, thus becoming a cure rather
than a care specialisation (Sargant, 1976; Gieryn, 1983, 1999;
Swayze, 1995). This demarcation would then allow the
practitioners to draw upon the legitimacy placed in core medical
practice: the holding of measures that were both heroic and
therapeutic.

The Founding Tale

"For the physical therapy of mental disorders they

[the neuropsychiatrists] had the malaria treatment
of neurosyphilis and prolonged sleep.
Electroencephalography was in its infancy, shock
therapy by insulin and metrazol almost coincided
with leucotomy, radioactive isotopes were unknown,
and control of the autonomic system by
pharmacological means was just beginning. The
introduction by Moniz of cerebral angiography in
1927, and of psychosurgery in 1936 brought about a
revolution in diagnosis and treatment, the eventual

44
 Sky E. Gross

extension of which is not yet in sight". Freeman

(1956:771).

An examination of the founding texts reveals that

psychosurgery's quest for scientific legitimacy involved a rhetorical
portrayal of the practice's birth as a momentous breakthrough.
Throughout the years, the tale of its burgeoning was reiterated in
the work of Walter Freeman, one of its most powerful and diligent
proponents. Within several important publications, Freeman
persistently re-established the ethos of psychosurgery's 'discovery',
by Egas Moniz:

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

during their presentation, Jacobsen and Fulton]
noted a profound alteration in response to
frustration in the chimpanzee with both frontal
poles excised. Before the operation, if the animal
made a few mistakes, it would scream with rage,
urinate and defecate in the cage, roll in the feces,
shake the bars and refuse to continue in the
experiments. After the operation [the excision of the
frontal lobes], the same animal would continue in
the experimental situation long beyond the patience
of the examiner, making mistake after mistake,
without the least indication of being upset
emotionally." (Freeman and Watts, 1947:417)

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

stood up in admiration of Jacobsen and Fulton's presentation. He
is said to have inquired as to whether the reproduction of such
attempts on human would be conceivable. The murmurs of
disbelief in the crowd did not discourage Moniz. In fact, he is

45
 Black Butterflies

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

have soon begun his experiments.

This founding tale is present in numerous reports, while,

according to Pressman (1988), having little grounds on reality. The
drawing of the events seems to serve as a constitutive myth, much
less than as a historical account. In a way, the portrayal of Moniz'
deductive mind offered the endeavour a halo of insightful scientific
thought.

Out of the Laboratory

Psychosurgery's initial association with neurology, rather

than psychiatry, would (and eventually did) provide a powerful
stamp of legitimacy. Thus, not incidentally did Freeman observe
that Moniz' 'Eureka' was sounded in the course of a prized
academic neuro-anatomical presentation, and in response to
empirical data advanced by two of the world's most prominent
neurologists: John Fulton and Carlyle Jacobsen. Walter Freeman
and his associate, James Watts (1947:417) begin their presentation
of ten years retrospective on psychosurgeries by presenting the
founding tale again, stressing psychosurgery’s basis on a logical
derivation from the respectable scientific laboratory work on
animal anatomy:

"Moniz presented many of his angiograms at the

Second International Neurological Congress in
London in 1935. It was at this Congress that the
symposium on the frontal lobes brought forth a
great deal of discussion concerning the disturbing
effects upon personality that followed wounds and
tumours in this region. […]". (Freeman, 1956:769)

46
 Sky E. Gross

The presentation of psychosurgery as evolving as part of an

existing line of work in the scientific community did seem to have
had an effect on its endorsement, if only by asserting its position
within an ontognostic 'normal science' (Kuhn, 1970). For instance,
linking the practice to the body of accumulated knowledge on brain
localisation, Marchand and his colleagues reported that frontal
lobotomy would allow to "enrich our anatomo-physiological
knowledge of the human brain." (Marchand et al., 1949:515). Moniz
himself sought to advance psychosurgery's position within his
contemporary’s work on the localisation of cerebral functions,
thoroughly underlining his leaning on "anatomical, physiological,
and clinical facts" (Moniz, 1936a:55).

"In the brain there are regions that are particularly

related to mental activity. If we wish to drift away
from this organic orientation, we will enter domains
that seem to us entirely unacceptable". (Moniz,
1936a:40)

"Psychic life is exteriorized in a different manner,

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

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

practice not only in terms of the relief it could allow the mentally
ill, but also in terms of the potential accumulation of knowledge on
the brain and its functions. There, by being able to spatially define
the mind, science could replace explanation by classification.
Moniz will then take part in the quest for the Holy Grail of science:
the mind. This presented psychosurgery as a symbol of a genuine
scientific quest for 'Truth' through objective observation and

47
 Black Butterflies

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

endeavour:

"[if our experiments prove to be successful] we

would have put in relation, and in a definitive
manner, the mental functions, and the parts of the
brain that take part in their production. It would be
a great progress as a primordial fact in the study of
the organic bases of the mental functions". (Moniz,
1936a:55)

In sum, the underlining of this empirical basis served to

reinforce the founding myth, and to support the rhetoric placing
the procedure on an ontognostic-based legitimacy, as out of the
laboratory, the 'factory of Truth'.

Men of Science

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

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

"Here was a brilliant discovery belittled through

political antagonism and possible professional
jealousy, but more likely through philosophical
tenets that blinded Sobral Cid to the extraordinary
alterations that occurred in psychotic subjects at the
moment of prefrontal leucotomy".

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

grounds: political antagonism, professional jealousy, and

48
 Sky E. Gross

"philosophical tenets". Moniz himself is presented as being

"extraordinarily modest":

"He was never flamboyant in his speech; rather he

lectured or presided with courtesy and dignity, and
gave expression to his thought in measured terms.
His was an inner life of thought rather than an outer
one of action" (Freeman, 1956:771)

or,

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

the results of his meditations and experiments, often
in the face of considerable opposition, including
attempted piracy and murderous assault. The
intellectual vigor of the man, hampered by physical
handicaps, indicates true genius". (Freeman,
1956:771)

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

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

49
 Black Butterflies

Locating the Mind

Moniz, in his book (1936a:40) states over and over again that
the central nervous system (which includes the brain) is the seat of
mental manifestations. The physical is the ontological basis of the
explicit phenomena of the mind:

"In the brain there are regions that are particularly

related to mental activity. If we wish to drift away
from this organic orientation, we will enter other
domains that seem to us entirely unacceptable".

"Psychic life is exteriorized in a different manner,

but completely comparable to other functions of the
organism". (Moniz, 1936a:42)

These claims did not grow in a vacuum. The ontognostic

foundations of biological psychiatry (or 'neuropsychiatry') can be
traced back to Franz Joseph Gall’s phrenological theory, which, at
the beginning of the 19th century, linked brain and skull structure
to personality traits (Barker, 1995). Indeed, not unlike phrenology,
the reason for the success of this popular (albeit later declared only
'pseudo' scientific) predecessor in the study of brain localisation:

"The reason for this [success] was the astounding

nature of its claim: that it solved at one stroke the
problem of the mind; that it gave a complete and
accurate picture of the nature of the mind and at the
same time defined and fixed its functions" (Grant,
1968)

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

"…grasp the material conditions of the immaterial

50
 Sky E. Gross

principle, which manifests itself through its action,

and seems to undermine our research".

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

Wernicke’s in 1861 and 1874 respectively, persuaded many central
figures -such as Meynert, Liepmann, Charcot, Kraeplin, Freud and
Alzheimer - that the brain was indeed the seat of both mental
functions and mental pathology (Young, 1970; Barker, 1995;
MacMillan, 1996; Kolb and Whishaw, 2003). Freud's work,
although developed along different lanes, was itself based on a view
of the brain as the physical seat of psychic activity. In fact, in his
well known "Beyond the Pleasure Principle" (Freud, 1955[1920]), he
is unambiguous: one needs to apply strict empiricism, reject
speculated metaphysical explanations, and keep in line with
scientific methods. By progressing from observation to theory, one
would find the key to understand the workings of the brain. This is
precisely how psychosurgery's early proponents sought to portray
their undertakings.

World War I further produced clinical evidence on the various

effects of head traumas, thus contributing to already the dominant
trend of cerebral localisation. Studies used more and more
elaborate methods, including electrical stimulation, post-mortem
investigations, experiments on animals, and later, different imaging
techniques. All would suggest some important correlations between
function and location.

Although the understanding of 'higher' brain functions (such

as thought, imagination, emotion) still lingered, even in the context
of mental disease, localisation was still able to replace a nebulous
notion of the mind as a vague spiritual essence, and assert its
fundamental form as purely material. This provided psychiatry a
clear epistemological primacy over claims based on phenognosis,

51
 Black Butterflies

thus justifying a denigration of subjectivity, reducing it to mere

products of brain function.

Psychosurgery took on this lane of scientific studies by

asserting, de facto, the spatial grounding of the mind as well as its
material ontology. Porot (1947:126), for instance, describes the
surgical proceedings of Freeman and Watts:

“The surgery is usually conducted with local

anesthesia. After the surgery, X-rays are performed
in order to precisely localize the plan of the section.
The films are put against the trepan holes”.

Thus, by endeavouring a mapping -however primitive and

restricted- of the mental, the technique drew significant attention,
undoubtedly more than any other non-localised attempts to treat
psychopathologies (such as shock therapy from the early 1930s,
and, in the second half of the century, psychoactive drugs). A more
thorough study of the literature supports this assertion. Much of
the work on psychosurgery involved notions of gross anatomy, a
few practitioners going as far as to weight the brain tissue excised
in the course of surgery. According to Puech (1949:117), for
example, 72% of the cases operated on had a "macroscopically
pathological brain". This anatomical knowledge, as general and
imprecise as it may have been, may have well served as a source of
authoritativeness grounded on materialist ontological concepts.

However, once the localisation of mental illness was largely

discredited as a scientific endeavour, the idea of gross intervention
into the brain to alter mental status began to seem unreasonable
(Koupernik, 1977). The cutting of brain tissues, considered then as
the epitome of the scientific ethos, now served as a rebuttal to the
practice. Baruk (1956), for instance, will claim that psychosurgery

52
 Sky E. Gross

should be morally forbidden since it would transform a functional

disorder into an irreducible disease. The idea of physical
intervention into the realm of the mental began to lose its
association with a momentum of scientific advances.

Medicalising the Mind: Symbolic Correlates of Ontognosis

This trend soon moved from the field of research to the field of
practice. As noted, ontognosis lies within an overwhelmingly
materialistic episteme where the primal focus of attention is the
body (Eisenberg, 1977; Dew, 2001). This predisposition involves a
form of objectification by which the human body is stripped of its
subjectivity and transformed into a plain object (Babbie, 1970;
Csordas, 1994). An ideal form of these processes occurs in the
operating room.

Surgery, by definition, demands a suppression of the

subjective, and the reduction of the human body from a sentient
whole into a seemingly lifeless object, accessible to dissection and
rearrangement. The creation and maintenance of the operating
room as a well-guarded shrine of ontognostic purity are supported
by a surgical ethos as well as by several symbolic elements (Katz,
1981, 1999; Fox, 1992, 1997). These include, for instance, the
scrubbing rituals preceding the entry into the operating room and
the elaborate draping of the patient which absorbs him/her into a
small, depersonalised, objectified body-part upon which the
surgeon holds complete visibility (Hirschauer, 1991; McNay, 1991).
This 'symbolic theatre' thus creates a demarcated space within
which ontognosis prevails 4.

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

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

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

53
 Black Butterflies

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

the spirit through the severing of a physical essence provided clear
evidence to the spatial subsistence of the mind, as well as to its
materiality. Although most biomedical practices do hold implicit
reductionist bases, seldom do they constitute, in and on
themselves, such powerful proclamations on the very nature of
mind-matter relations. Psychosurgery, however, did not only
comply with ontognosis, but also substantiated it by providing it
direct and unequivocal evidence. As practiced, it was not only
reductive, it also reduced: It brought the mind onto the surgical
table based on it being deemed operable, but ipso facto, it also
created and recreated this 'operable mind', this ontognostically-
approachable mind.

This may explain why other measures, such as

psychopharmacology, did not raise nearly as much outrage as
psychosurgery. The introduction of anti-psychotics in the mid-
1950s did have direct effects on the practice of lobotomy, and the
former almost instantly substituted the latter as the treatment of
choice in cases of severe agitation and hallucinations (Snaith,
1994). Clearly, psychopharmacology offered a less costly, safer
alternative, with more readily visible and immediate results, as well
as less serious and permanent side-effects. This brought about
psychosurgery’s transition from a state-of-the-art endeavour to a
second-line treatment at best.

More significantly, however, psychopharmacology proposed

what was, at least in appearance, a more subtle paradigm of mind-
brain activity. Although equally based on ontognostic views and
although equally establishing a domination of brain over mind,
some of its characteristics were more compatible with phenognostic
views than its therapeutic predecessor’s. First were the symbolic
aspects of its administration, involving the body as a whole, rather

54
 Sky E. Gross

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

seated. This stood in clear contrast to the protruding intervention
and intrusion of an external, technical, and artificial object: the
lobotomist's knife. Second was the fact that the mechanisms by
which the psychoactive substances actually affect the brain are
still little understood, allowing the 'mind' to retain its mystique as
being too complex for science to grasp. Psychopharmacology’s
superiority over psychosurgery, thus, would be more than just
therapeutic: its characteristics would be more in line with
epistemological assumptions on the nature of the mind. While this
may not be enough to explain the replacement of one treatment by
another, it may well account for the lesser magnitude of the debate
surrounding drug therapy.

Another form of physical therapy for mental illness should

perhaps be mentioned in this context: Electroconvulsive therapy
(ECT), better known as 'shock therapy'. This technique, introduced
in the 1930s and still of widespread use in treatment centres
around the globe, involves the induction of electric stimulation 5
causing the patient transient seizures. This would be highly
effective in cases of severe depression, and to a lesser extent, in
some cases where psychotic symptoms became unmanageable
(Braslow, 1997). The mechanisms of ECT's action are still poorly
understood, although two main sets of explanations were brought
forward: psychological and physiological. According to the former,
the shocks would be so unpleasant to the patient to have him
cease his 'bad behaviour'. On a more psychoanalytic note, it would
satisfy an unconscious need to be punished. In contrast, according
to the physiological thesis ECT will have the brain respond to the
electrical charge by altering its own electrical activity and restore it

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

55
 Black Butterflies

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

physical explanation is regarded as more sensible.

As with psychosurgery, the usage of the technique will

become less common with the apparition of psychoactive drugs,
but readopted with the disenchantment from psychopharmacology,
from the 1970s onwards (Friedberg, 1977; Weiner, 1984). Since,
the procedure has greatly improved, reducing side effects such as
memory losses, limb fracturing, and general anguish to the patient.
The debates over both psychosurgery and ECT followed psychiatry
throughout its development as a legitimate 'cure' expertise
(Valenstein, 1986). The latter, however, remains in use to this day
and is still given a place of honour in the panoply of psychiatric
treatments (Alexander and Selesnick, 1997).

As with psychopharmacology, there are several symbolic

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

56
 Sky E. Gross

Losing Grounds: Away from Ontognosis

The Traps of Rhetorics: Facing the Debate

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

psychosurgery held a strong ontognostic position of legitimacy.
Science, Babbie (1970:14) tells us, is ideally amoral: its role is to
judge on questions of truth and falsehood, not on questions of
right and wrong (or what would be moral or immoral). Indeed,
initial disapproval of the practice belonged to the realm of science,
and not of ethics: Opponents insisted that the practice of
psychosurgery was justified by poor research methods. More
specifically, it would be claimed that a systematic, empirically-
based assessment of outcomes was unattainable, none the least
because more than twenty different techniques developed over the
years, a similar number of theoretical rationales proposed, and
more than a dozen different sites targeted (Huyn-Dornier, 1992;
Kolb and Whishaw, 1994; Pressman, 1998; Feldman et al., 2001).

While initially, the disapproval of psychosurgery focused on

the delicate process involving the choice of lesion as well as on the
intricate selection of candidates, it became increasingly apparent
that the results of psychosurgical procedures were equally difficult
to assess: First was the lack of precision inherent in the technique
(Andy, 1977; Lopez-Ibor and Lopez-Ibor, 1975; Ballantine, 1980).
Secondly, the patients were typically under several therapeutic
courses, which made the attribution of success or failure less than
certain (Bockoven, 1950; Bockoven et al., 1950). Thirdly, the group
of patients operated on was nosologically heterogeneous: there was
no common pathology that could be given to proper
experimentation (Malizia, 1997; White, 1998).

57
 Black Butterflies

In these respects, the practice proved to be in discordance

with a valid scientific model by which results could lead to a
falsification of the theory (Popper, 1965). The responses to some of
these claims involved a drawing on the words of psychosurgery's
mythical father, Egas Moniz, who reported his attempts as
representing but a first success, still needing refinement (Moniz,
1936b). This portrayed the procedure as correctable and dynamic,
staying in touch with empirical facts and ongoing observations.
Practitioners, rather than addressing ethical and moral questions,
continued to urge the development of better and more precise
surgical techniques, and for a more effective choice of candidates.
The discussion remained almost entirely restricted to the 'science'
of the practice, keeping relatively insulate from the spheres of
public debate. The procedure indeed grew more precise and less
hazardous, thereby diminishing both frequency and severity of its
side-effects (Fairman, 1950; Greenblatt and Solomon, 1953;
Hitchcock et al., 1972; Gildenberg, 1975).

Although these responses did allow for some justification for

psychosurgery’s shortcomings, the initial questioning of the
practice will result in an abrasion in its status as a pure scientific
endeavour. De facto, psychosurgery surrendered itself to public
scrutiny.

The Traps of Science: Methods and Rationalisations

Moniz conducted the first operations with a methodical

approach, both with the dosage of alcohol he injected into the
brain, and with the choice of medical apparatus. Beginning with
the use of a Berthelemy's syringe, he went on to design a
specialised instrument: the leucotome, a device used as a way to
pit (as one would do an apple) selected sections of the brain (Moniz,
1936a).

58
 Sky E. Gross

The procedure was such that a hole would be drilled into the
patient’s skull (depending on the patient, this would be performed
under local or general anaesthesia), and the device would be
inserted into the frontal lobes of the brain. Then, the steel thread
attached to the leucotome would be manipulated to cut through
the white matter (where neuron cells are linked), and dissociate
'pathological' neuronal connections. Based on Moniz’s reports, we
could abridge the rationale behind the procedure as such:

Healthy psychological functions depend on a flexible and

adequate set of neuronal connections within the brain;

Mental disease is due to a malfunctioning of these sets of

connections, the lack of flexibility leading to pathological "idées
fixes";

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

disconnect the underlying nervous ties;

Psychological activity is mainly located in the frontal lobes of

the brain, although we are still unable to precisely locate and
differentiate the different functions;

An ablation of the frontal lobes will not result in irreversible

psychological damage;

Based on those assumptions, Moniz decided to concentrate

his efforts on the frontal lobes of the brain, and cut through
pathological nervous connections, which are, according to him, the
basis of pathological ideation. Rather faulty or not, Moniz
presented an elaborate theoretical basis for his work, a basis which
he would carefully associate with neuroanatomical advances of the
time.

59
 Black Butterflies

The Traps of Symbolics: Freeman and the Ice Pick

Some years later, psychosurgery's most fervent supporter,

Walter Freeman -himself not qualified as a surgeon- contemplated
on transferring psychosurgery from the sacrosanct operative room
into the mundane world of the asylum. In fact, he went as far as to
suggest psychiatrists employ the procedure within the setting of
their own private practices. This brought Freeman to propose, in
1947, 'Transorbital Lobotomy', a procedure based on the insertion
of an ice pick (on which the name of the ice company was still
engraved) through the eye orbits, and into the frontal lobes of the
brain. The psychosurgeon would then manipulate the instrument
in swift vertical movements and sever groups of nervous
connections. The operation barely lasted a few minutes and
allowed Freeman to perform dozens of lobotomies a day.

Freeman ignored much of the developing models of

neuroanatomical functioning, and suggested but a primitive
rationalisation for his work: The idea behind the operation was to
cut-off the frontal parts of the brain (which were believed to be
associated with self consciousness, as well as rational and
imaginative thought) from the more irrational, affective lower parts
of the brain, and, further in the back of the skull, from 'primitive'
areas. By so doing, a certain measure of affectivity would be lost,
making the pathology less significant for the mentally disturbed
patient. This was, at the time, an explanation that was considered
weak to the very least and improbable at best.

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

medical object. Transorbital-Lobotomy turned the practice into a
form of 'non-surgical surgery', most particularly with the
introduction of a 'psychiatrist-friendly anaesthesia', based on
electroconvulsive shocks. In fact, unlike Moniz, who conveyed his

60
 Sky E. Gross

patients from mental asylums into his well-equipped operative

room, Freeman chose to perform some of the surgeries in his own
consultation office (Bernstein, et al., 1975; Valenstein, 1986).

Neurosurgeons soon objected this trend. James Watts,

Freeman's co-author in major psychosurgery publications, decried
transorbital-lobotomy, claiming it unbearable to witness this:

"….theatrical sideshow, with Freeman administering

electroconvulsive shock for anaesthesia, holding an
ice pick for a surgical instrument, and taking no
time to wear gloves" (quoted in Valenstein,
1986:257).

The lack of medical caution in the care of the postsurgical

patients was also apparent in many of the reports:

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

very carefully, as he is completely unaware of his
condition and may, as we have recently reported,
tear away his bandages and put his fingers into the
surgical wound, and up through his brain, which can
lead to unfortunate consequences". (Porot,
1947:127)

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

as its detachment from the powerful ethos and symbolic aspects of
medical practice and science, undoubtedly contributed to
psychosurgery's declining legitimacy as an endeavour based on
scientific, ontognostic demarcation. Its introduction into the
asylum and away from the control of specialised neurosurgeons
denuded it of its biomedical aura and demoted it to the mundane
universe of daily-life. Ironically, while supporting psychosurgery
until his very last day, Freeman contributed to the vulgarisation of

61
 Black Butterflies

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

The role of conquering the realm of the mind could not be left in
the hands of mere 'technicians', and this is precisely what Freeman
portrayed himself to be.

From the Medical into the Social and Back Again

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

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

Social Control and the State

An important polemic arose in the 1970s following the

publication and wide circulation of Mark and Ervin's monograph:
"Violence and the Brain". In this text, the authors proposed a
surgical intervention that would solve the social problem of
violence: psychosurgery. A suggestion within the same range

62
 Sky E. Gross

appeared a year earlier, encompassing a vision of a utopian

'psycho-civilised society', where individuals would be controlled
through electrical brain stimulation (Delgado, 1969; Mark and
Ervin, 1970). The outrage was immense, and reflected the changes
in the assigned power of medicine, and more particularly, of a
medicine of the mind: its intervention into the social, however
effective, constituted now but a malice intrusion into an illegitimate
area (Chorover, 1980). Equally, the very involvement of social
interests in the provision of medical treatment became increasingly
objectionable, in sharp contrast to the formerly accepted vision of a
'psychosocial' medicine (Breggin, 1975; Scheflin and Opton, 1978;
Kaimovitz, 1980).

That being said, the psychosurgical treatment of certain cases

seems to have been more controversial than others, such as in
instances of criminal deviance, and, to a perhaps even larger
extent, where homosexuals and children were chosen to undergo
the operation. This led to a perception of psychiatric treatment as a
means of social normalisation, and further reinforced the view of
an omnipotence of the institutionalised power over the individual.
This would remain an issue of concern to this day, as Howard
Dully, a lobotomy 'survivor', will open his 2008 biography with:

"In 1960, when I was twelve years old, I was given a

transorbital or 'ice pick' lobotomy. My stepmother
arranged it. My father agreed to it. Dr. Walter
Freeman, the father of the American lobotomy, told
me he was going to do some 'tests'. It took ten
minutes and cost two hundred dollars" (Dully and
Fleming, 2008: ix)

Another troubling element was amplified by the air-du-temps

of a post WWII Western world: The association of the technique

63
 Black Butterflies

with attempts to apply 'Brain Control' over the general population.

The period of World War II, with the eugenic notions of sterilisation
and euthanasia of deviant population, brought a certain sensibility
regarding issues of mind control, and questions of social control
over individual differences. Freeman himself would declare that the
best candidate to undergo lobotomy would be "women, black and
Jews". Those were described as having a lesser degree of initiative,
and therefore as expected to have lesser difficulties in adapting to
their new post-operatory personality (Brisset, 1949). The relation
with localisation, this powerful enterprise of revealing the mind
through a science of the brain, associated psychosurgery with what
was seen as a perhaps equally dangerous trend: control through
omniscience. The ability to see through the mental would create a
dangerous panopticon, at the head of which would stand
neuroscientists accompanied by 'surgeons of the mind'.

Psychosurgery found itself connotating with such

controversial ideas, an association not totally unfounded.

Dystopic Prospects: Psychiatry in Charge

How much could mental patients be seen as responsible for

their own choices? How much control should the psychiatric
institution and caretakers in general have on their decision
making?

Informed consent is a central issue in all questions relating to

therapeutic choice. Yet, it seems to be even more complex in the
context of psychosurgery. The fact is that informed consent is
difficult to assert in the case of mental patients, especially those
locked behind the closed doors of the world of the asylum. A
second problem is based on the assumption that psychosurgery
brings about basic changes in the patient’s self: does it not mean

64
 Sky E. Gross

that the patient agreeing to go through the operation is not the

same person coming out of it, in him\her having an – at times
radically- different constructed image of him\herself, his\her
values and preferences. The 'neuropacified' patient has better
chances to be compliant with the advices of his caretakers: this
would hardly mean that his pre-operation person had 'genuinely'
consented to be mentally transformed: this, especially considering
that the effect of 'pacification' and the general agreeableness of
post-operative patients may have been, after all, the very target of
the procedure.

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

Back to Society: The Social Cure

“…[Interesting is] the case of a 15 year old young

girl, who was going through episodes of violent rage
during which she would rhythmically hit her head
on the ground or on the wall, or would bit her hands
and knees and scream for hours. Her parents were
forced to attach her hands and legs to her bed as
well as her head and chest. After the surgery, this

65
 Black Butterflies

girl could be left alone with her toys; she walks

around the apartment, eats on a table. She has
become capable of living in society. Such a result
aids in legitimizing lobotomy…”. (Klein and Tardieu,
1949: 113)

The patient could be back to 'society'. This idea of a

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

"Lowering the tone in delirium and hallucinations;

gradual modification of behavior; and progressive
adaptation to exterior circumstances" (Brisset,
1949:491).

This reframed the intervention as a cynical brain erasing and

rewriting, compromising the sense of self-determination of the
psyche and the agency assigned to the individual- all central
elements of a phenognostic discourse. Proponents acknowledged
this loss from the very beginning, but considered it as a relatively
small price to pay in return to the benefit of re-socialisation:

"Whether the effects of frontal lobe deficit will

neutralise or accentuate the disharmony already
present, whether the individual will be able to think
more constructively with less brain at his disposal,

66
 Sky E. Gross

whether the relief of the depression and its

conversion into euphoria will permit of adequate
adaptation in society, and whether the individual so
treated stands a better chance of survival in the
highly competitive society of today than he would
with intact frontal lobes and a potentially
recoverable psychosis." (Freeman et al., 1942:214)

Or, according to Porot (1947:130):

"Their [the post-surgery patients’] behaviour is as a

rule impeccable since, even more so than normal
person, they are sensitive to the demands their
education impose on them; they also know with
much precision the sanctions that are involved in the
transgression of moral codes".

Hence the growing (but eventually little effective) demand for

the legal regulation of psychosurgery (the then famous 'Habeas
Cerebrum'). This demand most often referred to the question as to
whether the psychiatric institution has a legitimate right to act
upon the minds of institutionalised individuals, might they be
conceived as mentally ill or as responsible criminals.

Illegitimate Interests: The Costs of Mental Asylums

In the beginnings of the 20th century, a patient entering a

mental asylum had lean chances of ever coming out alive. In
Warren Hospital in Pensylvannia, for instance, 75% of patients
would die in the five years following their first hospitalisation
(Duffy et al., 1997).

The two World Wars brought a growing rate of

institutionalised mental patients, which turned 20th century

67
 Black Butterflies

asylums into crowded 'human warehouses', with no efficient

treatment available. In is in that context that Fulton, at the time
optimistic about the treatment, will declare that psychosurgery
should be able to decrease the number of institutionalised patients
by a fourth and save close to a million dollar a day for the tax-
payer. Even patients not be able to be released after a lobotomy will
at least be more manageable, not requiring as much staff and
facility costs as the pre-lobotomised patient (Swayze, 1995). Other
proponents will talk of 40% of mental patients being able to be
released after psychosurgical treatment (Sargant, 1976).

Anti-psychiatry advocates could easily use these types of texts

to establish their claims: psychosurgery, as an important
constituent of psychiatry’s therapeutic arsenal, was but a
conspirative means for social control not only at the state level
where it is embedded within political and ideological interests: This
'surgical strait jacket' also served ill-intended asylum psychiatrists,
seeking to make their patients more manageable, both in the
asylums and in the home – thereby benefiting the patient’s
caretakers as well. For Baruk (1956), for example, these
procedures would only serve to relieve some unmanageable
symptoms, and will have no effect on the patient’s well-being as
such. He himself could base his claim on the very words of
psychosurgeons:

"We are familiar with this lamentable picture of

these children with profound imbecility who are but
a long scream and whose agitation makes life
impossible for their parents or any other persons
who would be willing to take care of them. An
intervention holding but a modest intent to cease
this agitation is received as a deliverance by the
family". (Klein and Tardieu, 1949:116)

68
 Sky E. Gross

In effect, Szasz (1977), arguably the most important figure in

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

The Homo Vadum

Black butterflies appear on Walter Freeman's 1942 book

'Psychosurgery', and represent the releasing of madness from its
captivity, under the skull, inside the brain. By destructing their
prison of material flesh and bone, these creatures of the mind will
be freed back into their own universe. Black butterflies endanger
the materiality, efficient causality, and orderliness of the physical,
the brain. By doing away with these uncanny creatures, order
could be restored, control re-established. The brain would be but a
bodily organ. Ideas of free will, of an immaterial and unreachable
mind, of the unobservable phenomena of subjective experience will
all be cast out from a medicine of the mind: either tamed or
overthrown, madness will cease to operate its threat on ontognostic
reason. It is only when the price of these 'emptied' brains, i.e., the
loss of a phenognostic compass, became intolerable that this
surgery of the mind became a practice with victims and
perpetrators, rather than patients and healers.

While the outcomes of psychosurgery were of a wide range,

the 'flattening' of human subjectivity is by far the most discussed
in both professional and lay literature. According to these
accounts, the personality of the lobotomised patient hold fairly
consistent traits, including a so-called 'loss in human's superior
mental capacities', such as creativity, reflexivity, and fore vision:

69
 Black Butterflies

"The lobotomized patient achieves his

normalization at the price of the vertical component
in his being-in-the world, at the price of a loss of
horizon and perspective […] Neither hopes nor fears,
desires, nor regrets can present themselves in his
greatly reduced temporal horizon…". (Vidor, 1963,
in Freeman, 1965:654).

or,

“The outstanding feature [of the emotional set that

characterizes people who have been operated upon]
is a lack of self-consciousness […]. They cannot be
insulted; no matter what one says to them, they do
not take offense. They laugh easily and flare up in
anger on slight nagging or frustration, but seldom
weep. […] Life is enormously simplified by the
relatively complete obliteration of the need for
introspection.” (Freeman and Watts, 1947:416).

The rationale Freeman (1951) provided for the workings of

prefrontal lobotomy seems to reflect this notion. As discussed
earlier, according to Freeman, the frontal lobes inhabit the
functions of foresight, imagination, and the consciousness of
oneself, while their emotional tonality is provided by the limbic
system located deeper within the brain. A disconnection between
the two areas will pacify the emotional tone, or associated
phenognostic experience, of any higher-level functions.
Hallucinations may still be present, but will not necessarily be
experienced as 'true' to the individual.

70
 Sky E. Gross
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 responses 6. This is which places them at the centre of
Moniz' book:

"Two categories of clinical facts can be used in this

study: the different types of lesions of the frontal
lobes and the results of mutilating surgical
operation on these lobes" (Moniz, 1936a:30).

He reports:

"We have noted with those who have injuries of the

frontal lobe disorders of voluntary attention skills
and of mental synthesis. They are in fact incapable
of the most simple of intellectual tasks; they are
unable to group and orient the different elements of
a given problem. […] in sum, the highest
manifestations of psychic life are altered". (Moniz,
1936a:31)

6
These assertions are generally believed to be correct to this day

71
 Black Butterflies

"It is […] certain that the frontal lobes tumors

present, above tumors of other lobes, the greatest
frequency of mental disorders". (Moniz, 1936a:31)

Moniz (1936a:35) goes on to report studies according to which

bilateral ablation of the frontal lobes will have two categories of
results: First, intellectual disorders and second, lesser control over
emotional responses. Interestingly, although later research will
refute the presence of the first effect, the image of the frontal lobes
as a form of super-ego, and a centre of 'reason' will remain central
to the description of psychopathologies related to lobotomies.

The gains of psychosurgery, according to Moniz (1936a:53):

"It would be the solution to a clinical problem of

great value: wipe out the intimate suffering of these
prisoners of anxiety, of hypochondriac, melancholic
and other forms of delirium: occult forces that lead
patients at times to acts of despair".

Frank, 1946:457:

“None of the patients regained full insight in the full

sense of the word, or is able really to appreciate
what the operation was for, or its importance. […]
The specific [personality] change was a poverty, or
entire lack of dreams, and a thinning, or
disappearance of dereistic experience-they cannot
daydream about their wishes, or be abstractly angry
in a sustained fashion. They become, due to this
emotional asymbolia, more plain, matter-of-fact
like”.

72
 Sky E. Gross

Let it be noticed that Frank added in the same paper that "no
cases were considered worse". Indeed, some will claim that the
beneficial effects of the procedure derive precisely from those
personality transformations, without which, the patient could not
have reorganised his psychic scheme (Mayer-Gross, 1949).

Yet, the fear of loss of the human, of the turning into a Homo-
Vadum, did seem to intensify over the last decades. With the
gradual rise in the authoritativeness of phenognosis, the position
towards the Homo-Vadum began to change. Normative functioning
could no longer compensate for the damage inflicted upon the
Homo-Vadum's phenognostic sense of truth. Existential ideals of
self-fulfilment became ever more dominant. The
straightforwardness of the surgical act stood in contrast to the
complexity accorded to human experience: the idea that a crude
'razing' of the brain could alter the multi-dimensional phenomenon
of consciousness led to an overt discomfort. As sentience prevailed
as a discursive force, this formerly amoral scientific endeavour
turned immoral.

Corporeality, Pain and Phenognostic Truth

Perhaps not unsurprisingly, over the years, a growing body of

literature referred to the patient's inability not only to reflect upon
his/her own condition and behaviour. Indeed, although the
patients that were to undergo lobotomy seem to have had some
improvement as far as their pathological symptoms (at least those
related to anxiety and agitation), this would often be
counterbalanced by certain personality changes. Reports describe
the post-lobotomy patients (as many as 91% according to one
source) as being apathetic, lacking motivation and spontaneity,
childish, passive and dependant. Some will add the notion of "post-
operatory personality"(or "moria") to describe the combination of

73
 Black Butterflies

symptoms observed after psychosurgery has been performed. It

seems that the patient’s initial complaint of having to deal with
overwhelming emotions was substituted by a total loss of the
ability to feel any emotion at all. This was associated with the loss
of a full consciousness of his/her own corporeality and emotional
state:

“[Freeman] points out that the person whose frontal

association areas have been particularly inactivated
by prefrontal lobotomy presents a number of
peculiarities that distinguish him from his pre-
operative self. […] he loses interest in himself, both
as to his body and as to his relationship with his
environment, no longer caring whether his heart
beats or his stomach churns, or whether his remarks
embarrass his associates”. (Porot, 1947:129)

The Homo-Vadum, as termed here, was thus to a certain

extent aware and conscious, yet incapable of sentience, the quality
that translates mere stimuli into full-fledged qualia and by which
experiences feel pleasurable or painful. These patients had a
tendency to be unconcerned by subjective aspects of their being:
while acknowledging drives and feelings, and internalising sensory
information, they reacted as if these cues were external (based on
out-there sources of Truth –ontognostic knowledge), rather than
internal (experience-based Truth – phenognostic knowledge).

“[after a prefrontal lobotomy] pain may be present;

but it no longer arouses a mental picture of future
disability and all that this may mean in terms of
disaster to the person and his family, the experience
can be borne with equanimity” (Freeman and Watts,
1946:445).

74
 Sky E. Gross

Or:

“L.S. A 44 year old woman was first seen in

November, 1936, at which time she had spent two
years in bed because of “arthritis”. There was
moderate lipping of the vertebrae, but no other
significant changes. However, the patient
complained so bitterly and was so apprehensive that
it was impossible to make any headway in
treatment”.

After being lobotomised:

“Within three days the patient permitted

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

Madness and Ontognosis

The concept of 'madness' is intriguing in this regard. This

phenognostic experience cannot, by definition, comply with an
ontognostic agreed-upon Truth as to a world-out-there, hence its
characterisation as deviant in thought, affect, and/or perception.

"More difficult to influence satisfactorily are those

persons who have drifted away from the world of
reality.[…] [Only when] the individual lapses
completely into a dream world of psychosis with no

75
 Black Butterflies

struggle against the manifestations of disease, is he

to be considered too emotionally deteriorated to be
aided by psychosurgery." (Freeman, 1943 in
Fleming, 1944:490).

When intractable, 'madness' remains, in fact, resistant to the

reasoning of ontognosis, and thus expressing an incapacity – or
unwillingness- to recognise what is collectively considered as True.
This will, in turn, justify the use of techniques intended to secure
willing or coerced subordination of what is seen to be a faulty or
muddled phenognostic experience.

As psychosurgery did not seem to have negative effects on

one's intelligence, at least as far as studies of the time could show.
Some proponents went on to claim that the inflicted personality
changes allowed patients' intelligence to actually become more
effective, providing them with the ability to perceive, analyse, and
respond to the world more 'rationally':

"After a prefrontal lobotomy, a person who was

previously trained for the practice of law,
engineering or scientific work, remains capable of
calculation, deduction and accomplish all mental
operations that concern productive activities"
(Wertheimer, 1948:497).

Here, while typical patients' sensitivity to ontognosis grew,

their phenognostic consciousness deteriorated: the patient would
know but not experience.

The Homo Vadum and Society

Still, in line with the idea of the 'social cure', psychosurgeons

who did refer to the personality dimension argued that the creation

76
 Sky E. Gross

of the Homo-Vadum was a moral act par excellence, for it enabled

the return of the insane into the laps of a normative society. One
must consider that, based on an ontognostic conception of
humanity, turning a socially incompetent individual into a Homo-
Vadum was a valuable accomplishment. Rather than referring to
the patient’s acquired condition as a regrettable – albeit perhaps
unavoidable - side effect, proponents of the technique used the
descriptions of the Homo-Vadum as a validation of the beneficial
results of psychosurgery. At the peak of its popularity,
practitioners depicted psychosurgery's effects as pointing out to the
success of the procedure.

Questions as to normalisation and the creation of Homi

Vadum are apparent in other areas of culture, notably in fictional
literature. Ken Kesey's influential novel "One Flew over the
Cuckoo's Nest", published in 1973, depicts its protagonist as
resisting the system of the mental asylum only to be eventually
lobotomised. Eager to empower a group of mental patients to trust
in their own phenognostic sense of Truth, in what they believe to
be right, the central character was calling for an alternative source
of power: a Truth that feels true to the individual, a Truth that
cannot be challenged by external authorities, a Truth that does not
have to be subordinate to the gaze of the world-out-there. The
'hero' was finally defeated: lobotomised and turned into a Homo-
Vadum, he was now both literally and symbolically at the hands of
the more authoritative power: Ontognosis. Surgery left him barely
conscious: a mannequin, a 'thing'. As an act of mercy, his friend
would euthanise him.

This classical piece of literature became one of the strongest

manifests for the liberation of individual thinking from the hands
of a normalising society. Its mere popularity demonstrates the
claims presented throughout this analysis, namely, the idea that a

77
 Black Butterflies

rise in the discursive power of phenognostic Truth would place free

subjective thought, although deviant, above the ability to accept an
agreed-upon ontognostic Truth. The practice's discordance with
emerging phenognostic conceptualisations of the self placed
psychosurgery in the focus of debates on the significance of
sentient experience. Over the years, the procedure came to
symbolise "the substitution of a soulless robot for the insane
patient" (Mayer-Gross, 1949:320), and the diminution of the full-
fledged subject into a shallow façade of self: "exhibiting a purely
objective mentality" (Golla, 1946:444). Yet, in an era where
questions of value are so often approached with a phenognostic
view in mind, to be reasonable by ceasing to be does not make
sense anymore.

Concluding Words

I have attempted here to present a historical motion involving

two powerful sources of Truth, phenognosis –based on inner
experience- and ontognosis –based on observation of a world-out-
there. I have then used the case of psychosurgery to substantiate a
somewhat provocative claim: this sense of Truth experienced at the
level of the conscious individual— would play a role in the
sociocultural realm, not as a prediscursive form, but rather as a
full fledged discourse; not necessarily as a negative picture of an
objectifying gaze, but as a positive picture in and on itself.

The conceptual scheme proposed here is potentially useful in

the analysis of other phenomena where ontognostic knowledge
finds opposition in the form of phenognostically based claims. This
seems evident in the study of New Age spiritual movements. Both
practices and epistemological bases of such movements typically
involve some extent of disregard of external cues (as conceived in
ontognostic terms) as well as the assigning of high legitimacy to the

78
 Sky E. Gross

Truth as experienced by individuals in specific states of

consciousness (claims of re-incarnation for example, or sensing the
presence of spiritual entities, all clearly not supported by empirical
evidence). Indeed, although often contrary to ontognostic evidence,
these subjective experiences will be given high status as True, as
long as they 'feel' authentic, genuine, non-mediated, to the
individual. Another example may involve the understanding of the
credibility associated with states of trance, in the context of healers
and shamanist medicine and the authoritativeness attributed to
those able to experience it. All can benefit from the positioning of
phenognosis against ontognosis on the issues of credibility, faith,
and beliefs.

One may find similar trends in modern psychotherapeutic

discourses, where one’s inner feelings are considered a priori
legitimate. Along a similar line, one is often advised to seek for an
'authentic self' through deep introspection rather than through
external appreciation of 'reality'. The fact that these trends are all
accompanied by oppositions and by countering phenomena may
point to the power ontognosis maintains, and to the complexity of
the proposed forms of analyses. In effect, it is precisely these
exchanges and conflicts, which may profit from an analysis based
on an opposition of phenognosis and ontognosis and on a dynamic
view of the exchanges between these two sources of power. I
suggest here that further understanding and empirical grounding
of the scheme proposed here may be of value in both anthropology
and social studies in general.

In the next section of this work, I will hope to show how the
dynamics of more and less phenognostic sources of knowledge
come about in the routine workings of a clinic. This will be based
on a synchronic, rather than diachronic view of the phenomena,
and on a sustained in-situ observation rather than on a more

79
 Black Butterflies

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.

80
 Sky E. Gross

Part IVa: Experts and ‘Knowledge that Counts’(background)

The World of Brain Cancer Diagnosis

The Neuro-oncology Clinic

During the first half of 2006, I followed members of a neuro-

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

The Clinic: Spatial Characteristics

The neuro-oncology clinic is an outpatient unit located in a

general oncology clinic. The secretariat is shared by both groups of
physicians (the latter's forming a more substantial share of the
staff). The clinic includes about ten offices. Each office has, nailed
on the wall next to the door, a metal name-tag-holder that can be
replaced at need, according to the physician who happens to be
using the room on that particular day. Thus, there is no
permanent office for any of the NROs, although on the days in
which the neuro-oncology clinic is active (Mondays, Wednesdays,

81
 Black Butterflies

and Thursdays), the working physicians tend to be placed in a

habitual office (used by other physicians -or even nurses - on the
days they do not receive patients). The neuro-oncology clinic has
thus no actual spatial presence: it is a virtual set of specialised
knowledge held by 'visiting' professionals.

Each Sunday is spent around professional conferences. The

conferences take place at different locations, none of which is
actually secured for the NROs. The conference room at the "Moses
Institute" -a building with mostly oncology-related inpatients units;
ambulatory divisions; and out-patients clinics- is used for the
weekly NROs' staff meeting. However, was some other group
needing this room, the NROs will find a temporary office at the
clinic, squeezing in into a room much too small.

The Radiology conference takes place at the radiology (MRI)

unit, in a small office, where the experts usually sit and go through
the MRIs (and reporting, in writing, their impressions and
interpretations of the images they survey). The Neurosurgery
conference (referred to as the 'tumour board', hinting to its more
decision-oriented character) takes place in a conference room at
the radiotherapy unit. At times, when the conference room is used
for other purposes, the whole team will go up to another conference
room, at the neurosurgery inpatient unit, at the hospital main
building.

Professor Lise, the head of the Neuro-oncology team has a

large, luxurious office at the Moses Institute, albeit at some
distance from the actual clinic, or the inpatient unit. Her office is
actually located at the one floor where the services provided are not
targeted toward cancer patients – i.e., where nuclear medicine tests
are conducted. Her office has an interesting standing: it is both the
heart of the clinic, in terms of research mostly and administration

82
 Sky E. Gross

at times, but it never serves as a meeting place for the different

NROs. There is, in fact, little cohesiveness or sense of 'team'
between the NROs, or the rest of the staff, for that matter. The
spatial arrangement may reflect that, while also contributing to
this state of affairs.

The Moses building has many floors, some of which are

underground:

The -2 floor includes the radiotherapy (RT) facilities and

completely lacks windows or direct access to the 'outer world'. It is
a dark, 'spaceship'-like floor, with instruments and names on the
doors that would not shame any science fiction movie. The
outpatient clinic is located on -1. One will also find there the
refurbished conference room serving the NROs on Sunday
mornings' meetings. As expected from a frontstage area, which
serves the general public rather than patients (whose pathological
state allows them some access to backstage areas), the place is
bright, easily accessible, and a coffee shop is located in the general
hall located on the East, leading almost directly to the hospital's
mall. A small but lovely patio separates the Western and Eastern
wings, i.e. the reception area and the conference room (which is,
interestingly enough, surrounded by glass walls from which the
conferences may be seen but not heard). Floor B is where Lise's
office is located – just near the corridor leading to the general
hospital. Again, this is the only floor where the activity has little to
do with oncology. No one could guess he had entered the "cancer
building", or as another patient called it: "the death wing".

The first floor is where the oncology inpatient unit is located,

and where the general hospital is directly linked to the institute's
building. This unit is where most neuro-oncology patients are
hospitalised, alongside general oncology patients. Naturally, this is

83
 Black Butterflies

where most of the rounds take place. The second floor includes
the haematology inpatient unit. At any given moment one-to-two
neuro-oncology patients are to be found hospitalised, usually due
to secondary complications of treatments. The third floor includes
a large, quite modestly but recently refurbished ambulatory
service. This is where patients are submitted to chemotherapy by
perfusion and return home at the end of the day, after a short
recovery and observation period. The onco-psychological unit is
also located on the floor, with a consultation room of its own. The
team of psychologists usually works with ambulatory patients,
perhaps much more than with hospitalised patients. This might be
explained by the longer life expectancy (and chances of recovery, in
some cases) of the not-yet- hospitalised patients as opposed to the
near-death, and often unconscious, condition of many inpatients.

Schedules and Organisation of Time

On each of the days in which the clinic operates, one or two

physicians receive patients. The reception hours tend to begin at
around 8:00, although most physicians turn up only by 9:00. The
last appointments are set for around 12:00, although this may
actually last until 15:00.

Sundays are organised around conferences and rounds. The

morning begins with a NROs' staff meeting. This may last until
10:00, or end by 9:00. If the former is the case, the group will go
straight to the next meeting (which is invariantly scheduled for
10:00) with the radiologists. If the latter happens to be the case,
they will take the opportunity to finish the rounds before the
radiology conference. The rounds usually do not take more than
forty minutes. The meeting with the neurosurgeons (the 'tumour
board'), usually begins at 14:00. There, the day ends as far as the
NROs are concerned. As most of the staff members (Lise excluded)

84
 Sky E. Gross

also work as general neurologists, they will spend their 'free time'
as 'plain' neurologists.

The Neuro-oncology Meeting

The first meeting includes the NROs, the head nurse, the
social worker and the neuropsychologist. From time to time, fifth
year medical students are allowed in. The meeting is organised
around a briefing of each NRO on the cases he/she had seen over
the week. Each NRO presents about ten cases, while the others
listen and make suggestions as to treatment options or diagnosis.
This usually happens when the presenting NRO specifically says
that "this is a difficult case" or "that is an interesting case".

None of the NROs consider him\herself as mere clinicians,

and all are involved in research at one level or another. Thus, the
meetings also include research presentations (such as dr. Levitz'
presentation of findings related to "chromosomal differences
between infratentorial and supratentorial ependymomas"), and
reviews of state-of-the-art literature, at times by the NROs
themselves, and at others by peripheral experts such as the
histologist or the neuropsychologist. While the first is filled with
technical terms and arise much interest, the latter is often
regarded more as an opportunity to discuss patients' personal lives
and personal peculiarities: as cases are presented along with the
results of the neuropsychological testing, the team members would
take these on to describe curious encounters they may have had
with this or that patient. The neuropsychologist would typically not
get involved in these discussions but neither would she try and
resume them, however eager she may be to continue with her
professional presentation.

85
 Black Butterflies

The Patients

Patients –adults alone, as children are referred to a paediatric

unit- are referred to this clinic from all over the country, since this
particular centre is considered to be providing the most
professional and specialised care available (in fact, it has a
reputation of being among top neuro-oncology centers in the
world).

There is no particular social characteristic which makes the

patients' population remarkable. Most of the patients I see come to
the clinic for follow-ups. Some would only come once a year (once
every three months is more typical) to have their MRI done, and
consider the progression of the tumour. Patients under active
treatment will come up to once a week when under radiotherapy,
and once a month when on chemotherapy. New patients almost
invariably know about their condition beforehand. They have either
been referred to the NRO after a diagnosis has been given by
another physician, or did they already have an attack which
rushed them into neurosurgery – only then to understand they
have a brain tumour. Actually, the second scenario is much more
common.

The Consultation

The patient arrives at the clinic, gives his/her name to the

reception clerk. His/her file is then placed on a pile which will be
taken to the physician's office from time to time. The files of
patients due to have an appointment are drawn from the clinic's
archive the day before. The physician will find, upon his arrival to
the clinic, a list of appointments for the coming day. As the NROs
tend to be late, they will also find a pile of files – meaning that
patients are already ready to be seen. The physician would not see

86
 Sky E. Gross

them in the waiting room (and they would not know whether
he/she had arrived) since he/she will typically use the back door
entrance to the clinic. This entrance demands making a small
detour, but allows to remain unseen.

The ways the NROs conduct the consultation is very similar:

as the patient enters and take a sit, the NRO would utter a "how
are you doing?" without really hearing the answer 7. 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 room 8.

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.

87
 Black Butterflies

Family Members

The patients usually come with a family member. Close to the

time of diagnosis and often towards the patient's death, more
members of the family tend to join in. The family members are a
critical part of the consultation. They usually take on an active
stance, some answering the NRO's questions for the patient (even
in cases where the latter is well enough to answer himself). This
applies to technical questions such as the dosage of drugs taken
but also to more abstract questions such as the type of pain the
patient suffers from.

Something About Brain Tumours

Types of Tumours

At the most elementary level, one may define two general

types of brain tumours: Primary, i.e. forming in the brain itself,
and secondary (or 'metastatic'), i.e. originating from another
cancerous process elsewhere in the body. The types of cells
involved and the form of its spreading give indication to whether
the tumour is primary or secondary. Life expectancy differs
dramatically, that is, once a tumour has metastasised, there is
little chance in effectively controlling the process.

Unlike many other forms of cancerous diseases, there are no

known risk factors to primary brain cancer, and etiology is little
understood. There is thus no known way to prevent the apparition
of the disease.

8
Notwithstanding these comments, it has to be noted that at no point do the physicians use their time
for personal or leisure activities. They are clearly overwhelmed. One cannot but be impressed with
their efforts to keep pace with their extremely demanding schedule.

88
 Sky E. Gross

The largest group of primary brain cancers is referred to as

'Gliomas'. Gliomas involve abnormal growth of glial cells (the
supporting cells of the brain) and include four main categories of
tumours, based on the types of the underlying cellular formation
and the location of the tumour: 'astrocytomas' (the most common),
'ependymomas', 'medulloblastomas', and 'oligodendrogliomas'.

All tumours are assigned a 'grade', that is, a I-IV classification

relating to the current speed of growth, the presence of necrosis
(dead tissue), the number of blood vessels providing nutrients to
the tumour, and the level of differentiation (pathological
deformation) of the cells .

Grade I-II tumours are considered benign, although may

become more aggressive at a later stage of growth. They can also be
located in or near a part of the brain which, if damaged, may cause
serious handicaps or even death. I saw only a few of these patients,
as they tend to come to the clinic for yearly follow-up only.

Grades III-IV tumours are referred to as 'anaplastic

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

Location of the Tumour and Functions Threatened

The brain is divided into six primary regions, each controlling

specific functions. The following is a brief overview of each region
and their correlating functions.

The Brain Stem. The area where the brain connects to the
spinal cord is called 'brainstem'. It controls vital heart and lung
functions such as breathing, digestion, heart rate and blood

89
 Black Butterflies

pressure, as well as the ability to remain awake and alert. It is the

pathway for all nerve function through the spinal cord to the
highest part of the brain. Problems in the brainstem often cause
symptoms such as double vision, abnormal functioning of facial
muscles, nausea, sleepiness, or weakness on one side of the body
(hemiplegia). However, since so many nerves go through the
brainstem, pathologies associated with this area can cause almost
any form of symptoms.

The Cerebellum. Located at the back of the brain above the

brain stem, the cerebellum coordinates balance, posture, and
coordination, and affects activities such as eating, walking, talking,
and eye movement.

The Frontal Lobes. The frontal part of the brain is

responsible for organising thoughts, planning, problem solving and
selective attention. It is also where higher functions, such as the
control of behaviour and emotions and moral judgment. The
posterior parts of the frontal lobes also houses nerve cells that
produce movement. Patients suffering from tumours in or near the
frontal lobes may not only have symptoms related to motor
functions, but may also suffer from extreme personality changes.

The Occipital Lobes. Located in the mid-back of brain, the

occipital lobes are 'in charge' of vision. The neural network takes
input from your eyes and turns it into the pictures that you see.
Presence of pathology in this lobe can cause partial blindness or
the inability to recognise shapes, colours, or faces.

The Parietal Lobes. Located behind the frontal lobes, and at

the top of the brain, the parietal area comprises a right and left
lobe, which together, control our sense of touch, our feel and
understanding of weight, size and texture, as well as much of our

90
 Sky E. Gross

cognitive comprehension of the world. Pathologies of the parietal

lobes can cause numbness, tingling, and other sense-related
symptoms. Tumours affecting the right parietal lobe can cause a
lack of spatial orientation and may hinder the ability to recognise
one's own body. Tumours affecting the left parietal lobe can cause
difficulty speaking or difficulty understanding speech.

The Temporal Lobes. Located on the right and left side of the
brain (near ear level), the two temporal lobes help us distinguish
smells and sounds, and may be involved in the experience fear,
and may impact short-term memory. The right lobe is primarily
responsible for visual memory while the left controls verbal
memory.

Treatment

The term 'treatment' is misleading. Except for a number of

first grade tumours, the progress of the mass is inevitable,
although it may proceed over decades. Treatment is thus meant to
prolong life or to better the patient's quality of life. The NROs are
unambiguous: there is no 'cure'.

There are three types of treatment, provided usually in this

order: Surgical resection, chemotherapy, and radiotherapy.

Surgery. Surgery is usually the first step. Most of the reports

I heard from patients place the beginning of the brain-cancer
'odyssey' at the point where the tumour made its first dramatic
symptomatic appearance. Almost invariably do they then report on
their being rushed to surgery. Surgical intervention is seldom able
to remove the entirety of the mass' tissues – microscopic malignant
cells almost always remain to begin the growth anew. In most
cases, the benefit of surgery must be weighted not only against the

91
 Black Butterflies

risk involved in any serious operation, but against the neurological

deficits that may result from the assault on the brain.

Chemotherapy. Brain cancer has its own set of

chemotherapeutic agents. The reason for that is that the brain
keeps some of the body's material out, through what is called the
'Blood Brain Barrier'. Unfortunately, this barrier is not penetrable
by the chemotherapeutic agents known to be effective for tumours
across the body. One agent is, however, able to reach brain tissue
is in the form of tablets: Themodal©. The treatment is given for one
month at a time, at the end of which blood tests and imaging are
given. If the blood tests do not allow the continuation of the
treatment (typically – anaemia, low platelets count or
neutropaenia), if the treatment turns out to be ineffective, or if two
years have passed – it is terminated, and the patient will be
referred to radiotherapy. Themodal is self administered, at home,
does not cause hair loss, and has in fact little side-effects. In all
these, it will create but little a sense of "Cancer self perception".

Radiotherapy. Radiotherapy is typically administered daily

for a number of weeks, in the course of which the patient is to
meet the NRO weekly and give blood on a regular basis. The
radiotherapy causes many side-effects (which severity depends on
the dosage and the areas being targeted), including hair loss,
extreme fatigue, burns on the scalp, oedema and more. The series
of treatments is usually given once in the entire course of the
disease. It also does not have remedial powers. However, it usually
does contribute to the shrinking of the tumour and does slow its
growth.

Symptoms Relief. Epilepsy is one of the most troubling

symptoms of the presence of the mass itself and the oedema
forming around it. The oedema tends to become more severe as a

92
 Sky E. Gross

result of radiotherapy and surgery. Steroids are provided for the

relief of oedema, thereby providing relief in epileptic seizures and
intracranial pressure (a situation that may be uncomfortable at
first, but will eventually cause death). Epileptic seizures are also
treated with anti-epileptic drugs, some of which must be
continuously accompanied with a monitoring of the active agent's
level in the blood.

A major sign of brain cancer is the loss of strength (paresis) or

paralysis of one or more limbs and/or enervated body part. These
symptoms have usually no treatment available, perhaps besides
steroids which would relieve some of the pressure on the part of
the brain involved. Steroids are eventually devastating for many
body systems, especially when given in high doses. It will also give
the patient a typical bloated look, making the surroundings
accutely aware of their condition.

Palliative and Supporting Care. When the treatment

panoply has been exhausted, there is no role for the NRO but to
follow from distance the palliative care provided to the patient,
usually in a hospice or at home. There is relatively little pain
involved in dying from a brain tumour, unlike with most other
types of tumours. The end may be uncomfortable, when more basic
functions begin to deteriorate, especially breathing. But, in general
the process is gradual and loss of consciousness usually appears
before the patient has the chance to enter the more agonising
stages of dying.

93
 Black Butterflies

Part IVb: Experts and ‘Knowledge that Counts’

The World of Brain Cancer Diagnosis*

*An abridged version of this paper was published in "Social

Science and Medicine" 2009 in press, and available online

The brain has much significance in broad aspects of Western

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

Introduction

The majority of medical texts represent brain tumours as

involving fairly clear-cut entities and categories of entities,
amenable to 'discovery' through different ontognostically-based

94
 Sky E. Gross

practices. A closer look into the life of a neuro-oncology clinic

proves, however, that the solidification of neuro-oncological objects
is less than straightforward, in both epistemological and practical
terms. This study sought to provide such an in situ understanding
of the ways in which diagnoses are handled in medical experts’
daily routine via a deep insertion into the everyday practice of a
wide range of experts. The aim of this paper is double: first, to
underline the technological and epistemological grounds of
'expertise' in the medicoscientific practice of diagnosis, and their
roles in the assertion of expert authoritativeness; and second, to
propose analytical tools to approach the complexity involved in the
creation of knowledge,the potential frictions it may create, and the
mechanisms of their resolution.

Methodology

Over the last decades, a new approach to the study of

medicoscientific work has arisen, seeking closer attention to the
everyday practices of 'making science' (e.g. Latour and Woolgar,
1986; Lynch, 1988; Pickering, 1992; Rabinow, 1996). Drawing on
this now considerable body of research, this paper will present an
ethnographic study which allowed for a sustained in situ look into
the daily micropolitics of the diagnostic practice.

Being, in a way, the physician's home ground, the hospital

constitutes a precious setting for understanding the world of
medical experts (e.g. Anspach, 1993; van der Geest and Finkler,
2004; Mizrachi, Shuval and Gross, 2005). In this case, a lengthy
and laborious work of negotiation and clarification, namely with
the head of the clinic led to the gradual gaining of the staff's
confidence. Finally, a formal permission from the hospital's board
of ethics (the 'Helsinki Committee') allowed me to begin my work.
By the end of this process, I was accorded access to the most inner

95
 Black Butterflies

stages of the clinic, naturally conditional on the informed consent

of both the professional and the patients taking part in the
research project. Anonymity is ensured by the use of pseudonyms
throughout, again, for both patients and staff. Considering the
level of intimacy I developed with the patients, I felt more
comfortable using first names as pseudonyms, while referring to
staff members in a manner that would reflect their professional
roles, rather than on ad-hominem aspects of their work (i.e. Dr. X.).

In view of the intricate nature of the field of neuro-oncology

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

At the Clinic: The Diagnostic Process

According to textbook medical knowledge, a brain tumour

arises out of the proliferation and multiplication of a single cell,
which, for reasons little understood, undergoes molecular
mutation. At the histological level, these will reproduce, create
their own blood supply, and eventually become numerous enough
to apply pressure on adjacent nervous tissues. The tumour
presents itself through a neurological realm of signs and
symptoms, which may include epileptic seizures, total or partial
paralysis, speech malformations, visual disturbances, loss of
sensation in the limbs or, in some cases, personality changes.

96
 Sky E. Gross

Reporting diagnostic information such as biopsy and MRI studies,

along with clinical impressions allow NROs to determine the
locality of the tumour, its size, the types of cells involved, and its
degree of malignancy.

At the clinic, this process begins with the first encounter with
the patient. There is a fairly ritualistic intake of new patients,
where the NRO assesses previous findings, gathers clinical history,
and performs a physical examination. If judged necessary,
immediate intervention is considered, albeit only once options are
discussed in conjunction with other experts, such as radiologists
and neurosurgeons, and, if applicable (viz. the tumour is
metastatic), with the primary oncologist. In either case, treatment
options (including, typically in this order: neurosurgery,
chemotherapy, radiotherapy, clinical trials, and palliative care) are
deliberated among a relatively wide array of biomedical
professionals.

Routine assessments of cases are typically performed in the

course of three weekly conferences. First, during the NROs’ staff
meeting: there, each physician is expected to present the files of
the patients he/she has seen throughout the week, his/her
colleagues offering their opinions and evaluations. The second
meeting proceeds at the MRI unit, where the radiologists go
through recent imaging tests while the NROs provide clinical
information on their patients. The formers then report their
impressions, first orally to the staff (“things look bad, tut tut tut”),
and later in writing (“a slight compression of midbrain structures
was observed”). The third meeting, the 'tumour board' –which
includes the NROs, neurosurgeons, and radiotherapists- seeks a
collective appraisal of the applicability of different surgical or
radiotherapeutic protocols ('treatment algorithms'). Its place within
the diagnostic complex is limited, and the approach is largely task-

97
 Black Butterflies

oriented. The only common participants in these three sessions are

the NROs, a fact that reinforces their centrality in the diagnostical
process. Indeed, as the integration of reports into a compiling
diagnosis requires the adoption of a common way to ‘speak of' the
disease, the participants (i.e. the reporting experts) are expected to
conflate their way to 'speak of' the disease to the NROs’, thus
placing the latter in a junction of significant power (Mol, 2002).

The interaction between professionals is critical both before

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

Medicoscientific Diagnosis

"In order to be able to offer each of our patients a

course of treatment perfectly adapted to his illness
and to himself, we try to obtain a complete, objective
idea of his case; we gather together in a file of his
own all the information we have about him. We
‘observe’ him in the same way that we observe the
stars or a laboratory experiment". (Foucault, 1963:
XV)

With the proliferation of diagnostic technologies, the practice

of medicine has become increasingly dependent on expert

98
 Sky E. Gross

medicoscientific observation, adding to the intricacy of medical

work (Howell, 1995; Dew, 2001; Clarke et al., 2003). This is
accompanied by the need for a constant reshaping of the definition
and conceptualisation of disease, most prominently in fields where
diagnosis remains complex and critical (Reiser, 1978; Clark and
Mishler, 1992; Casper and Koenig, 1996).

Facing sets of signs and symptoms, physicians are expected

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

In many biomedical settings, this process involves a

multiplicity of experts: within each expertise, diagnostic elements
are observed, explained, assigned attributes and boundaries within
its specific 'styles of reasoning' entrenched within formal and tacit
knowledge (e.g. Good, 1994; Bos, 2004). As Polanyi (1998) and
others (e.g. Hacking, 1982; Collins, 2001) have shown, expert
conceptualisation of pathologies is further mediated by technology
(e.g. an MRI machine), a form of attention (e.g. the analysis of the
spatial characteristics of a tumour) and a hermeneutic agent (i.e.
what does this finding mean?) (Foucault, 1963; Berg and
Harterink, 2004). This ‘gaze’ then provides further interpretation of
reality within these styles of reasoning (Latour and Woolgar, 1986;
Latour, 1993; Haraway, 1997), and mediates the definition of the
disease as a thing-out-there, an object (e.g. Koenig, 1988; Rabinow,

99
 Black Butterflies

1996; Boumans, 2004). Different expertises are sustained within

their own technological, rhetorical, and epistemic systems
(Goodwin, 1994; Knorr-Cetina, 1999), each creating what shall be
referred here as 'expert-mediated objects'. These will then be
made comparable and manipulable within an established
nosological order, where they can be 'spoken of' in a common
language. They will they be placed within a delineated, organised
conceptual chart of identified pathologies (Lynch, 1985; Hacking,
1992), and amenable to integration or alignment with other
objects.

Both the ontological status and communicable qualities of

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

100
 Sky E. Gross

The Web of Expertise

In order to create the neuro-oncological object as a coherent

'ontologically asserted' (or 'ontognostically-based') referent (Bos,
2004), the NRO has to draw beyond his or her own field of
expertise well into the neighbouring provinces of knowledge and
technology. Within the scheme proposed here, this involved
exchanges between what I shall define as three relatively distinct
diagnostic positions: reporting, independent, and compiling
expertises.

Reporting experts provide expert-mediated objects aimed at

assisting in the overall assessment of each particular case. At the
clinic, these included several professionals, including the
histopathologist, radiologist, clinician, and neuropsychologist. In
Marfa’s case, for example, her file showed the radiology report on
the disease as an object with measurable spatial characteristics ("a
two centimetres neoplasm located in the left parietal lobe"); The
histopathologist, on a qualitatively distinct object ("a mixed-cell
oligodendroglioma with a necrotic centre"); The clinical, on a set of
observable patterns ("a contra-lateral hemiparesis with frequent
grand-mal seizures"); And the neuropsychologist on a series of
scores along different scales ("a normal IQ test; low tendencies
towards anxiety; normal results in the capacity to comprehend
abstract notions"). In general, the fact that these expert-mediated
objects are communicated in different forms seldom challenged, in
itself, neither the ontological status, nor the pathological definition
of 'the Disease'. However, reaching a sensible overall diagnosis did,
as shall be shown, require translation and juxtaposition of these
heterogeneous reports.

Independent experts remain external to the main expertise's

(e.g. neuro-oncological) sphere while being potentially involved in

101
 Black Butterflies

the assessment of a patient's condition, depending on his/her

known co-morbidities and general health status. Here, these
experts (such haematologists or general oncologists) served as
autonomous physicians holding their own clinical complex and
definitions of disease. Still, while conducted independently, their
diagnostic and record-keeping activities (including, typically, a
separate file) were occasionally integrated into the patient’s neuro-
oncological case, although chiefly in its margins. This placed them,
in relation to the NROs, at the periphery of the diagnostic web.

The compiling expert faces a multiplicity and disparity of

objects presented in reports gathered from independent and
reporting experts. Occasional disparity of mediated-objects,
however, can potentially threaten the establishment of an
integrated and congruent image of the disease as a relatively well-
defined entity. This tension positions the compiling expert (here,
the NRO) at a unique and most instructive junction which will be
expanded upon throughout the paper.

On the Ontognostic Authoritativeness of Reports

The last century saw biomedicine develop more and more

elaborate tools to assert objective grounds for its practice and
science, including dimensions such as accuracy, accountability,
validity, transparency etc (Boumans and Beaulieu, 2004). For
instance, medicine will seek to redefine itself from a focus on
'artisanship' based on personally-owned tacit knowledge, to an
emphasis on 'profesionalism' based on accumulated agreed-upon
scientific knowledge. 'Objectivity' is also sought through the
development of well defined protocoles, a growing use of technology
in both diagnosis, treatment, and follow-up, and a quantification
and standartisation of reports.

102
 Sky E. Gross

The report is both an artefact allowing communication among

professionals, and a channel through which independent and
reporting experts translate the observed disease into expert-
mediated objects (Berg and Harterink, 2004; Joyce, 2005). As
suggested by Callon and Latour (2006), it is through such
translation processes that epistemologically distinct objects come
to be linked together.

In practice, the translation (i.e., in the production of

radiology, histopathology, clinical, or other forms of reports) was
often poor: the reports seemed to serve more as means of asserting
expert authoritativeness than to communicate information among
experts or to patients. For example, the clinical report was handed
over to the patient at the end of the consultation, whether asked
for or not. As the reports were characteristically composed in a
cryptic language, the patient typically read and re-read it once
having left the room, often baffled by the swiftness of the
consultation. As one perplexed patient said:

"This is a summary of my disease, so I know whether

I am better or not. I will show it to my children".

She would remain unsure of whether she was "doing well" or

not until having the report deciphered for her.

The radiology reports were no more 'user-friendly'. For

example, Alyosha’s MRI report read the following:

"CVB 3, in MRS CHO/CR=4/3, CR/MI=0.9".

This was obviously unapproachable, even for Alyosha, who

usually tried to keep informed. Indeed, reports, say Good (1994)
and others (Bourdieu, 1992; Beaulieu, 2002), tend to use jargon
and rhetorics which make them appear more reliable, conceal

103
 Black Butterflies

areas of uncertainty, and ultimately reify the experts' position as

holding exclusive knowledge and thus epistemological
authoritativeness. This can be said of reports produced by each
and every reporting expertise at the clinic. In the case of radiology,
however, this may be more salient: as the visual medium may
point to a lesser need of expertness in reading (it is "right there", "in
black and white" some patients told me when asked whether they
could recognise their tumour on the MRI), the need to assert the
uniqueness and complexity of their expertise was obviously more
critical. This will have clear manifestation in the form of a relative
indecipherability of the reports.

The Sight of the Tumour: Radiology

The radiology meeting takes place in the general hospital's

building, on the underground floor, where the MRI machines are
located. This is where patients are examined and results are
processed and interpreted by the experts. The NROs and MRI
experts stare at computer screens while patients’ ID numbers are
called by one of the neuro-oncologists. For each patient two MRIs
are uploaded on the screen: the 'before' and 'after'. The NROs then
all offer their opinion, hoping to be approved by the MRI expert:
"the tumour has grown", "the tumour has not changed", "wow, this is
a big one". The questions to be answered are of two kinds: spatial
and temporal. Where is the tumour? Between now and then, is it
larger, smaller, or unchanged?

There are two radiology experts: Prof. Soren and Dr. Martin.
Soren is a quiet but impressive man of about 60 year old, with a
beard that gives him the appearance of a wise oracle. Unlike his
junior colleague, he is never turned to by his first name, but rather
with his full title: "Professor Soren". Martin is younger and his lack
of experience is critical: in the field of radiology, tacit knowledge

104
 Sky E. Gross

acquired through experience is which allows the expert to 'see'

phenomena which may pass unacknowledgded by others. Training
the senses may be the only way of reaching accurate
interpretations. Therefore, in practice, whenever possible, Soren
worked with the team, while his colleague continued working on
'general patient's reports. When Martin did replace Soren, the
meetings were tenser, and most of the final judgements on the
meaning of the image on the screen were given by the neuro-
oncologists rather than by the radiologist. Clinical information was
more often sought and drawn from when the picture seemed
inconclusive (i.e., if unsure of whether the tumour has grown or
not, a worsening in the patient's symptoms was used to settle the
interpretation – the tumour must have grown as well).

All four NROs were present at each of the weekly meetings, as

well as the head nurse. Joining them was Lise's secretary, Gila.
Gila sat with Lise's laptop, plugged onto the hospital's intranet,
and equipped with the software especially designed for keeping and
documenting patients' cases, albeit for the neuro-oncology team's
use only. Gila entered the evaluations she received from the group,
usually as summarised by Lise. She often did not understand the
jargon, thus not knowing what she was writing. She never made
any comment on patients, nor shown emotions when news were
particularly diffficult. In fact, she never expressed any interest
beyond what was directly dictated to her. In this sense, she served
more like a mediating device than an actual 'professional'.

The more formal report was composed by the radiologists

themselves before (forming the grounds for the discussion with the
NROs) or after the meeting (then formed around the reading
suggested in the course of the exchange). It included several
carefully operationalised components, each conceivably
contributing to the diagnostic effort: the location of the tumour, the

105
 Black Butterflies

colouring of its centre and borders, the number of foci, the

regularity of its margins, etc. This, along with the clinical and
histopathology reports, enabled a grading of the tumour, and a
characterisation of its cellular bases.

This report played an important role in the continual

examination and re-examination of the state of the disease; so
much as to have patients sent home --without being examined-- if
their MRI had not been yet deciphered by the expert. As far as the
team was concerned, it was arguably the most straightforward and
informative means of assessing the tumour's progression: “I see
now…” or “It's right there” were typical ways of referring to the
radiology-mediated object during MRI meetings. This has grounds
on several broader cultural stances, including the
medicoscientifical tendency to regard sight as evidence, with
'seeing' being almost inseparable from 'knowing' (Lynch and
Woolgar, 1990; Jenks, 1995; Draper, 2002; Dumit, 2004; Joyce,
2006) and vision as an unmediated perceptual source of
knowledge: the images themselves purportedly allowing an
ontognostic, non-interventional access to the truth (Foucault,
1963; Knorr-Cetina and Amann, 1990; Daston and Galison, 1992;
Cartwright, 1995), and ruling out phenognostic interferrences and
interpretations not intended by the reader (Bastide, 1990; Ala,
2004).

Although the MRI is by definition a mediated view of the

patient, there is a process by which the technicians seek eliminate
this very mediation by creating an object: the 'thing' that they look
upon becomes the ontognostic 'real thing' that needs to be
approached. This materiality is what enables them to approach the
thing, and make the subject of this thing transparrent (Duden,
1993; Boumans, 2004). It is easy for MRI technicians to forget that
there is a 'body' there (Rohrer, 2007), that is: that the screen shows

106
 Sky E. Gross

an abstraction of something, a mediated 'something' rather than

the 'real thing'.

Once the visual is alleged to provide the most authoritative

access to the object of disease, radiology would undoubtedly
represent the epitome of diagnostic science (Gunderman, 2005;
Burri, 2008; Joyce, 2008). In fact, some will claim that radiology
may make things 'more real than real' or 'hyperreal' (Baudrillard,
1988; Frank, 1992), that is, more accurate than would any direct
assessment of the 'object itself', including phenognostic
assessments by the object itself (i.e. the patient).

'Space' is another crucial element in the assertion of the

authoritativeness of radiological knowledge (Leigh Star, 1989):

"Wow, it is indeed large, now I get it [why the

symptoms are as serious]!"

or:

"How can he even walk around with a tumour that

big?!"

These are types of phrases I would regularly hear in radiology

meetings. The diagnosis of a brain tumour, in the NROs' own terms
'a space occupying process', indeed involved an emphasis on
spatialisation: brain-cancer is a local, non-systemic disease,
unlikely to metastasise to other parts of the body; The symptoms
tend to be in correlation with the surfaces of the brain affected by
the disease; The site of the symptoms often directly reflects the
location of the tumour, its spatial characteristics, and to the rate of
its spreading.

107
 Black Butterflies

Often, however, when speaking of a patient's pathology, the

physicians would rather use gestures that point to the area of the
brain involved rather than to the location of the symptomatic
revelation of the tumour. For instance, when Lise left Simon's room
and discussed his condition with her colleagues, she naturally
placed her hand on the left side of her skull, rather than where the
(very visible) paralysis was, i.e. on the right side of the face.

The spatial attributes of the tumour are strongly tied to every

aspect of the physicians' work, including in the clinic. Radiology,
thus, as a space-oriented measure, has powerful epistemological
affinity and mimetic relations with the disease as it is conceived: a
spatial diagnostic technique, for a spatially defined pathology.

This is well examplified in the case of Simone, a 25 year old

woman, with advanced cancer. Her husband, Albert, accompanied
her along with her mother to Franz' office. Simone sat on a
wheelchair, completely lethargic, keeping an empty smile when
spoken to, only to go back and doze off again. Franz read the file:
Simone had just completed a round of radiotherapy, and yet, she
looked considerably worse. He looked at the MRI and without
uttering a word, turned the screen towards Albert: "Look", he said.
Yassar remained unsure of the thing he was supposed to 'look' at,
but understood that something must be wrong. This is when Franz
solemnly announced:

"The radiotherapy had no effect. In fact, the tumour

has grown, and surgery is now impossible: the
tumour takes on half of the brain".

"This", Franz pointed at the screen, now more clearly drawing

around the edges of the tumour, "explains how she is", as if the
visualisation of the tumour actually explained anything. Albert:

108
 Sky E. Gross

"Couldn't you suck it up, like in a biopsy?". Franz bluntly answered,

annoyed by the naïve question: "This is not a liquid! You would suck
up all the brain out!!".

This is when the mother burst into tears, now joined by

Yassar. I was interested as to whether actually seeing the tumour
made any difference: Just a few minutes before, Albert proudly
showed me how her hair had begun to grow again, asking a
rhetorical question: "she'll be alright, now, right?" to which I
answered with a smile. After the consultation, I asked him whether
he was surprised to see the MRI:

"Yes, after 30 days of radiotherapy, it isn't supposed

to grow. I don't understand".

"You didn't think she looked tired?"

"I thought it was the radiotherapy that made her

tired".

He was by now completely deflated. It was as if he finally 'got

it', did the picture make the disease more 'real'?

Sorting Things Out: Histopathology

The work of the histopathologists is perhaps one of the more

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

109
 Black Butterflies

complex, especially in terms of correlating pathology with existing

(and continuously growing) nosological schemes. To mention only a
few criteria of histopathological categorisation: one form of gliomas,
astrocytomas, may be either well-differentiated or anaplastic, either
fibrillary, pilocytic, or gemistocytic, with low or high degrees of
cellularity, low or high degrees of pleomorphism, etc.

Patients, one must note, were seldom aware of such minute

details regarding their tumours – they would rather turn to plain
binary terms: about the mass being either cancerous or not, or
about their cancer being either malignant or benign. These
sophisticated schemes of identification and classification are,
however, central to the creation and preservation of the ontognostic
medicoscientific ethos (Foucault, 1963; Cicourel, 1964; Reiser,
1991a; Keating and Cambrosio, 2003). Histopathology’s ever-
growing categories of mediated-objects, its high tech procedures,
and its position at the cutting edge of research contribute to its
prestige as providing an exclusive corpus of knowledge.

Another characteristic appears to be involved in this assertion

of authoritativeness. In sharp contrast to the 'hands-on' clinical
evaluation, the removal of biological tissue and its analysis outside
of its human context allows 'social distancing'. The living person
becomes literally out-of-sight, out-of-site, and, in a way, out-of-
time, isolated from subjective time and space (and thus from
subjectivity itself) to create alternative sterile, motionless, and well-
defined areas where scientific work can proceed. This, in turn,
provides the laboratory a distinction drawn on a halo of pure
science, clear of the 'fuzziness of reality' (Foucault, 1963; Bourdieu,
1977; Thompson, 1995; Rosenberg, 1999). Removing the personal
particularities of the patient enables a more clear-cut alignment
with existing nosological categories, both within the realm of

110
 Sky E. Gross

histopathology and within the broader neuro-oncological compiling

diagnosis.

Figuring it out: Neuropsychology

Unlike the psycho-oncologists, whose task was to provide

patients emotional support, the neuropsychologist (Keren) was
regarded as a diagnostic source. Keren was assigned patients that
seemed to suffer from cognitive or emotional deficiencies related to
the organic effects of the tumour, or to side-effects of the treatment
provided for the tumour. She administered psychological tests and
interpreted them; but also guided psychology students who are
obligated to practice giving these tests to patients.

Yet, Keren's job was no less practical than diagnostical: She

suggested technics by which the patient might find a way around
his/her neurological deficits and still maintain some quality of life.
Her contacts with the staff were very limited, and her reports were
usually filed, never to be read by the NROs. She was consulted in
rare cases to consider a patient's capacity to give proper consent to
medical interventions or his/her need of being referred to
psychiatric or psychological care. That being said, neuropsychology
played little or no part in the actual medical decision process.

Arguably with the aim of establishing medicoscientific status,

neuropsychological evaluations tended to be presented as highly-
detailed statistical reports. Still, such knowledge – however
justified and materialised in the form of standardised and
empirically confirmed scales and numbers - remained illustrative
rather than demonstrative. If the neuropsychologist was so seldom
consulted, it was probably based on the low authoritativeness and
epistemological profile of psychological methods (and 'psy-

111
 Black Butterflies

knowledges') in the medicoscientific complex (Rose, 1985; Reiser,

1991b; Hacking, 1992; Porter, 1995).

Relying greatly on statistics, numbers and standardisation

allowed a rising of psy-knowledges towards the level of
authoritativeness assigned to more conventional biomedical
sources. This allowed it to be distinct from other forms of
knowledge that would have been brought forward but which may
not have had the same communicative value. It would perhaps not
have been regarded as worth mentioning – just like a patient's
astrological map or his reading of his hands would not. The
knowledge was allowed in, as advertently or not, it was presented
through a filter of 'epistemotechnics' that would 'truthicise' 9 it in
the context of scientific medicine Indeed, if psychology wants to
take full part in a purely medical practice (here: neuro-oncology), it
must relates to 'epistemotechnical' aspects of its work that put it in
the same (or close) epistemological level as medical science. Keren
was open about that: she insisted on sitting in team conferences
because she wanted her work to be treated as a meaningful and
"serious" contribution to the more medical clinical work- she
refused to have neuropsychology remaining as peripheral to neuro-
oncology as it was now.

Hands-on: The Clinical Report

The first component of the clinical exchange, the physical

examination, comprises a direct, usually non-instrumented,
assessment of a number of parametres. According to textbook
directions, although rarely meticulously followed in practice, these
include the tone of each muscle group, muscle power, and reflexes.
Changes in sensation will be identified by means of a probing of
different parts of the body, and coordination by observing body

9
'make true'

112
 Sky E. Gross

movements. Also central to the examination is the evaluation of

gait, during which the patient will be asked to walk back and forth.
The clinician is expected to provide expert deduction and gather
relevant information from the patient, while drawing on haptic
skills and limited technological aids (Foucault, 1963; Porter, 1993;
Moreira, 2006). This 'low-tech' practice is believed to be highly
susceptible to errors and inaccuracies: the patient's body viewed as
disordered and 'messy' in conveying valuable data, and the method
itself based on phenognosis and overall 'primitive' (Joyce, 2005).

The second component of clinical practice, history-taking,

demands a systematic gathering of information (e.g. headaches,
seizures, visual disturbances, motor or sensory dysfunctions, pain,
nausea) which must be characterised by time of onset, duration,
location, frequency, severity, progression or remission,
precipitating circumstances, and associated complaints. A history
of administered treatments must also be sought, as well as should
a more general background of co-morbidities, past medical
interventions, and cases of severe illness in the family.

The lack of neutrality, objectivity, and preciseness attributed

to this practice is critical in the evaluation of the validity – and
thus authoritativeness – of knowledge portrayed in such reports.
Arguably, patients have a 'privileged access' to their own inner
world of experience, and are able to reach a phenognostic 'truth'
that is beyond scientific exploration (Heil, 1988; Gertler, 2001).
This impinges upon the ethos associated with ontognostic thought,
whereby the physician would necessarily have epistemological
supremacy as holding total and absolute knowledge of the
phenomenon of disease. In order to retain ontognostic
authoritativeness, the expert must bind his/her perspective to
observable and accessible aspects of the 'reality' he/she faces,
rather than to the patient's life-world: his/her belief system,

113
 Black Butterflies

background, personality, particularities, emotional issues, etc

(Cicourel, 1983; Mishler, 1984; Anspach, 1988; Gunderman,
2005).

The patients themselves cannot be assigned 'expertise', a

clear form of power, even in the context of reporting their own
subjective experience: doing so would challenge the hierarchical
physician/patient relations in the sacred biomedical space of the
clinic and would allow in a non grata phenognostic knowledge.
While the patients may influence the actual process of diagnosis
(e.g., overemphasise some minor symptoms in order to assure full
attention and treatment), they are denied any status of expertise:
the expert is the 'reader' of the body, the deciphering agent of the
narrative, both of which are –more or less-- reliable givens

At the clinic, written reports showed patients' accounts

preceded by a sort of 'disclaimer', noting their relative unreliability.
Typically, the reports included clauses such as: “according to the
patient...” or, quoting from one clinical report:

"[The patient] describes events of abnormal smells,

tastes, and panic feeling up to 10 times a day"

or,

"He complains of some difficulty getting his words

out in conversations".

A similar trend was found in oral exchanges: the 'had' – as in

"the patient had headaches"- was presented during meetings as if
of higher authoritative status than the 'described', and –to a lesser
degree-- than the 'complained of'. The first was assigned some
legitimacy as the reporting physician ipso facto provided a seal of
approval to the actuality of the symptom. The second portrayed the

114
 Sky E. Gross

patient as able to observe, reflect on, and effectively communicate

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

The Patient

A clinical evaluation, as defined above, does not solely rest on

the examination of the patient's body, but also on the accounts
he\she may provide. This makes the definition of the
authoritativeness of phenognostic, first-person information highly
critical.

Observations of the field suggest that a classification of

patients into reliable ('good patients') and unreliable ('bad
patients') is most sensible. This classification has its basis on a
range of characteristics. In general terms, the ideal patient is
cooperative and compliant. Yet compliance does not merely involve
following 'doctor's orders'. The term, I shall argue, also applies to
the patient's ability or willingness to internalise the biomedical
gaze and its ontognostic claims for epistemological
authoritativeness (Gross, 2009a). He does not have to be
knowledgeable on the subject of his illness, and in fact, being too
knowledgeable may be seen as an annoyance. He still needs to be
able to ask intelligent questions, or to refrain from asking
questions at all, thereby re-affirming the physician's skills in
providing all relevant information. In general, the patient is
expected to be straight and to-the-point in reporting his
complaints, asking the right questions and responding in an
appropriate way to the the physician's inquiries.

115
 Black Butterflies

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.

116
 Sky E. Gross

The 'good patient' must also report symptoms that 'make

sense': problematic accounts may include "feeling as if crossed-
eyes, but in the ears". The good patient also never argues with
neither the diagnosis nor the advised course of treatment. Lise's
account of an exchange she had with a patient:

"His wife doesn't understand the drug thing. She

argues with me and won't agree with me. She is
retarded, I think". [In my view, the woman did not
show any sign of mental retardation]

Although some information may only be sough from the

patient's account, such as feelings of numbness or pain, one may
distrust these first-person mediated, phenognostic accounts. This
has two major reasons: one, the person may simply be not truthful
(lie), and second, the person may not be aware of his own
condition. The field teaches us that the patient must provide
specific forms of accounts that eliminate, or diminish these two
considerations: he must speak of symptoms in a credible way -
talking about witnesses, referring to the 'right' symptoms according
to the 'book': this may include a "my head is on fire" as an
unsophisticated but accurate account of what a patient may feel
like after radiotherapy. In fact, it is considered most credible when
the patient seems to 'incidentally' report symptoms that, without
him holding true knowledge of it, would be compatible with the
textbook account of the disease.

A good patient will provide just the right amount of reporting,

being succint but informative. He must also not be "overly anxious"
(this being a typical term used), although, where brain cancer is
involved, one may wonder whether there is such a thing as being
'overly' anxious. There is also a right timing when the symptoms
must be mentioned: an eagerness to report symptoms may have

117
 Black Butterflies

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).

118
 Sky E. Gross

One memorable case of such 'bad patienthood' is Benjamin

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

General Oncologists: Peripheral Experts

The oncologist that worked most closely with the NROs is

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

119
 Black Butterflies

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

120
 Sky E. Gross

finds the chosen cases most instructive, perhaps as a by-product

of the nosologically-based criteria of inclusion:

"By operating a process of selection, it alters in its

very nature the way in which the disease is
manifested, and the relationship between what is
present is the disease itself, in the body that is
appropriate to it, which is not that of the patient,
but that of its truth" (Foucault, 1975: 26).

This perhaps defines best the importance of the nosological

complex that would define or be defined by the institutional-
epistemological separation of neuro-oncology from oncology.

The Neurosurgeons and the Tumour Board: Peripheral Experts

Once a week, the neuro-oncology staff (the four physicians

and the head-nurse) meets with the neurosurgeons. The name of
the weekly meeting, 'the tumour board' is somewhat enigmatic: as
if this was when the tumour would be defined, identified, and
characterised. This has in fact little relevance to what actually
ocurred in these meetings.

The neurosurgery staff comprises three middle-aged men,

assertive and at times even aggressive in their manners. The
athmosphere is quite different from the radiology meeting's: the
power dynamics put the NROs on contested grounds as far as their
expertise is concerned. This aside, the meeting is not diagnosis-
oriented, but rather centres on decision making: 'can and should
this patient be operated on?'. Each meeting focuses on no more
than three to four patients where surgery might be considered.
Then, clinical evaluations are brought up along with radiology
reports, and treatment options are deliberated. Although the NROs
are the ultimate decision-makers, and will never suggest surgery
121
 Black Butterflies

when deemed impossible or not beneficial by the surgeons, the

latter remain highly authoritative, probably due to the high status
brain surgeons have in the medical field and to the uniqueness of
the tacit knowledge they may have acquired over the years: a form
of knowledge innaccessible to the NROs.

One must remember, however, that the neurosurgeons play

no role in actually diagnosing the patient, and are therefore
somewhat outside of the scope of this scheme.

Mechanisms of Integration

The raison d'être of neuro-oncological expertise lies in the

contention that brain cancer is a distinct, well-defined, and
conceptually unified disease entity. Asserting the coherence
between mediated-objects not only reaffirmed the soundness of
each individual form of inquiry and validated the meta-diagnosis of
one particular case, but also served to support the general notion
of brain cancer as a cellular based, spatially spread, and
scientifically detectible form of disease, one for which a specialised
compiling expert should be ascribed. In other words, the
ontological, pathological differences between 'body cancers' and
'brain cancers' are replicated in the field of relations between
professions and profesionals: between oncologists and neuro-
oncologists. These boundaries are further replicated in the spatial
organisation of the clinic, as described at length in an earlier
chapter.

In terms of the web of experts, the hierarchical distinction

between neuro-oncologists and general oncologists was
continuously sought to be preserved not only by the NROs forming
a 'clique of their own' as one onco-psychologist put it, but also via
the establishment of disease categories and diagnoses pointing to

122
 Sky E. Gross

the particularities of brain cancer over other oncological diseases,

and the affirmation of the diagnosis as requiring neuro-oncological,
rather than oncological, expertise. When faced with a collection of
disparate reports, the NROs thus sought to establish the case as of
a well-asserted neuro-oncological nature. In this sense, the meta-
diagnosis also served to delineate, and then preserve the areas of
jurisdiction and epistemological boundaries of the compiling
expertise (Abbott, 1988; Gieryn, 1983, 1999). This secured the
NRO's prerogative to elect and determine treatment options, to
provide reliable prognosis, and to centralise documentation and
records for future research: to be the compiling expert.

As claimed above, this endeavour involved five relatively

distinct mechanisms: hierarchisation, sequencing, negotiation,
peripheralising, and pragmatism.

Hierarchisation

Forms of knowledge, as well as the objects produced by this

knowledge, are created and sustained by having its different forms
become authoritative, and others subjugated, marginalised, or
excluded from the sphere of legitimacy (Foucault, 1980; Latour and
Woolgar, 1986; Latour, 1996). As shown throughout the text, the
forms of expertise associated with neuro-oncologic diagnosis
differed not only in terms of instruments and types of knowledge
applied to the mediated-object, but also in terms of their perceived
authoritativeness, and, consequently, hierarchical position. The
NRO, confronted with the task of incorporating the disparate
reports, could (and often did) choose to constrict the range of
available knowledge by discarding information from less
authoritative sources, settling for a diagnosis based on narrower --
albeit more solid-- foundations.

123
 Black Butterflies

This was the case with Ilya. At the radiology meeting, his
latest MRI took Lise by surprise: "this looks bad…", she told her
colleagues, "It’s amazing, he has no symptoms! This guy walks
around with a ticking bomb in his head, but is completely
asymptomatic…". In other words, the MRI suggested a progression,
while the clinical picture pointed to a more stable and benign
condition. The pictures were unquestionably there, thus the
'anomaly' had to be located at the clinical level, the less
authoritative of the two forms of knowledge. As well put by
Gunderman (2005:342):

"We radiologists sometimes find ourselves giving

more credence to the images than to the patient,
rendering the patient’s experience subordinate to
the images on the monitor."

Lise declared a worsening in Ilya’s state: now judged

ineffective, Tal’s chemotherapeutic treatment was discontinued.

Sequencing

Brain tumours are conceived as having a dynamic

constitution. First, it is granted that the tumour may progress from
one grade to another, may respond to therapy --at times long after
the treatment itself has been interrupted or concluded-- or may
simply remain unchanged. Moreover, symptoms tend to
accumulate and aggravate, and their response to medication may
decrease over time. Sequencing uses this set of temporal factors to
account for diagnostic changes without challenging the unity of
'the Disease', substituting ontological fluidity for temporal fluidity:
the object may not be stable as an entity, but still retains a
continual consistency as a neuro-oncology-mediated object.

124
 Sky E. Gross

On one occasion, for example, Karl’s wife called Franz to

report that her husband had a new symptom: he felt 'tingling' in
his left arm. She was surprised as the MRI, taken two weeks
earlier, suggested a shrinking of the tumour. Considering the
authoritativeness assigned to medical images, Franz did not readily
discard the imaging report as unreliable. Rather, she answered
that the disease had probably worsened since. As MRI images were
never compared unless taken at least one to two months apart,
this was an assertion that, while sensible, was impossible to be put
to the test, and thus also impossible to challenge. Yet, as it allowed
the initial diagnosis to remain valid, it was accepted, to the very
least until other evidence came along (the next MRI suggested that
the tumour was indeed growing).

In general, in case presentations, the sequencing of the events

is very much put at the centre, and the temporal dimension is
central to the characterisation of the disease. Only with little
exceptions does it not make complete narrative 'sense' as the
development of one (or several concomitant) diseases.

Negotiation

It is during the weekly radiology meeting that 'negotiated

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

On some occurrences, the NROs were provided with non-

negotiated reports. These, compared to reports resulting from the

125
 Black Butterflies

MRI-NRO meeting, tended to be vague and obscure. One such

report was Friedrich’s. According to Lise, the clinical picture
suggested a slowing down of the tumour's progression, while the
MRI report remained 'incomprehensible'. She advised Friedrich to
phone her the subsequent Monday for a more definite answer. In
the course of Sunday's meeting, Lise briefed the radiologist on
Friedrich's clinical improvement, emphasising the fact that he had
recently received treatment. The highly negotiable nature of the
imaging report permitted the team to agree that the MRI showed
some decrease in the tumour's size.

The use of this mechanism was also evident where clinical

reports were concerned. The NRO, one may recall, performed a
dual role in the web of expertise: once as a compiling expert and
once as a clinical reporting expert. The NRO, when clinically
evaluating one particular patient, could thus favour interpretations
that were most consistent with his/her overall preconceived
impression. Hence, by the time the file reached the NRO as the
compiling expert, some degree of compatibility could already have
been incorporated into the reports, facilitating the reaching of the
meta-diagnosis.

Negotiation was less apposite where histopathology reports

were concerned. First, unlike MRI reports, which were delivered
also orally, the histopathology report was customarily
communicated solely in writing. Secondly, histopathology was
conceived, overall, as involving a lesser degree of human
interpretation, and thereby as being more rigid to processes of
negotiation. Thirdly, the NROs tended to regard themselves as
more competent in reading MRI pictures than in the deciphering of
cellular formations, thus having little to add to the
histopathologists’ interpretations. Finally, the importance of the
histopathology report was often only tangential to decisions on

126
 Sky E. Gross

treatment, and was conducted significantly less frequently than

radiology tests.

Negotiation was also present in clinical exchanges with the

patients. For instance, when Misha came to hear about his latest
MRI and discuss his condition, he was almost literally told what he
'should' be feeling, and conseqently abided to this normative
statement. The MRI showed that the tumour had slightly grown
over the last two months. Looking carefully at the MRI, Lise
asserted:

"I don't believe you should feel any change"

Misha: "Well, I do have some headaches…".

Lise: "It's… I don't think it's really something".

Misha, mumbling: "OK…right..."

The headaches, a symptom now completely discredited, were

never brought up again.

Peripheralising

Sofya, a 52 year old woman with a highly malignant cancer,

was told by Franz that "the latest MRI shows [she is] doing better".
Now almost completely blind, holding her face in her two hands,
she mumbled in response: "but my head aches so much that I can’t
even touch the tips of my hair without feeling like screaming!". Franz
interrupted her short monologue: "That, I can’t explain". As she
attempted to persuade him that her pain was real, he referred her
to a dermatologist: "it could be a different problem", he concluded.

127
 Black Butterflies

Here, as in other cases, the independent expert was sought once a

diagnostic element could not be accounted for within the neuro-
oncological sphere: the dermatologist could, however, explain
away the 'hair ache' without openly dismissing the patient’s
complaints on the one hand, or challenge the already well-
established diagnosis on the other.

This dermatology-mediated object could then be incorporated

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

Pragmatism

In neuro-oncology, treatment options are comparatively

scarce. They include a few forms of chemotherapy, a limited array
of surgical interventions, and relatively little room for intense
radiotherapy. The primary brain tumour will almost invariably be
fatal to the patient: more than half will succumb to the disease
within the twelve months following diagnosis. Only one fifth will be
expected to survive for more than five years (Coldman, Phillips and
Reid, 2004). In practice, once treatment options run out, the NRO
usually ceases to be involved. The patient will then be offered
supportive and palliative care, typically in a hospice or among
his/her relatives. This being the case, elaborate and minute
diagnosis may, in some cases, seem somewhat less crucial. This

128
 Sky E. Gross

was the case with Grushka, a 84 year old woman, whose precise
type and grade of tumour were unknown. The group was
unanymous: she will not have her tumour biopsied, rather, she will
be given something for her symptoms, i.e. a large dose of the most
common steroid used in brain cancer: dexamethazole©.

In effect, patients themselves were little interested in precise

diagnosis. Treatment prospects seemed more salient: "Will I have to
go through chemo?" "Will I lose my hair?". Simon, for example, spent
months visiting the clinic without showing any interest as to
whether his tumour was graded III or IV. Although undoubtedly
aware of the grading system, he "never thought of asking". Indeed,
for many patients, beyond general notions of improvement or
degradation ("Has it grown?", "Am I doing better?"), formal diagnosis
remained futile.

As a rule, the neuro-oncology clinic saw patients only once a

brain-tumour diagnosis was reasonably established. At this point,
however, the diagnosis remained vague: "There is a finding in your
brain, we are still unsure of its exact nature" was a classical
opening. Patients rarely demanded much more details, and, more
often than not, avoided using the term 'cancer', to rather refer to
hazy notions such as 'my condition', or 'the lump'. Oren, for
example, was surprised to hear me refer to the 'oncology clinic'
when we set a location for an interview. He said he never noticed it
was a clinic that "also deals with cancer"- this after five years of
follow-up.

Recently diagnosed patients tended to use the more hesitant

"I was diagnosed with…" than the definite "I have…". Both patients
and physicians entered a sort of unspoken pact, where the precise
diagnosis was regarded by both as merely tentative. In line with the

129
 Black Butterflies

"pact", the physician would respond with such uninformative

remarks as:

"Let’s not jump our horses"

"Let’s talk after we have some further tests done"

or,

"We’re never sure of anything, but we have to do

what needs to be done".

In the course of more than one hundred such consultations

observed, only a few patients inquired into expected consequences
of their diagnoses: the "how long do I have, doc?" question was
never raised, under any variation. When at all, prognostic
information was only vaguely sought, with a "can this be treated?",
rather than "will I live?". Physicians themselves never went beyond
a general: "it’s all just statistics", or "each case its own". While
family members did occasionally sought online information on the
expected lifespan of their loved-ones ("for practical reasons", they
would typically claim), as far as patient-physician interaction was
concerned, precise diagnosis did not serve any prognostic aim. In
fact, one of the younger patients, a computer programmer well
acquainted with the web, told me he read "a lot" about his
condition. As to his life expectancy:

"Really?! Do they [the websites] say anything about

that?! It must be in small letters, or I must have
missed this line [where life expectancy was
mentioned]…".

In the case of Alexey, an 18 year old boy, he would go on and

on about becoming a physician. Although aware of many aspects of

130
 Sky E. Gross

his condition, he seemed completely oblivious to the fact that his

life expectancy was of a year or so, during which he will probably
be increasingly handicapped. The prospect of medical school was
poor, as was his life prospects in general. However, like many other
patients, he would simply deny this reality.

This trend was also evident among another significant group

of patients. These were referred to the clinic after the treating
oncologist (being, here, the compiling expert) suspected the
presence of cerebral metastases. At this point, the neuro-oncologist
(here, serving as an independent expert) tended to provide an
assessment that was more quantitative than qualitative: the
tumours were either present or absent, single or multiple, active or
stable. Patients were then less concerned about the precise nature
of the neuro-oncological aspect of their disease. Gabriel, a 66 year
old man, just heard about his melanoma (skin cancer) having
metastasised to his lungs and brain. He "doesn't want to know too
much":

"The only information I have is what my sons tell me.

As far as I'm concerned, I don't need to know
anything beyond the tip of my nose [places his finger
on his nose]".

Also, as the presence of metastases remained an almost

definite death sentence, as far as the NRO was concerned, a more
pragmatic approach was be adopted, focusing on treatment options
and palliative care rather than on elaborate diagnostic
undertakings. The disease may itself be loosely defined as
belonging to a more general diagnostical category.

In these cases, NROs often favoured the use of as little

information as needed for the determination of the most

131
 Black Butterflies

advantageous course of therapy. In practice, this stance of

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

Concluding Words

As part of a larger attempt to consider issues of dynamics of

knowledge and their relation to social phenomena, this study
demonstrated the significance of the web of expertise in the
production of diagnosis, most particularly where the latter tends to
be ubiquitous, and involve highly heterogeneous epistemological
forms.

While widely acknowledged in past literature, little research

was based on thick descriptions of expert exchanges in the
backstages of a hospital setting. The ability to witness the
processes of diagnosis from various angles, including different
actors and different settings, allowed for a thorough and detailed
presentation and schematisation of the microdynamics of a central
aspect of medical work, i.e. the undertaking of diagnosis.

132
 Sky E. Gross

As defined above, expert gaze incorporates sets of

epistemologies and technologies, both of which mediate diagnosis
and reduce a multileveled phenomenon into one single manageable
object. The replicated flows of artefacts, concepts, and
interpretations among experts were shown to have an important
role in asserting both reporting and independent expert
authoritativeness, but also in reifying the legitimacy of neuro-
oncology as a compiling expertise. Participant observation of the in-
situ workings of the clinic suggested that this reification involved,
on the part of the compiling experts, the use of five mechanisms of
consolidation: hierarchisation, sequencing, negotiation,
peripheralising, and pragmatism. These mechanisms were shown
to involve different cases at different conjunctures, and with
different sets of expert relations, emphasising the complexity of
diagnostic work.

Many of the patients discussed here died before this

manuscript was finalised. Others will soon die, some more in
comfort than others. All being said about the ontognostic 'reality' of
these 'objects of disease', it eventually comes down to the effort to
save patients’ lives, to give them more time with their family and
loved ones, to make their last moments more bearable.

I propose concluding with an afterthought. The analysis

presented here may seem abstract. In an ironic, yet mesmerising
way, by reflecting biomedicine’s utopian vision of diagnosis as
sterile from non-scientific spheres (e.g. phenognostic forms of
knowledge), this work was narrated in a way that suggests the
presence of a similar bias. Yet, it is through exchanges between
experts, through mechanisms of diagnosis and decision-making,
that actual, experienced lives are altered, prolonged, or less
painfully ended. It is through dynamics of knowledge exchange, of
human exchange that the enterprise sustains itself. One cannot,

133
 Black Butterflies

and indeed should not, lose sight of the fact that ethos, symbols,
technology, epistemology, and eventually the experts themselves,
do not live in an abstract world of theory, or objective insularity.
They are encroached in the flesh, in the suffering, in the existence
of actual men and women.

A discussion of these very issues will stand at the centre of a

later section of this work, when the individuality and subjective
depth of one particular patient will be brought to the fore. This
section will be based on a notion of the brain as an intermediary
between matter and consciousness; brain is both the assigned
locus of phenognostic knowledge, and an ontognostically
observable 'thing'; it thus only makes sense to place the brain at a
most significant juncture of this work.

134
 Sky E. Gross

Part V: The Brain Exposed

On Neurosurgery and the Nature of Objectification

Introduction

"The presence of disease in the body, with its

tensions and its burnings, the silent world of the
entrails, the whole dark underside of the body lined
with endless unseeing dreams, are challenged as to
their objectivity by the reductive discourse of the
doctor, as well as established as multiple objects
meeting his positive gaze….thus the articulation of
medical language and its object will appear as a
single figure". (Foucault, 1975: XI)

As described earlier in this work, modern Western culture has

always held an intricate view of the body: while still being
considered as an object among others, the body will keep its
singular phenognostic status as the locus of a subjective
consciousness (Sartre, 1956; Merleau-Ponty, 1962; Lanigan,
1995a, 1995b). Focusing upon this dualist epistemology, social
studies have repeatedly shown how biomedicine, as a dominant
discourse of modernity, tends to refer to the body in terms of the
former, discarding the latter (e.g. Martin, 1994; Cartwright, 1995;
Lock, 1997). Indeed, over the last decades, a significant range of
research has accumulated, associating biomedicine’s practices and
epistemological bases with stances of depersonalisation and
objectification of the patient (e.g. Scheper-Hughes and Lock, 1987;
Thornquist, 1997; Scambler and Higgs, 1998). Arguably, this
tendency toward objectification will have biomedicine centre its
attention upon the body as a material, ontognostic entity (e.g.
Eisenberg 1977; Mishler et al. 1981; Dew 2001), where it would be
treated as a machine, observable through expanding scientific
135
 Black Butterflies

technologies and knowledge (e.g. Arney and Bergen 1984; Synott,

1992; Walters, 2004). According to this claim, the observable and
ontognostically-graspable body will take precedence over which
remains beyond biomedical epistemological reach, i.e. subjective
experience (Babbie 1970; Armstrong, 1983, 1984; Csordas, 1994;
Good, 1994), and thus favouring the ontognostic over the
phenognostic.

These lines of argument have become the dominant voice in

broad areas of social study of biomedicine, and the portrayal of
biomedical epistemology as reductionist and materialistic is by now
little questioned. The split between experience and the body is
perhaps most salient in studies of patient-physician interactions
(Murphy, 1990; Toombs, 1990; Wiltshire, 1999), where these
interactions are typically portrayed as consisting of a dialectical
exchange between two voices: the voice of medicine and the voice of
the life-world. As the former will relate to the body in abstract
decontextualising terms, the latter will see to the patient’s
experiences as grounded on his/her social and personal life as it is
narrated from a subjective position, and based on phenognosis as
a source of knowledge (Mishler, 1984; Young, 1997; Barry et al.,
2001). An overbearing claim – albeit often implicit – in these texts
is that since medicine seems to disregard this life-world, it remains
to the researcher to be attentive to it and to relate to it in a more
empathetic manner: either by pointing to what he/she considers as
an excessive attention to its supposedly symmetrical opposite (the
body), or by applying more sensitivity toward the complex,
subjective, personal aspects of human existence. Indeed, in
important works studying the body as a site of conjunction
between the two spheres (e.g. Turner, 1992; Csordas, 1990, 1993,
1994), the researcher is typically portrayed as more aware to the
phenognostic, lived aspect of the body, as if a necessary

136
 Sky E. Gross

consequence of his/her position (e.g. Featherstone et al., 1991;

Haraway, 1991; Berg and Akrich, 2004).

Phenognosis, however is not a mere pre-discusive form,

necessarily applied unless 'disciplined' by ontognosis. It is, as I
have argued before, a consequential discursive force, which
requires fit contexts upon which to attach itself in order to gather –
and retain- power. This means that a phenognostic-based attitude
toward the 'other' is not a mere default position, held in non-
medicalised settings by not medically-socialised individuals. It is a
discursive power in and on itself.

Although biomedicine might indeed use a dualist, or

materialistic view of the person, it is neither a constant position,
nor is it a necessary by-product of epistemological, historical,
technological, or even political characteristics of the profession.
Rather, the patient is defined and redefined in interactions,
alternating subject and object positions, passive and active
stances, and definitions as either patient or person (Berg and
Akrich, 2004). Taking this a step forward, I will argue that one
cannot, and must not, exclude the researcher from these
microdynamics. The researcher, however reflexive and empathetic,
is hardly immune to objectification tendencies. If the body is
imbedded in contexts within which it appears, and if dependent on
its characteristics and positions, both ethnographer and biomedical
practitioner will find themselves in transition between stances of
objectification and empathy. Any participant observation in the
social studies of medicine will have to address this issue prior to
the actual insertion into the field.

137
 Black Butterflies

Methodological Notes

I will present this movement using a first-person narrative of

my own relationship with Ivan 10, an informant encountered in the
course of my fieldwork at the neuro-oncology clinic. Six months of
intensive participant observation pursued by a year-long follow-up
allowed a close rapport to develop. As I accompanied this 32 year
old man throughout his battle with brain cancer, I attended the
many clinical exchanges he had along the way, and eventually
accompanied him into the surgery room where I would witness his
brain exposed. There, where a last attempt to prolong his life was
undertaken, it seems the complexities of our relationship would be
taken to their extreme.

An interesting feature of this case is that, while becoming

increasingly intimate with both him and his close ones, I also had
continual access to the purely biomedical aspects of his condition -
this by attending staff meetings where his case, among others, was
discussed. Along parallel, yet at times intersecting lines, I followed
his disease as an ontologically-asserted physical entity but also as
it was experienced by a person with full subjectivity, as an illness
(Kleinman, 1988). Tied with the development of his illness
trajectory, I gradually took on the role of a confident and provided
some of the mental and emotional support he desperately sought.
Ivan became a principal research subject and, to some extent, a
friend.

In an attempt to understand this fluctuation in my stance

toward him, I use this essay to reveal my internalisation of
different roles, at times as part of the clinical team, at others, as a
lay (i.e. non-medical) researcher with strong personal relationships
with the subject. I depict the ways in which my own experience

10
As with all names mentioned throughout this work, this is a pseudonym

138
 Sky E. Gross

was altered by replicated 11 ritualistic and symbolic elements, often

said to serve as facilitating medical objectification. These elements
may be discerned in many arenas where the body prevails.
However, and as made ever more evident in this work, I shall claim
that one organ holds particular features, features which make the
analysis around it more complex, but also more promising: The
Brain.

The Sacred Brain: The Matter of the Gnostic Split

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

Western medical thought is largely based on an organ-

oriented view. Its ontognostic components are further based on the
concept of efficient causation – of biological processes being linked
together as sequences of cause and effect. The brain plays a central
part in this anatomical-causal complex, in being both the causal
source of every bodily process (from blood circulation to muscle
coordination), and the point which every bodily process eventually
affects. It is the source of action and the endpoint of both internal
and external sensory input.

Social science literature has brought us several illustrations

for the centrality of the brain in biomedicine. First may be the
conviction that, although biologically viable, brain-dead individuals
11
The idea of replication of boundaries is discussed in the introductory chapter and will be developed
here at later stages of the analysis.

139
 Black Butterflies

have lost their personhood or humanhood, and can be referred to

as beating heart cadavers or neomorts (Youngner, 1989; Okhuni-
Tierny et al., 1994; Kaufman, 2000; Lock, 2002). The central
position of the brain in Western society can also be seen in its
cultural emphasis on reflexivity, and "the paramount cultural and
material importance of the mind" (Webb, 1998:1). Webb, for
instance, analyses cases of brain injured individual and explains
their expulsion from modern society by referring to the particular
features of the brain as an organ rich in meanings that are central
to Western society (Webb, 1998). Another example can be found in
Popper and Eccles' work (1977:177), according to which it would
be clear that a transplantation of a brain onto another's body
would amount to the complete "transference of the mind, of the
self" into the latter. Then, the brain, rather than the body as a
whole, holds paramount significance in the definition of selfhood
and subjectivity.

At a different level, the brain can have primacy over the body,
such as in cases of phantom limb syndrome, when the brain
creates a seeming perception of one's body. This leads amputees to
experience sensations (e.g. pain, tingling) as having their source in
the limb removed. This phenomenon may be explained by the
presence of neuronal representation of the arm or leg at the level of
the brain, which, when cerebrally activated, can 'feel' as the 'real
thing', external to the brain. A related (and, in a way, reverse)
condition is of 'asomatognosia'. This takes place when a person's
limb 'feels' like an external object 'glued' onto one's body, having
nothing to do with his/her perceived 'self' (i.e. Tsementzis, 2000;
Greenberg et al., 2002). In these cases, patients may go as far as
calling this limb by a name, such as 'Joe' or 'Mary' (Sacks, 1985;
Feinberg, 2006). This phenomenon has its source on disorders of
brain activity, again providing a vivid instance of brain's
domination over the body.

140
 Sky E. Gross

This idea of the brain as the apex of subjective/objective

liminality, will have clear ritualistic expressions in the surgery
room. It will create multiple dimensions within which the
subjective will be dealt with, replicating the liminality and the
boundaries created as a result of this liminality. Based on the
following ethnographic description, I shall turn to the analysis of
these dimensions.

The Story

'Prelude'

I had barely begun my fieldwork when I met Ivan. The last

patient had left Lise’s office and Ivan's dossier laid on the top of the
pile. I looked at his name and remembered his case, which was
just brought up during the last staff meeting: my field notes read
"Ivan Katz is a 31 year old patient with a grade II
oligodendroglioma", a type of brain cancer with a life expectancy of
seven to ten years. He was diagnosed in 1999. We were now at the
end of 2006.

The day of our first interview, set at a coffee house near the
hospital, was incidentally the day when Ivan experienced the first
epileptic seizure he had in the last two years. As far as I could
gather from the situation, he was probably emotionally drained
from having to recall his seven years experience with brain cancer
and, ten minutes into the interview he left the table to freshen up
in the bathroom. On his way back, however, he collapsed. Lying on
the floor of the staircases, he regained consciousness surrounded
by strangers, mostly nurses and other hospital employees. As I was
later told, he immediately asked for me, calling out my name and
describing me to the security man. The latter reached the coffee
house and almost out of breath, asked me whether I knew a 'Ivan

141
 Black Butterflies

Katz'. "He doesn't feel well" was all he said as he was leading me to
the staircases. I naturally found myself helping him to the
Emergency Room (ER) – the access to which was much facilitated
by the fact that I was wearing my white gown. We were able to use
– unquestioned – the back entrance, usually reserved for staff
members.

There, we were to spend the next seven hours together. I

knew that the seizure was a clear sign of relapse. I was told a few
days later that the chemotherapy ceased to be efficient and that his
tumour was growing. The following year would be his last.

On the day of this dramatic interview, Ivan had an MRI taken.

Later this week, I would be the first to see the image, as I regularly
participated in staff meetings. There was little need for professional
deciphering: the tumour grew considerably, a fact which explained
the seizure. As to my question on the specific episode and its
timing, the physicians all categorically ruled out any causal
relation between the seizure and Ivan's emotional tension at the
time – the subjective was not allowed into the loop of causation. It
was the tumour "having its will when it had its will". Ivan would
continue to see this as a direct reaction to his emotional
experience, while I remained indecisive, although continuously
troubled by the question: was this a purely bodily phenomenon –
with its own causes and effects - or was I to take Ivan's account as
a fact, as The Truth?

In medical terms, however, there was little doubt that Ivan's

condition was deteriorating. As a behind-the-scene, backstage
observer, I was well aware of that. However, as my research placed
Ivan –rather than the medical team- at the centre, I had to wait for
him to reveal this unfortunate development: for me to convey the
results to him directly would not only be a breach of ethics. It

142
 Sky E. Gross

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 hemiparetic 12 and suffered an almost
complete loss of sensory and motor capacities on the right side of
his body. After the last chemotherapy round turned out to be
almost lethal, the Jerusalem team gave up on treatment. They had
nothing else to offer. Palliative care was all that remained.

Ivan, however, refused to give up without what he considered

as a fair fight. He and his family turned to another hospital, now in
Tel Aviv, seeking advice. There, the team offered one additional
surgical intervention in order to remove a part of the tumour. That,
they thought, might possibly allow for the chemotherapy to be
more effective. The surgery was to take place a month later.

12
A neural weakness on one side of the body, typically leaving the other completely functioning

143
 Black Butterflies

Ivan was amused when I first asked him whether I could join
in on the operation. He dared me to go through this, and swore me
to talk to him afterwards about "what [he] looks like inside". I
wondered whether knowing what his brain looked like would add
anything to his understanding of himself, or to my understanding
of him, and as to whether he would have had the same request was
another organ the target of surgery. When I inquired about it, he
responded that "it wouldn't have been that cool". As far as I was
concerned, the baring of the 'organ of the self' bared nothing of his
'self'. I could only speak figuratively, and tong in cheek, on how
large his brain was, as if it reflected his intelligence. Sadly, the size
of his brain had more to do with the space-occupying presence of
the tumour. His brain said nothing.

The story of our relationship and the difficulties I had in

positioning myself in relation to Ivan found their epitome during
the day of the operation: all seemed to be encapsulated in those
hours before, during, and right after Ivan’s brain surgery.

The S-day

The morning of the surgery, the pressure Ivan’s swollen brain

applied on the inner walls of his skull was so severe that he had to
keep his eyes shut in agony. The increasing doses of steroids had
his face so puffed-up that he looked like a giant squirrel. I looked
curiously, a bit detached, at this grotesque figure being wheeled to
the OR, his hands nervously petting his skull. On the top of his
head were scattered a few chick hairs, huge bold blemishes, and a
long purplish scar at the centre of which stood a bulging bump of
fatty tissue– both remainders of his first surgery, eight years ago.

I myself could now hardly recall the way he looked 'before',

when his body did not declare that it was a cancer patient's. In

144
 Sky E. Gross

fact, as Ivan bought his first hat, after having lost most of his hair,
he proudly told me how he "gave the man [the salesperson] a heart
attack" when telling him he was buying it "for the radiations". He
now did not only feel like a cancer patient, he looked like a cancer
patient.

Throughout, I had to remember to hold Ivan's left hand rather

than his right, where he was completely insensitive to touch, but
somehow, in these moments, all clinical details of his case seemed
to evade my mind – I was with him, at times detached, at others
immersed in his experience. He looked at me and made a slight
attempt to smile from time to time, but raising his heavy eyelids
seemed extremely painful. Not able to make genuine eye contact
with him, I kept asking myself who this body was, and whether it
was at all somebody's.

I followed the wheeled bed down the elevator along with his
parents and sister. We reminded ourselves of the evening Ivan, his
mother, and I spent at the hospital inn (where he was staying for
the course of his radiotherapy). There, as we were chatting about
this and that, Ivan ran to the window: Jerusalem was covered with
a white blanket of snow. So little snow ever falls in Israel, that we
were all three captivated by the scene. Reaching the door to the
surgical area symbolised the breaking of our serene silence and
sense of 'normality'. As if suddenly awakening us all, the nurse
abruptly halted, firmly instructing us to be careful not to cross this
boundary and to say our goodbyes now, here. The family kissed
Ivan, and asked me, in tears, to take care of him, as if reminding
me to treat him as a friend, rather than as a patient, even now, as I
was about to cross into the biomedical realm.

I followed the nurse to the Intensive Care Unit (ICU), where

patients were kept and monitored right before and after surgery.

145
 Black Butterflies

After a short inquiry as to my relation with Ivan ("who are you to

him?" was the typical phrasing – to which I responded by
presenting myself as a researcher from the Jerusalem clinic), I was
requested to wear disposable shoe covers and a non-formal yellow
coat loosely tied on the back – an attire available to all family
members and close ones who happened to be allowed into the ICU.

Ivan’s bed was positioned between two other patients’. His

eyes still painfully shut, I quietly arranged his pillow – this familiar
(albeit futile), gesture of concern. As I rubbed his good arm, the
anaesthesiologist approached his bed and began asking questions.
Since Ivan found it difficult to answer -his speech being highly
hindered at this point – I intervened and answered myself. I used
the medical jargon I knew so well by now, and provided clear,
short, efficiently phrased information. My answers surprised the
anaesthesiologist who, only at this point, asked me who I was. I
explained my position as an anthropologist, and my affiliation to
the Jerusalem neuro-oncology team. The scarce attention he gave
to my response seemed to reflect his lack of interest in 'gate-
keeping', a fact compatible with the analysis of his position in
relation to the the replicated boundaries as provided later in this
text.

Shortly after Ivan had signed the consent forms (which he

could obviously not see at all), the surgeon then arrived, a young,
impressive man wearing his 'scrubs'. As he approached the bed, he
announced Ivan that he will shortly be brought to surgery. Much
more careful as a gatekeeper, his gaze pierced my eyes: "and who
are you?", I answered that I was a doctoral student conducting
anthropological research at the neuro-oncology clinic in Jerusalem.
I immediately stressed that I was given permission by Professor
Zosima (the head surgeon) to attend to surgery. He smiled and
replied "of course, no problem at all". Treating me as courteously as

146
 Sky E. Gross

one would a guest in his own home; he called on who turned out to
be the OR head nurse: "This is – what is your name again?...". Once
I have reminded him of my name, he turned to the nurse again:

"... [This is] Sky Gross, she is from neuro-oncology in

[the name of the clinic in Jerusalem], she will be
joining us. Can you show her where she can get
ready?"

The nurse reluctantly showed me to the changing area. She

searched for her employee card (only a few of the personal were
allowed access to this high-status outfit) and used it on an
automatic machine from which sterile uniforms, carefully bagged
in plastic, were dispensed.

The nurse handing me the blue nylon pants and shirt found
me a bit embarrassed: was I to wear the uniform on top of my
current clothes? No. I must take off my casual clothing and wear it
directly on my bare skin. Entering the changing room dressed as a
lay person, I remained there virtually naked for a few moments, my
identity in Dantean limbo until I wore the uniform, now my
uniform. I could feel it on my skin as I unwittingly adopted a
slightly different walk (faster than usual) and handled my body
differently (less eye contact and a more upright position). As I
passed through the ICU, I was told by one of the surgeons not to
forget to put the hair cap and mask on before entering the OR.
These were available only very near the entrance to the OR, an
even more restricted area, and consist of the last piece of garment
promising me a place in this in-group. My position as an outsider
would be hidden behind these clothes: fully camouflaged, I could
then identify myself and be identified as a member of the
biomedical team.

147
 Black Butterflies

Under the Skin

As I was struggling with the hair cap – reminding me how

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

The room was relatively free of tension. The staff (which at

this point included a junior surgeon, a surgical intern, an assistant
nurse, a head-nurse, a practical nurse, an anaesthesiologist, and a
neurophysiologist accompanied by his assistant) moved freely
around the room, talking, organising their gear in relative leisure.
When the first stage of the actual operation began, the room
gradually turned silent. I applied myself as I followed the knife
going over the long crescent-shaped scar and two centimetres
further down. I remained standing over the orifice, feeling
surprisingly little awe or disgust -as one would perhaps expect
from an 'outsider'- but was rather directed by an acute sense of
curiosity. The skin was pinned to the sides, allowing the opening of
a fist-wide cavity at the centre of the wound. The cutting revealed

148
 Sky E. Gross

five pieces of bone stapled as to form a sort of jigsaw puzzle, a

remainder of the previous intervention.

As the two junior surgeons removed the white eggshell pieces

and dropped them into the stainless steel bowl, only a thin layer of
tissue, the dura, kept the majestic organ in. Swollen and eager to
escape its captivity, the brain herniated and literally broke out into
the open air. The staff showed interest in the unusual extent of the
phenomenon. For me, it was as if I could now see why he was
under so much pain: His brain was about to burst out of his eyes'
orbits, literally. I could empathise with his pain as he moaned and
groaned, yet something about the sight of this bulging lump of
flesh made it more 'real'. When I heard his mother tell me, a year
before that her son's head was a closed box, and she was afraid his
brain will 'leak out', I found this portrayal curious. Although I
never questioned the subjective truth he communicated, still, the
physical, the ontognostic, the visible seemed to provide me more
'evidence', and seemed thus more authoritative. In the surgery
room, I held on to a model that is classically claimed to pertain to
the world of physicians: valuing visible, material phenomena over
patients' reports.

The Peak of Surgery

As the team was getting closer to the handling of the actual

brain – and entering deeper into the body, the ritualistic aspects of
surgery became more dominant. For instance, only once
objectification reached its peak did the head surgeon make his
appearance. After intensive and extensive scrubbing, he sat on a
high chair, carefully prepared in advance, covered with a sterilised
sheet, curiously resembling a king's throne. The junior surgeon
also took a sitting position at this time. He sat on a similar chair,
albeit at a less central position, beside (rather than directly behind)

149
 Black Butterflies

Ivan's head. Other members of the team remained standing, with

some level of freedom of movement which was only rarely taken
advantage of. At this point, the OR became silent, still, and tensed.
The lights were turned off, except for a beam of pale light
illuminating Ivan's Skull. The LCD screens, from which the site of
the operation was 'broadcasted' to the OR audience, were turned
on. From one of the screens, the head surgeon could observe a live
MRI picture of Ivan's brain as he inserted his instruments. He then
set 'coordinates' which will serve him in the spatial handling of this
complex organ.

As I was to realise later on, I found myself disenchanted. I

knew how the brain looked like, but I did not know how Ivan's
brain would look like. At some level, I expected it to look like him,
like Ivan. It did not. Seeing the brain without seeing the mind,
observing its actuality, its fleshiness, one has to admit: in the OR,
the mind is nowhere to be found.

Time went by as the surgeons were methodically vacuuming

tumour tissue and were carefully closing blood vessels, and I
became increasingly focused on the physical biological
presentation of the tumour. I felt I had developed a relationship
with Ivan's brain, a relationship that was in many ways
independent of its carrier, Ivan the person. After all, in the course
of the last eighteen months, I had almost as many direct
encounters with Ivan's brain as with Ivan himself. This was
perhaps most striking when the surgeon showed the latest MRI
image on the screen: its shape, its shades of grey were all-too
familiar as I recalled the many staff meetings it had appeared in. I
remember the remark, which made the team giggle: Impressed by
the tumour's current size, I said I knew it 13 "since it was this little!",
as if I had been speaking of a child. Was I taking lightly the sight of

13
In Hebrew, the 'it' and the 'he' are interchangeable

150
 Sky E. Gross

this immense lump slowly killing a beloved person? Was I talking

about Ivan at all?

As discussed earlier in this work, prognosis is a form of

knowledge which is habitually held away from patients, and this
for various reasons, including the detrimental health impact
receiving bad prognosis can have, the inadequacy of medical skill
and knowledge to deal with issues related to emotional challenges
and lifestyle choices associated with a patient's management of
prognostic information. In cases of life-threatening brain cancer,
prognostic information (and at times, even diagnosis) is clearly,
although often not explicitly, unwelcomed by the patient. The latter
expects his physician to act as a 'responsible adult', and manage
his condition without burdening him with details he is not able to
deal with (such as one's impending death). This trust is a form of
'you know best' reflecting upon a surrender of full and complete
conscious involvement in the matter under exchange: the
knowledge of one's own state of affairs.

Brain surgery is often performed with the patient fully awake:

This serves the surgeon as he\she is able to hear reports from the
patient, and thus localise functions in the areas neighbouring the
site of intervention. Ivan's surgery was planned to be performed
thus, since his tumour layed in the midst of critical senso-motor
function areas. His condition, however, was decisively too
deteriorated and the idea was abandoned hours before the
intervention. As his phenognostic account became of little value,
Ivan had to be treated as an ontognostic source: a more 'objective'
– and objectifying—measure was used, and a neurophysiologist
was asked to join the team. Wires were attached to Ivan's legs, and,
as the surgeon moved an electrode on the surface of Ivan's brain,
the neurophysiologist reported on movements detected - meaning
essential motor tissue was stimulated. Ivan's body was

151
 Black Butterflies

electronically probed and mapped, making the mediation of a

subject redundant. The clinical gaze involves the creation of a
spatial dimension which will create the disease as an entity, the
body as an ontognostic-based 'thing':

"… a space whose lines, volumes, surfaces, and

routes are laid down, in accordance with a now
familiar geometry, by the anatomical atlas".
(Foucault, 1975:8).

These postoperative hours spent in the ICU were perhaps the

most tensed to the family – this was when I found myself most torn
between my two roles: I came in and out, reporting to the family
whether Ivan was awake, since only once he regained
consciousness were family members (one at a time) allowed in, and
supervision was loosen. Once alll would have access to Ivan as a
tangible, palpable, source of knowledge into his own wellbeing, my
mediation was little needed.

While perhaps not unusual in the field of medical diagnosis,

the fact that the organ involved in this latitude-longitude definition
was the brain, that the functions observed were speech and
movement (both typically associated with purposeful volition), and
that the process took place in 'real-time' made this event
particularly intriguing.

Closing up: The last stages

Once the thrust of the surgical intervention (i.e. the removal

of tumour tissue) over, the head surgeon told the juniors to "close
him up" and left the room. As the pieces of bone were placed back
and the skin stapled, lights were turned on again, and movement
became freer. As if now having gone through an initiation ritual,
the younger surgeons included me in their small talk. Overall, the

152
 Sky E. Gross

tension was released, masks were taken off, cables and electronic
devices were removed, and Ivan's face and body were again visible.

I followed the head surgeon as he went over to discuss the

operation with Ivan's parents. The despair with the intractability of
his condition and "the impossible mess the tumour made in his
brain" was reserved to backstage discussions. Not entering into
details, the surgeon gave a relatively reassuring impression: Ivan
survived and the surgery did buy him some more time. Only when
directly questioned did he admit that, considering what they
observed in surgery, they will not be able to offer him any more
chemotherapy. Again, I knew what my informants did not: the
surgery was in vain – this serious and dangerous intervention only
gave Ivan a few more weeks, which he will spend in nursing and
palliative care.

The operation lasted more than five hours, during which I

remained standing – directly looking into Ivan's skull. However, it
was only a few hours later, once having taken off 'my scrubs',
leaving the hospital, and searching for my car in the parking lot
that I began to feel a throbbing pain in my legs and a general
feeling of physical exhaustion. It was as if I now returned to myself
as a lay person, i.e. not only mentally but also in terms of how my
body felt to me.

Just a Story

The account of the past is almost inevitably tainted with

current interpretative schemes, focusing on concerns that are
particularly meaningful to the teller. Thus, one important aspect of
narratives is that they are typically told in hindsight, which makes
past events appear as if naturally leading to the 'now' as it is
understood (Mattingly, 2008; Williams, 2008; Gross, 2009b). The

153
 Black Butterflies

narrative form allowed me here to create coherence and continuity

in the sequencing of events and the unfolding of what I believed to
be their significations (Ewing, 1990; Becker and Kaufman, 1995). It
also allowed me to create a common thread of meaning around a
series of noteworthy moments or 'events' (Polanyi, 1985; Mattingly,
1998), and to thereby justify current claims: First, that my
experiencing and perceiving of Ivan as a subject and object was of
a fluctuating nature; Second, that this reflected on and was
reflected by contextual elements within which our interactions took
place; And finally, that these contexts all involved some extent of
boundary definition (replicated in the conceptual, spatial,
professional, symbolic layers) between two seemingly opposite
sources of Truth: phenognosis and ontognosis. I shall now like to
unfold some of these points as they arose in the field, and as they
relate to recent and contemporary work in adjacent subjects.

Liminalities and Replicated Boundaries

The OR as a Space of Multiple Liminalities

The OR might be regarded as the epitome of biomedical

practice, as restricted both physically and symbolically from
everyday life, and secluded from the less distinct areas of the
hospital (e.g. Wilson, 1954; Goffman, 1961b; Foucault, 1975;
Moreira, 2004). This is where the invisible becomes visible, the
inaccessible accessible. The OR is also a space where states of
liminalities are omnipresent, and most particularly liminalities
where scientific thinking ceases to exert its conceptual control
(Van-Gennep, 1960; Douglas, 1966; Turner, 1969). This includes
the patient oscillating between life and death, and between forms of
'presence': i.e. a state of simultaneous presence (as a body) and
absence (as a person).

154
 Sky E. Gross

This liminality and confusion of categories demand a clear

ordering of things through elaborate rituals. As has been well
shown in previous studies (e.g. Katz, 1981; Katz and Kirkland,
1988), OR rituals are associated with the need to facilitate the
transition between categories of things by clarifying their
distinction, more particularly the distinction between things that
belong and things that do not belong in the OR, the sacrosanct of
biomedicine.

Rituals, however, can do more than create boundaries. They

may also convert mundane objects into entities that belong to the
'sacred' and are thus less likely to form objects of liminality. For
instance, when transformed from a sentient whole into an operable
body, the patient can be allowed into the OR (Katz, 1981; Fox,
1992). The medical personnel itself also goes through processes of
transformation: these might include scrubbing rituals preceding
the entry into the operating room and special attires worn by the
staff (Moerman, 1979; Felker, 1983; van der Geest, 2005). Along
with specific rules and practices, these allow a conversion of the
life-world into an object that can be dissected and manipulated in
the setting of the OR (Gaines and Hahn, 1982; Hahn and Gaines,
1985; Hirschauer, 1991).

I shall claim that rituals serve to restrain and manage

subjectivity in a way that would minimise the soiling of the purity
associated with the ontognostic realm of 'things'. While the
discussion of objectification in medical contexts is omnipresent in
the social sciences of medicine, and while the issues of purity and
danger (and their relations to social practices and categories)
constitute one of the pillars of cultural anthropology, the wedding
of the two subject of interest has never, to my own knowledge, been
directly attempted. Here, I shall advance the idea according to
which the gnostic split is symbolically, practically, and

155
 Black Butterflies

epistemologically replicated as comprising a 'dirty' element

(phenognosis) and which can be regarded as its mirror reflection:
the 'pure' element of biomedical ontognosis.

If phenognosis is the matter out of place (Douglas, 1966), it is

not only categories of life and death, of inside and outside which
boundaries must be reinforced and safeguarded, but also
categories of subjectivity and objectivity: of sentient person vs.
present body. In this shrine of objectivity, the subject must be
either subdued (anaesthetised), hidden (draped), or made sterile
(disinfected). In other words, in settings such as the OR,
ontognosis will be seen to annihilate, dominate, or restrain
phenognostic presence. This is in fact much similar to the type of
boundaries shown to be drawn and replicated in other layers of the
gnostic split, e.g. between an 'ontognostic neurology' and a
'phenognostic psychiatry', and as shown by Mizrachi, Shuval and
Gross (2005), between an ontognostic biomedicine and a holistic,
at times 'spiritual', approach to the patient. In all three cases, the
subjective will need to be conquered, as its epistemological
resistance contests ontognostic authoritativeness.

In the case of surgery, however, boundaries cannot and will

not remain blurred: surgical intervention is the pure manipulation
of matter. Whichever is not clearly assigned to this sphere must be
either eradicated, constrained, or subordinated.

The Temple of Ontognosis: The OR

Questions of objectification arose in the field around several

elements. These worked in unison to replicate a movement from
the subjective to the objective and from the personal to the
biomedical. First, with anaesthesia, which transforms the sentient
self into a passive body; Second, with sterilising practices, which

156
 Sky E. Gross

separate the OR from a 'messy' outside world where body and mind
are meshed up (and where forms of knowledge can be confused as
well); Third, with spatial definitions, which create clear boundaries
between areas of objectification; Finally, with components such as
clothing, language and technology associated with this stance. I
shall now discuss each of these.

Keeping Phenognosis Out: Sterility

"Rituals exaggerate the discontinuity in the

operating room and they proclaim definite
categories. An instrument is either sterile or
nonsterile; it is never almost sterile or mostly
sterile. A person is either scrubbed, gowned, and
gloved, and, therefore, sterile, or he is not scrubbed,
gowned, or gloved, and, therefore, not sterile." (Katz
1981:345-346)[my emphasis, S.G.]

According to Katz (1981) and others (e.g. Cassel, 1987), the

lengthened minutes of scrubbing immerse the professional into a
state-of-mind by which the patient turns into a physical entity
interacting with and endangered by other physical entities: germs.
Along these lines of arguments, Listerism and sterility would play
no role other than promoting practical aims of preventing
infections. My observations, however, suggest that these rituals
cannot be explained away by simply turning to this 'germ theory'.
More specifically, I will claim for an association between levels of
objectification (by different professionals, at different stages) and
the demand for elaborate scrubbing. The "precise and beautifully
choreographed ritual" of scrubbing (Cassel, 1991:91) involves
transformative practices in regard to the experience of surgery
(Landzelius, 2003), namely in keeping a view of the body as
belonging to the world of matter, whether germs are involved or

157
 Black Butterflies

not. In more concrete terms: the more one would treat the patient
as an object, the more one would be required to be sterile, that is,
to abide to this "stylisied, arbitrary, repetitive, and exaggerated"
behaviour (Katz, 1981:349).

Throughout the course of Ivan's operation, the

anaesthesiologist kept holding his mask rather loosely. Ivan
securely anaesthetised and his vital signs stable, the
anaesthesiologist sat at one corner of the room and engaged in
online crossword puzzles, occasionally joining me and offering me
trivial information on this or that procedure. As a rule, his active
presence was required only at the temporal edges of surgery, i.e.
the entering of Ivan into the anaesthetised condition and his
gradual emergence into full consciousness: Then, he would take on
a more religious attitude towards his scrubbing attire. It is then
that he would have most contact with Ivan's body, but it is also
then that the boundaries between conscious and unconscious,
between dying or viable would be most challenged.

Interestingly, I was the least sterile. Although I did wear a

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

158
 Sky E. Gross
Anaesthesia: Subduing Phenognosis

The effect of anaesthesia on objectification is undoubtedly

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

This is in fact precisely at this point, when the critical

spectator turns absent, that the team is able to make the
transition to a backstage form of interaction (Goffman, 1961a;
Pilnick and Hindmarsh, 1999; Hindmarsch and Pilnick, 2002).
They do provide powerful grounding to the change in the patient’s
'presence' (or rather 'absence') in the social interaction taking place
in the surgery room. Still, they focused rather on the team than on
the patient, and did not offer an analysis based on the observer’s
position.), which could not have been enacted in the presence of an

14
Or, as in Ivan's case, the anaesthesiologist

159
 Black Butterflies

outsider: the patient. Backstage, the language becomes more

technical and inside information is more freely communicated 15 –
including, as in this case, alarming news on the patient's
prognosis. For instance, while Ivan was deeply sedated, the head
surgeon called me over and showed me, right on the surface of the
exposed brain, the extent of the damage, announcing as if of a
matter-of-fact that the tumour was enormous and that Ivan's
prospects of survival were grim. This is a statement that could
hardly be made in the presence of a patient or his/her loved ones.
Perhaps most strikingly, Ivan himself was absent (i.e.
anaesthetised) as his death sentence was declared.

As discussed earlier in this work, prognosis is a form of

knowledge which is habitually held away from patients, and this
for various reasons, including the detrimental health impact
receiving bad prognosis can have, the inadequacy of medical skill
and knowledge to deal with issues related to emotional challenges
and lifestyle choices associated with a patient's management of
prognostic information. In cases of life-threatening brain cancer,
prognostic information (and at times, even diagnosis) is clearly,
although often not explicitly, unwelcomed by the patient. The latter
expects his physician to act as a 'responsible adult', and manage
his condition without burdening him with details he is not able to
deal with (such as one's impending death). This trust is a form of
'you know best' reflecting upon a surrender of full and complete
conscious involvement in the matter under exchange: the
knowledge of one's own state of affairs.

It was thus little surprising to see myself perplexed when

confronted with instances where my own knowledge regarding
Ivan's diagnosis greatly surpassed his. Not certain if the patient-

15
This is also when the team's sense of humor was more readily exercised. However, I must admit, that
never in reference to Ivan. I was not impressed that this was merely due to my presence.

160
 Sky E. Gross

physician 'pact' regarding prognosis applied to me, I was again to

wonder as to the nature of our relationship: As I knowingly
withdrew information from him, I found myself in the role of the 'I
know, but I know better than to have you know what I know' – an
expression of epistemological power I did not wish to hold against
whom I wished to remain a subject rather than a 'patient'. This
backstage stance was increasingly difficult from my position as an
ethnographer.

Another issue arose when, as Ivan's subjectivity has been

made to disappear, or made irrelevant, it refused to enter the
stream of my own. This stood in contrast to what Alfred Shutz
(1970:31) termed the 'we-experience': experiencing the other
experiencing. I could not create an intersubjective relation with
what seemed as a 'thing'. Intersubjectivity is present only when two
subjects experience a common situation. If one of the parties
become absent, my attitude becomes simply phenomenological –
that is, based on my own experience of a world of matter.

Space and Liminal States

As Young (1999) asserted in her work, the spatial

organisation of the hospital reflects conceptual elements central to
biomedicine's epistemological bases. In my study, the ICU, for
example, clearly served as a space of transition between the
outside and the inside, and as described above, between the sacred
and the mundane. The ICU was where a taxonomic order that has
been loosen and endangered in the OR could be reconstructed
(Turner, 1969; Turner and Turner, 1978; Landzelius, 2001). Still
in a state of limbo between life and death, and most vulnerable to
unforeseeable and rapid deterioration, the patient is there followed
with elaborate rituals and monitoring, until fully awake, 'stable'
and 'out of danger', i.e., when re-becoming a 'normal body'

161
 Black Butterflies

(Kaufman, 2000). At the point where there is less danger to the

ordering of the orthodox state-of-being (Van Gennep, 1960;
Landzelius, 2001), intensive surveillance is relieved. As life-world
modes of interactions become available (the patient regains
consciousness and is able to report on his/her subjective
experience), and biomedical, ontognostic monitoring becomes less
essential, the patient may be released to the outer circle of the
'sacred' space: into the ward. These postoperative hours spent in
the ICU were perhaps the most tensed to the family – this was
when I found myself most torn between my two roles: I came in
and out, reporting to the family whether Ivan was awake, since
only once he regained consciousness were family members (one at
a time) allowed in, and supervision was loosen. Once alll would
have access to Ivan as a tangible, palpable, source of knowledge
into his own wellbeing, my mediation was little needed.

Going Native

There are other elements affecting my own stance of

objectification, elements belonging to one of the oldest concerns of
anthropology: the adoption of the research subjects' ('emic')
viewpoint, and the keeping of an outsider's ('etic') distanced
position. One way to attain a deep understanding of the native’s
perspective is to find oneself within this perspective, or go native.
Whereas this argument seems well developed in other fields of
anthropology and ethnography, it seems little attended to in
mainstream social studies of biomedicine. According to Collins
(1994a, 1994b), this lack of understanding of the physician’s life-
world (or verstehen) leads to significant biases in ethnographies of
medical settings. Achieving, to the best extent possible, an emic
look into the surgeon's world would then allow a more elaborate
and accurate depiction of the field. In an attempt to achieve such
an understanding and become an expert observer (Bolton, 1995), I

162
 Sky E. Gross

undertook an elaborate preparation which included the study of

the technical and more theoretical aspects of the profession. I
acquainted myself with the different aspects of neuroanatomy and
clinical neurology and was able, through the internet, to watch
sequences of both general brain surgery and tumour resection
operations. I achieved some fluency in the native language and
acquired somewhat more tacit knowledge such as the ability to
distinguish between brain tissue and tumour tissue and the ability
to visualise the actual wound with the MRI images laid up on the
screen.

This knowledge allowed me to avoid, at least partially, what

Bolton (1995) defined as the inherent bias of non-medically
informed anthropologists: The incapability to really understand
medicine, thus to really enter the physician’s state of mind. In
biomedical settings the expert observer will perform as a native-
ethnographer, and will provide valid contributions, which might
not be available unless abandoning this lay naïveté which is often
overbearing in anthropological accounts of medical practice (Collin,
1994b). For instance, non-physician anthropologists tend to
romanticise the physician, to underrate instrumental aspects of
medical practice, and overrate the reductionism of medical texts.
Considering the methodological advantages of expert observation,
this enculturation has also affected my view of Ivan as a subject,
and my readiness to adopt a biomedical perspective when
approaching him in the OR: this eventually allowed me to
understand the shifting nature of objectification from a less
disciplinary distanced perspective.

Medical education includes the teaching of the ability to keep

role distancing, or hold clinical detachment from patients as human
beings (Goffman, 1961; Fox, 1979; Smith and Kleinman, 1989;
Good, 1994; Walters, 2004). It allows physicians not only to treat

163
 Black Butterflies

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 his 16 position in his disciplinary field
and his position in the ethnographic setting. Most particularly, in
the social studies of medicine, one may find oneself holding
incompatible ethical imperatives, depending upon the field he
regards himself as being a part of (Dingwall, 1980; Goodwin et al.,
2003; Dickson-Swift et al., 2006). There is little doubt as to the
effects of professionalisation and disciplinary field (Anspach and
Mizrachi, 2006) on the positioning in the field of a researcher.
Here, however, I have focused on the setting itself, rather than on
the disciplinary or professional background of the different actors.
The ways in which the field itself influenced my mode of attention
to the patient suggest that the setting holds immense power in
affecting the view of the patient as a subject, but not only that. It
also showed that relating to phenognostic forms of knowledge is

16
I again use the masculine stance here, so as not to impair the readability of the text

164
 Sky E. Gross

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 his 17 very own birth and throughout his infancy, the
human being learns to regard himself as distinct from the
surrounding world. This is when he realises himself as a subject
facing objects, including his own body (Mead, 1934). This type of
objectification is an inevitable consequence of the gnostic split, as
it binds attempt to understand the 'other' as a subject. According
to Western tradition, there would be two ways of 'knowing the
world': the phenognostic first-person perspective which provides
subjective certainty, or the ontognostic third-person perspective
which has been made secure by scientific method. In either way,
whether experienced first-hand or scientifically ascertained, the
other will seem as an object, as well may be one's own body
(Gallagher, 2000).

This problem has been addressed by philosophers, namely

around notions of solipsism and the presence of a 'theory of mind'.
The first relates to the fact that one can only be confident of his
own subjective presence: as far as can be ascertained, others can

17
Here again, based on considerations of style and readability, I will use the masculine form

165
 Black Butterflies

be automatons claiming to 'feel' and experience an inner world of

their own. 'Others' can alternatively be characters in a dream one
would be the protagonist of. The idea of a 'theory of mind' turns to
the understanding of the mechanisms by which human beings DO
ascribe 'minds' to others. According to many philosophers, thus,
one would hold a 'theory of mind' according to which others are
subjects if they happen to have characteristics deemed to belong to
a 'minded' thing. Some will have broader theories of mind to
include animals (which may squeak in pain when tortured, thereby
seeming to have a subjective presence). Others will have more
limited theories of mind, leading to the objectification (considered
more or less 'morally just' or 'scientifically justifiable' among
different cultures and societies) of entire categories of human (and
non-human) forms of existence, including comatose patients (or
'vegetables' accordingly), foetuses (or 'unborn babies', accordingly),
ethnic minorities, women, the aged, opponents in conflicts, etc.

Considering the inclusion of non-human categories – such as

animals, and in some religions, 'things' others may consider as
objects (i.e. objectify) – in theories of mind, I find the
'objectification' preferable to the 'dehumanisation' outlook.
However, as in the modern Western World 'things' considered as
holding subjectivity tend to be anthropomorphised, and as, in the
modern Western World, human deemed subjective beings tend to
be referred to as 'persons', I will have to treat objectification,
depersonification, dehumanisation as strongly linked notions. In
the setting of the clinic, and perhaps to a larger extent in the OR,
these can almost be used interchangeably. More than that: as more
'object'-looking one is (e.g. being still, being insensitive and non-
reactive to pain), the more he would be dehumanised; The less
'person'-looking one is (e.g. wearing uniforms, having masks over
one's face, blending in the crowd) the more he would be objectified
(treated like one piece of a faceless whole); The less human one

166
 Sky E. Gross

acts (being cruel, disregarding basic taboos, acting 'like an

animal'), the more he will be depersonalised (and can thus become
a target to violent acts of indignation).

The instances where Ivan most resisted objectification were

when he looked, acted, and was treated like a person. This
included his increasingly grotesque appearance as his disease
advanced, and his draped inertness in the OR, as he was attached
to non-biological electronic, digital, and mechanical devices
(creating a sort of cyborg as the mechanical extended to his own
body). It also included the sense in which he was 'reachable', or
respondent to communicative stimulations, such as touch, sounds,
words, and so on: e.g. his hemiparetic state outside the OR and the
effects of anaesthesia inside the OR. Not only was his ability to
perceive affected by this, but his ability to respond was as well.
This had to do with the level of pain he was suffering from, as well
as his cognitive and language processive deteriorating skills. Again,
his responsiveness to communication was gradually altered
throughout the general course of his disease and in the more
specific setting of the OR. In all cases, he acted and appeared as
less than a full ideal-type person, and this had deep effects on
stances of objectification, on both my part and the biomedical
staff's.

Conclusions

In the case presented here, both the biomedical team and

myself, as a researcher, eventually found ourselves within a
complex, yet basically dualistic attitude, as if in a dynamic flip-flop
between the patient as object and patient as subject. With Ivan, the
boundaries between absolute objectifying distancing and complete
personal identification seemed to be in a continual flux, and
replicated over different layers: This was true on this first day,

167
 Black Butterflies

when I only knew him as a medical case, and remained no less

salient as our relationship developed. In fact, I created Ivan's body
as much as my own presence is created by the network of objects
and relationships: both are of a fluctuating nature, contingent
upon the setting and my own role-taking. Indeed, the tendency
toward objectification is affected by ritualistic practices and
symbolic elements. The ethnographer is not immune to these
influences and might find herself involved in the objectification of
her research subjects, perhaps no less than biomedical
practitioners are claimed to.

The OR has its own rituals and is in many ways an extension

and intensification of biomedical epistemologies, practices, and
symbolic elements. This involves the transformation of a life-world
into an object which can be manipulated. The patient is then
absorbed into a small, depersonalised, objectified body-part
(Hirschauer, 1991; McNay, 1991). Often defined in terms of a loss
of human concern over another, objectification is overwhelmingly
used in a pejorative tense. Here, however, I sought to show how it
might be a necessary, undeniable, and unavoidable part of
biomedical work. Neither is objectification a process limited to
biomedical settings, nor is it exclusive to physicians: anyone can
objectify anyone. Ethnographers, in particular, often sway from
objectification to empathising positions (Fabian, 1983; Clifford and
Marcus, 1986; Pratt, 1986; Wiltshire, 1999). Using insights from
my own ethnographic work in a neuro-oncological clinic and a
neurosurgical unit, I raised the need for a multi-faceted approach
to questions of objectification, taking on the concept of
epistemological fluctuation in ethnographic studies of biomedical
exchanges. This interpretation of exchanges in biomedical spheres
points to the inherent tension between these two tendencies
(objectification-empathy), two roles (physician-ethnographer), two
perspectives (biomedical-personal), and two phenomenological

168
 Sky E. Gross

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.

169
 Black Butterflies

Part VI: Conluding Words

The Bounded Brain

The brain is the apparatus through which we experience the

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

As shown here, the brain can be regarded as an interim, a

colossal pineal gland, the site of the clashing of two ultimate
realms: the world-out-there, and the inner world of experience.
This clash, I have claimed, would be reconceptualised in a way to
assert clearly bounded categories: science and non-science, reason
and emotion, objective and subjective, at both ontological and
phenomenological levels. This work presents instances where these
boundaries are encountered, challenged, and replicated. The
understanding of these processes, I hope, allowed a refinement and
elaboration of concepts of scientific vs. subjective forms of
convictions, and the role these forms of knowledge may take in

170
 Sky E. Gross

both diachronic and synchronic perspectives on the sociocultural

world of biomedicine.

Somewhat unorthodoxly, I chose to present this analysis in

the form of three relatively independent essays - each with its own
body of literature and theory, each with its own empirical
foundations. This also demanded an intense focusing on which I
considered as the most essential aspects of the phenomena at
hand, as required in professional academic publishing. I believe
that this served not only to portray research in advanced scholarly
language, but also to distil my ideas, to carefully extract the most
powerful points I chose to advance, and to most thoroughly
consider their actual contribution to selected bodies of literature
and areas of concern.

The significance of the association of the papers stands at

their similarities rather no less than at their diversity. Indeed, it is
almost a truism to say that the consequentiality of theoretical
advances cannot be tested upon its elucidating one phenomenon or
another – it is its applicability and relevance throughout a full
array of empirical worlds that endow it with promise. In this, three
fields were chosen as epitomising the theoretical suggestions made
throughout this text, while still holding a substantial empirical
range.

First, I proposed a detailed picturing of the adoption and then

relegation of psychosurgery as a decreasingly 'purely scientific'
ontognostic medical procedure. This was shown to represent a case
of 'replicated boundaries': an occurrence in which boundaries are
drawn and concurrently replicated at several levels. This work then
took us to the in situ understanding of the assignment of
authoritativeness to different diagnostic forms of knowledge as
more or less purely ontognostic. Finally, I offered here a first

171
 Black Butterflies

person narrating of the effects replicated symbolic and ritualistic

Cartesian boundaries had on the objectification of a research
subject in the context of the operating room.

In all three cases, phenognosis was sought-after as a site of

knowledge to be tamed and conquered by science and biomedicine,
rather than a mere pre-discursive default. As it remained still
beyond the reach and control of the ontognostic endeavour, it was
to be kept strictly outside of the practical, epistemological,
rhetorical and symbolical of the ontognostic realm. Phenognostic
resistance to this reduction to the realm of matter created a clear
threat to the discourse of objectivism as potentially omniscient,
hence the great attention given to the creation and sustainment of
these boundaries.

I here sought to show how the boundaries are created in

several layers: The patterns of boundaries were drawn by
epistemology and reflect the rejection of the polluted, as was the
case in and around Ivan's brain surgery, in and around the debate
on psychosurgery and in and around complex processes of
diagnosis.

Cartesian boundaries were presented not as a philosophical

but as a cultural phenomenon: a phenomenon where both
professions and rituals, where both macro-levels and micro-levels,
where both institutions and personal thoughts were looked upon to
identify the replicated boundaries of 'Truth' around an obstinate
gnostic split.

A Contemporary and Future Look onto the Gnostic Split

Conceptions of the body are socially contingent and reflect the

critical elements of the culture in which they are formed and kept
alive (Kleinman, 1988; Martin, 1994). As mentioned, my aim here

172
 Sky E. Gross

was to refer to the mind-body problem as one such conceptual

complex. In terms of its social revelation, one thing seems to be
clear: Western culture has not yet overcome the gnostic split, and
still holds on to the two forms of 'truth'. This dualism continues to
create areas of contest where symbolic actions as well as rhetorics
are used to reassert an uncertain, not-commonly shared, unstable,
idea of 'what the world is'.

Over the years, the mind-body problem has indeed enticed

endless contemplations, and has been overwhelmingly portrayed as
the most perplexing epistemological chasm of post-enlightenment
society (e.g. Crick and Koch, 1990; Rosenberg, 1992; Chalmers,
1995, 1996; Searle, 1998). Withstanding all efforts of reconciliation
– notably in the field of neurosciences, artificial intelligence, and
functional imaging studies - this explanatory gap remains
insoluble, and is still of critical consequence in broad domains of
research (e.g. Levine, 1983; Nagel, 1986; Dennett, 1999). Still, and
despite some exceptions (e.g. Williams, 1996; Martin, 2000), a clear
disparity hangs between philosophical advances on the matter and
efforts made by social sciences to recognise, define, and study its
sociocultural grounds and implications. I shall claim, however, that
a number of recent developments have created a more urging need
to attend to this conundrum, These include the exponential growth
of neurosciences and the rising power of post-modern and New Age
epistemologies.

Long before the 1990's 'decade of the brain', long before the
neuroscientific revolution of the 1960s, the cerebral organ has
raised considerable interest from both medical and scientific
endeavours (Hyman, 2000). As has been well addressed
throughout this essay, the brain indeed holds peculiar attributes
which makes it such a fascinating object of study: It is, after all,

173
 Black Butterflies

the apparatus through which we experience the world and relate to

it, and is the ultimate locus of our selves.

The last decades saw a growing interest in the physiological,

chemical, biological, and electrical bases of mental activity, as well
as an exponential growth in neuroscientific technological
developments. Over the years, research has gain tremendous
successes in identifying the physical correlates of thought,
emotions, personality, and sensomotor activity. Today, it would be
nonsensical to deny the presence of some form of correlation
between mind and brain. Yet, it would seem almost as nonsensical
to claim that our sense of existence can be utterly reduced to the
brain. In other words, it seems unlikely that scientific advances in
the understanding of the brain will ever be fully able to reduce
subjective experience to the mere realm of matter. Subjectivity and
our sense of 'being-in-the-world', 'what it feels like' to be, to see the
sunshine, to experience pain, is doomed, if only by definition, to
remain in the private world of inner sensation and beyond the
reach of objective query. Science finds there its ultimate boundary,
and the most important threat to its ultimate authoritativeness. As
well put by Horgan (1999:4): "Inner space may be science's final –
and eternal -frontier".

Other sociocultural developments raise a need to deal more

substantively with the mind-body problem. Most significantly
perhaps would be the rise of the post-modern. The post-modern
movement provides definitions of 'Truth' which have by now
become widely accepted: Whilst the 'modern' had truth as a 'thing
out-there' ready to be unveiled by scientific efforts (ontognosis), the
'post-modern' claims for a multitude of 'truths' contingent upon
perspectives, cultural biases, and relations of power. This calls for
a more accepting stance towards claims to truth based on
subjective impressions and inner experience, i.e. phenognosis.

174
 Sky E. Gross

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

In sight of a possible contribution to these works, this study

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

175
 Black Butterflies

RReeffeerreenncceess

Abbott, A. (1988). The Systems of Professions: An Essay on the

Division of Labor. Chicago: The University of Chicago Press.

Abbott, A. (1995). Things of Boundaries. Social Research, 62,

857-882.

Abbott, P., & Meerabeau, L. (1998). The Sociology of the

Caring Professions (2nd ed.). London: UCL Press.

Abrams, P. (1982). Historical Sociology. Ithaca, NY: Cornell

University Press.

Ala, M. (2004). Negotiating Pictures of Numbers. Social

Epistemology, 18(2-3), 199-214.

Alexander, F., & Selesnick, S. (1997). Histoire de la

Psychiatrie. Paris: Librairie Armand Colin.

Anspach, R. R. (1987). Prognostic Conflict in Life-and-Death

Decisions: The Organization as an Ecology of Knowledge. Journal of
Health and Social Behavior, 28(3), 215-231.

Anspach, R. R. (1988). Notes on the Sociology of Medical

Discourse: The Language of Case Presentation. Journal of Health
and Social Behavior, 29(4), 357-375.

Anspach, R. R. (1993). Deciding who Lives: Fateful Choices in

the Intensive Care Nursery. Berkeley: University of California Press.

Anspach, R. R., & Mizrachi, N. (2006). The Field Worker's

Fields: Ethics, Ethnography and Medical Sociology. Sociology of
Health & Illness, 28(6), 713-731.

176
 Sky E. Gross

Armor, D. J., & Klerman, G. L. (1968). Psychiatric treatment

orientations and professional ideology. Journal of Health and Social
Behavior, 9(3), 243-255.

Armstrong, D. (1983). Political Anatomy of the Body: Medical

Knowledge in Britain in the Twentieth Century. Cambridge, UK
Cambridge University Press.

Armstrong, D. (1984). The Patient's View. Social Science and

Medicine, 18(9), 737-744.

Arney, W. R., & Bergen, B. J. (1984). Medicine and the

Management of Living. Chicago: Chicago University Press.

Audisio, M. (1968). La Psychiatrie Face au Mouvement

Biologique Contemporain. Evolution Psychiatrique, 33, 449-466.

Babbie, E. R. (1970). Science and Morality in Medicine, a

Survey of Medical Educators. Berkeley: University of California
Press.

Ballantine, H. T. J. (1980). Patient Selection. In E. S.

Valenstein (Ed.), The Psychosurgery Debate: Scientific, Legal, and
Ethical Perspectives (pp. 108-112). San Francisco: W.H. Freeman &
co.

Barker, F. G. (1995). Phineas among the Phrenologists: The

American Crowbar Case and Nineteenth-Century Theories of
Cerebral Localization. Journal of Neurosurgery, 82(4), 672-682.

Barry, C. A., Stevensona, F. A., Britten, N., Barber, N., &

Bradley, C. P. (2001). Giving voice to the lifeworld. More humane,
more effective medical care? A qualitative study of doctor patient

177
 Black Butterflies

communication in general practice. Social Science & Medicine, 53,

487-505.

Baruk, H. (1953). Les Méfaits de la Psychochirurgie. Revue de

Neurologie, 89, 152-154.

Baruk, H. (1956). Un Grave Probleme de Morale Medicale. La

Presse Medicale, 64, 371-375.

Bastide, F. (1990). The Iconography of Scientific Texts:

Principles of Analysis. In M. E. Lynch & S. Woolgar (Eds.),
Representation in Scientific Practice. Cambridge, MA: MIT Press.

Baudrillard, J. (1988). Simulacra and Simulations. Selected

Writings. Stanford, CA: Stanford University Press.

Beaulieu, A. (2002). Images are not the (only) Truth: Brain

Mapping, Visual Knowledge, and Iconoclasm. Science, Technology
and Human Values, 27, 53-86.

Becker, G., & Kaufman, S. R. (1995). Managing an Uncertain

Illness Trajectory in Old-Age - Patients and Physicians Views of
Stroke. Medical Anthropology Quarterly, 9(2), 165-187.

Ben Zeev, A. (1996). Being Mental: Discussions in the

Philosophy of Mind. Haifa, Israel: University of Haifa Press
(Hebrew).

Benjamin, J. (1988). The Mind-Body Problem, Another Deffect

in Training. British Journal of Psychiatry, 153, 123-124.

Bennett, M. R., & Hacker, P. M. (2003). Philosophical

Foundations of Neurosciences. Halden, MA: Blackwell.

178
 Sky E. Gross

Berg, M., & Akrich, M. (2004). Introduction - Bodies on Trial:

Performances and Politics in Medicine and Biology. Body and
Society, 10(2-3), 1-12.

Berg, M., & Harterink, P. (2004). Embodying the Patient:

Records and Bodies in Early 20th Century US Medical Practice.
Body and Society, 10(2-3), 13-41.

Berg, M., & Mol, A. (Eds.). (1998). Differences in Medicine:

Unravelling Practices, Techniques and Bodies. Durham, NC: Duke
University Press.

Bernstein, I. C., Callahan, W. A., & Jaranson, J. M. (1975).

Lobotomy in Private Practice. Archives of General Psychiatry, 32(8),
1041-1047.

Berrios, G. E. (1997). The Origins of Psychosurgery: Shaw,

Burckhardt and Moniz. History of Psychiatry, 8(29), 61-81.

Black, D. N., Stip, E., Bedard, M.-A., Kabay, M., Paquette, I.,
& Bigras, M.-J. (2000). Leucotomy Revisited - Late Cognitive and
Behavioural Effects in Chronic Institutionalized Schizophrenics.
Schizophrenia Research, 43, 57-64.

Blanc, C. (1968). Les Modeles Ontologiques en Psychiatrie.

Evolution Psychiatrique (Paris), 33(3), 421-446.

Bockoven, J. S., & Greenblatt, M. (1950). The Results of

Unilateral and Bimedial Lobotomy: A Pilot Study. In M. Greenblatt
(Ed.), Studies in Lobotomy (pp. 246-253). New York: Grune &
Stratton.

Bockoven, J.S., & Hyde, R. (1950). Application of a

Sociometric Technic to the Study of Lobotomized Patients. In M.

179
 Black Butterflies

Greenblatt (Ed.), Studies in Lobotomy (pp. 436-445). New York:

Grune & Stratton.

Bolton, J. (1995). Medical Practice and Anthropological Bias.

Social Science & Medicine, 40(12), 1655-1661.

Bos, J. (2004). Everyday Life Objectivity. Social Epistemology,

18(2-3), 123-138.

Bouchard, C. (1968). La Psychochirurgie. France Medicale

(Paris), 31(5), 229-234.

Bouckoms, A. J. (1988). Ethics of Psychosurgery. Acta

Neurochirurgica, supp. 44, 173-178.

Boumans, M. (2004). The Reliability of an Instrument. Social

Epistemology, 18(2-3), 215-246.

Boumans, M., & Beaulieu, A. (2004). Foreword to 'Objects of

Objectivity'. Social Epistemology, 18(2-3), 105-108.

Bourdieu, P. (1977). Outline of a Theory of Practice.

Cambridge: Cambrifge University Press.

Bourdieu, P. (1992). Language and Symbolic Power.

Cambridge: Polity Press.

Braslow, J. T. (1997). Mental Ills and Bodily Cures:

Psychiatric Treatment in the First Half of the Twentieth Century.
San Francisco: University of California Press.

Breggin, P. R. (1974). Psychosurgery for Political Purposes.

Duquesne Law Review, 13(4), 841-862.

180
 Sky E. Gross

Brisset, C. (1949). Psychochirurgie. Evolution Psychiatrique, 4,

487-516.

Brotchi, J. (2000). Le Futur des Neurosciences - Les Defis du

21eme Siecle et les Responsabilites Ethiques. Revue Medicale de
Bruxelle, 21(1), 3-6.

Burri, R. V. (2008). Doing Distinctions: Boundary Work and

Symbolic Capital in Radiology. Social Studies of Science, 38(1), 35-
62.

Callon, M., & Latour, B. (2006). Le Grand Leviathan,

s'apprivoise-t-il? Sociologie de la Traduction. Paris: Textes
Fondateurs, Presses de l'Ecole des Mines.

Cartwright, L. (1995). Screening the Body: Tracing Medicine's

Visual Culture. Minneapolis: University of Minnesota Press.

Casper, M., & Koenig, B. (1996). Reconfiguring nature and

Culture: Intersections of Medical Anthropology and Technosciences
Studies. Medial Anthropology Quarterly, 10(4), 223-236.

Cassel, E. J. (1987). On Control, Certitude and the 'Paranoia'

of Surgeons. Culture Medicine and Psychiatry, 11, 229-249.

Cassel, E. J. (1991). Expected Miracles: Surgeons at Work.

Philadelphia: Temple university Press.

Chalmers, D. J. (1995). Facing up the Problem of

Consciousness. Journal of Consciousness Studies, 2(3), 200-219.

Chalmers, D. J. (1996). The Conscious Mind: In Search of a

Fundamental Theory. New York: Oxford University Press.

181
 Black Butterflies

Chorover, S. L. (1974). The Pacification of the Brain.

Psychology Today, 7(12), 59-60.

Chorover, S. L. (1979). From Genesis to Genocide: The

meaning of Human Nature and the Power of Behavior Control.
Cambridge, Mass.: MIT Press.

Chorover, S. L. (1980). Violence: A Localizable Problem? In E.

S. Valenstein (Ed.), The Psychosurgery Debate: Scientific, Legal, and
Ethical Perspectives (pp. 334-347). San Francisco: W.H. Freeman &
co.

Cicourel, A. V. (1964). Method and Measurement in Sociology.

New York: Free Press.

Cicourel, A. V. (1983). Language and the Structure of Belief in

Medical Communication. In S. Fisher & A. Dundas (Eds.), The
Social Organization of Doctor-Patient Communication (pp. 221-240).
Washington, DC: Center for Applied Linguistics.

Clark, J. A., & Mishler, E. (1992). Attending to Patient's

Stories: Reframing the Clinical Task. Sociology of Health and
Illness, 14(3), 344-372.

Clarke, A. E., Mamo, L., Fishman, J. R., Shim, J. K., & Ruth,
J. (2003). Biomedicalization: Technoscientific Transformations of
Health, Illness, and US Medicine. American Sociological Review, 68,
161-194.

Clifford, J., & Marcus, G. E. (Eds.). (1986). Writing Culture:

The Poetics and Politics of Ethnography. Berkeley: University of
California Press.

182
 Sky E. Gross

Coldman, A., Phillips, N., & Reid, S. (2004). Cancer Survival

Statistics - 2004. Canada: The Surveillance and Outcomes Unit,
Population and Preventive Oncology, BC Cancer Agencyo.
Document Number)

Collins, H. M. (1994a). Dissecting Surgery: Forms of Life

Depersonalized. Social Studies of Science, 24(2), 311-333.

Collins, H. M. (1994b). Responses and Replies: Scene from

Afar. Social Studies of Science, 24(2), 369-389.

Collins, H. M. (2001). Tacit Knowledge, Trust and the Q of

Sapphire Social Studies of Science, 31(1), 71-85.

Crevier, P. H. (1976). La Psychochirurgie et l'Ethique de nos

Jours. Union Medicale du Canada, 105(7), 1089-1094.

Crick, F., & Koch, C. (1990). Towards a Neurobiological

Theory of Consciousness. Seminars in the Neurosciences, 2, 263-
275.

Crossley, N. (1995). Merleau-Ponty, the Elusive Body and

Carnal Sociology. Body and Society, 1(1), 43-63.

Csordas, T. J. (1990). Embodiment as a Paradigm for

Anthropology. Ethos, 18, 5-47.

Csordas, T. J. (1993). Somatic Modes of Attention. Cultural

Anthropology, 8, 135-156.

Csordas, T. J. (1994). Embodiment and Experience: The

Existential Ground of Culture and Self. Cambridge, UK: Cambridge
University Press.

183
 Black Butterflies

Damasio, A. R. (1994). Descartes' Error : Emotion, Reason,

and the Human Brain. New York: Putnam.

Daston, L., & Galison, P. (1992). The Image of Objectivity.

Representations, 40, 81-128.

Delgado, J. M. R. (1969). Physical control of the mind; toward

a psychocivilized society ([1st ed.). New York,: Harper & Row.

Dennett, D. C. (1991). Consciousness Explained. Boston:

Little, Brown and Co.

Dennett, D. C. (1999). Mind: Towards an Understanding of

Consciousness. Jerusalem Hed Artzi.

Dew, K. (2001). Modes of Practice and Models of Science in

Medicine. Health, 5(1), 93-111.

Dickens, D. R., & Fontana, A. (Eds.). (1994). Postmodernism

and Social Inquiry. New York: Guilford Press.

Dickson-Swift, V., James, E. L., Kippen, S., & Liamputtong, P.

(2006). Blurring Boundaries in Qualitative Health Research on
Sensitive Topics. Qualitative Health Research, 16(6), 853-871.

Diefenbach, G. J., Diefenbach, D., Baumeister, A., & West, M.

(1999). Portrayal of Lobotomy in the Popular Press: 1935-1960.
Journal of the History of the Neurosciences, 8(1), 60-69.

Dingwall, R. (1980). Ethics and Ethnography. Sociological

Review, 28(4), 871-891.

184
 Sky E. Gross

Donnelly, J. (1978). The Incidence of Psychosurgery in the

United States, 1971--1973. American Journal of Psychiatry,
135(12), 1476-1480.

Douglas, M. (1966). Purity and Danger; an Analysis of

Concepts of Pollution and Taboo. New York: Praeger.

Draper, J. (2002). 'It was a Real Good Show': The Ultrasound

Scan, Fathers and the Power of Visual Knowledge. Sociology of
Health and Illness, 24(6), 771-795.

Duden, B. (1993). Disembodying Women: Perspectives on

Pregnancy and the Unborn. Cambridge, MA: Harvard University
Press.

Duffy, J., Brown, E., Rosenstock, J., & Spillane, J. (1997).

Primum non Nocere: Somatic Treatments for Mental Illness in the
Early 20th Century. Connecticut Medicine, 61(9), 528-535.

Dully, H., & Fleming, C. (2008). My Lobotomy. London:

Vermilion.

Dumit, J. (2004). Picturing Personhood - Brain Scans and

Biomedical Identity. Princeton, NJ: Princeton University Press.

Edelman, G. M. (2000). Biologie de la Conscience. Paris: Odile

Jacob.

Edelman, G. M., & Tononi, G. (2001). A Universe of

Consciousness: How Matter Becomes Imagination. New York: Basic
Books.

185
 Black Butterflies

Eisenberg, L. (1977). Disease and Illness: Distinctions

between Professional and Popular Ideas of Sickness. Culture
Medicine and Psychiatry, 1(1), 9-23.

Eisenberg, L. (1995). The Social Construction of the Human

Brain. American Journal of Psychiatry, 152(11), 1563-1575.

Ewing, K. (1990). The Illusion of Wholeness: Culture, Self and

the Experience of Inconsistency. Ethos, 18, 251-278.

Fabian, J. (1983). Time and the Other: How Anthropology

makes its Object. New York: Columbia University Press.

Fadda, S. (1988). Le Corps, l'Ame, le Medecin. Revue Medicale

Suisse Romande, 108, 815-818.

Fairman, D. (1950). Evolution of Psychosurgery Technic. In

M. Greenblatt (Ed.), Studies in Lobotomy (pp. 57-66). New York:
Grune & Stratton.

Featherstone, M., Hepworth, M., & Turner, B. (1991). The

Body: Social Process and Cultural Theory. London: Sage.

Feinberg, T. E. (2006). Our Brains- Our Selves. Daedalus,

135(4), 72-80.

Feldman, R. P., Alterman, R. L., & T., G. J. (2001).

Contemporary Psychosurgery and a Look to the Future. Journal of
Neurosurgery, 95, 944-956.

Felker, M. E. (1983). Ideology and Order in the Operation

Room. In L. e. a. Romanucci-Ross (Ed.), The Anthropology of
Medicine: From Culture to Method. New York: Praeger.

186
 Sky E. Gross

Fleming, G. W. T. H. (1944). Recent Progress in Psychiatry:

Prefrontal Leucotomy. Journal of Mental Science, 90, 486-500.

Foucault, M. (1963). Naissance de la Clinique. Paris: Presses

Universitaires de France.

Foucault, M. (1972). The Archeology of Knowledge. New York:

Pantheon Books.

Foucault, M. (1975). The Birth of the Clinic; An Archaeology

of Medical Perception. New York: Vintage Books.

Foucault, M. (1979). Omnes et Singulatim. Paper presented at

the Tanner Stanford Lectures.

Foucault, M. (1980). Power/Knowledge: Selected Interviews

and Other Writings. New York: Pantheon.

Foucault, M. (1982). The Subject and Power. Critiqual Inquiry,

8(4), 777-795.

Foucault, M. (1986). The Care of the Self. New York:

Pantheon.

Fox, N. J. (1992). The Social Meaning of Surgery. Philadelphia:

Open University Press.

Fox, N. J. (1997). Space, Sterility and Surgery: Circuits of

Hygiene in the Operating Theatre. Social Science and Medicine,
45(5), 649-657.

Fox, R. (1979). The Autopsy: Its Place in the Attitude-Learning

of Second-year Medical Students. In R. Fox (Ed.), Essays in Medical
Sociology: Journeys into the Field. New York: Wiley.

187
 Black Butterflies

Francis, N. R., & Lewis, W. (2001). What Price Dissection?

Dissection Literally Dissected. Journal of Medical Ethics, 27(1), 2-9.

Frank, A. W. (1990). Bringing Bodies Back in: A Decade

Review. Theory, Culture and Society, 7, 131-162.

Frank, A. W. (1992). Cyberpunk Bodies and Postmodern

Times. Studies in Symbolic Interaction 13, 39-50.

Frank, A. W. (1995). The Wounded Storyteller: Body, Illness,

and Ethics. Chicago: Chicago University Press.

Frank, J. (1946). Psychosurgery. New York: CJ Thomas.

Freeman, W. (1951). Lobotomy: A Comparison of Prefrontal

Lobotomy with Transorbital Lobotomy. Surgery, Gynecology and
Obstetrics, 195, 603-606.

Freeman, W. (1956). Egas Moniz, his Life and Work. American

Journal of Psychiatry, 112(2), 769-772.

Freeman, W. (1965). Psychosurgery. American Journal of

Psychiatry, 121(7), 653-655.

Freeman, W., & Watts, J. W. (1946). Reports of Cases.

Proceedings of the Royal Society of Medicine: Section of Psychiatry,
39, 446-447.

Freeman, W., & Watts, J. W. (1947). Psychosurgery During

1936-1946. Archives of Neurology and Psychiatry, 47, 417-425.

Freeman, W. J., Watts, J. W., & Hunt, T. (1942).

Psychosurgery; Intelligence, Emotion and Social Behavior

188
 Sky E. Gross

Following Prefrontal Lobotomy for Mental Disorders. Springfield,

Ill.: C. C. Thomas.

Freidson, E. (1970). Professional Dominance: The Social

Structure of Medical Care ([1st ed.). New York: Atherton Press.

Freud, S. (Ed.) (1955 [1920]) The Standard Edition of the

Complete Psychological Works of Sigmund Freud (1920-1922)
(Vols. 18). London: The Hogarth Press and the Institute of
Psychoanalysis.

Friedberg, J. (1977). Shock Treatment, Brain Damage, and

Memory Loss: A Neurological Perspective. American Journal of
Psychiatry, 134(9), 1010-1013.

Gaines, A. D., & Hahn, R. A. (1982). Physicians of Western

Medicine. Culture Medicine and Psychiatry, 6, 257-293.

Gall, F. J. (1808). Discours d’ouverture, lu par M. le Docteur

Gall, à la première séance de son cours public sur la physiologie
du cerveau – le 15 janvier 1808. Paper presented at the cours
public sur la physiologie du cerveau.

Garber, D. (1992). Descartes' Metaphysical Physics. Chicago:

University of Chicago Press.

Gelfand, T. (2000). Neurologist or Psychiatrist? The Public

and Private Domains of Jean-Martin Charcot. Journal of the History
of Behavior Science, 36(3), 215-229.

Gertler, B. (2001). Introspecting Phenomenal States.

Philosophy and Phenomenal Research, 63(2), 305-328.

189
 Black Butterflies

Gieryn, T. F. (1983). Boundary-Work and the Demarcation of

Science from Non-Science: Strains and Interest in Professional
Ideologies of Scientists. American Sociological Review, 48(6), 781-
795.

Gieryn, T. F. (1999). Cultural Boundaries of Science :

Credibility on the Line. Chicago: University of Chicago Press.

Gildenberg, P. L. (1975). Survey of Stereotactic and

Functional Neurosurgery in the United States and Canada. Applied
Neurophysiology, 38(1), 31-37.

Goffman, E. (1961a). Encounters: Two Studies in the

Sociology of Interaction Harmondsworth: Penguin.

Goffman, E. (1961b). Asylums: Essays on the Social Situation

of Mental Patients and other Inmates. New York: Anchor Books

Goldstein, J. (Ed.). (1994). Foucault and the Writing of History.

Oxford: Blackwell.

Golla, F. L. (1946). Discussion: Prefrontal Leucotomy with

Reference to Indications and Results. Proceedings of the Royal
Society of Medicine: Section of Psychiatry, 443-445.

Good, B. (1994). How Medicine Constructs its Objects. In B.

Good (Ed.), Medicine, Rationality and Experience: An
Anthropological Perspective (Vol. 125-167). Cambridge, UK:
Cambridge University Press.

Goodwin, C. (1994). Professional Vision. American

Anthropologist, 96(3), 606-633.

190
 Sky E. Gross

Goodwin, D., Pope, C., Mort, M., & Smith, A. (2003). Ethics
and Ethnography: An Experiential Account. Qualitative Health
Research, 13(4), 567-577.

Goodwin, D., Pope, C., Mort, M., & Smith, A. (2005). Access,
Boundaries and their Effects: Legitimate Participation in
Anaesthesia. Sociology of Health and Illness, 27(6), 855-871.

Grant, C. (1968). New Light on an Old View. Journal of the

History of Ideas, 29(2), 293-301.

Greenberg, D. A., Aminoff, M. J., & Simon, R. P. (2002).

Clinical Neurology, Fifth Edition. San Francisco: McGraw-
Hill/Appleton & Lange.

Greenblatt, M., & Solomon, H. C. (1953). Relative Therapeutic

Efficacy of Several Operations: Superiority of Bimedial Lobotomy.
In M. Greenblatt (Ed.), Frontal Lobes and Schizophrenia: Second
Lobotomy Project of Boston Psychopathic Hospital (pp. 384-390).
New York: Springer Publishing Company.

Gross, S. E. (2009a). ‘The Alien Baby’: Risk, Blame and

Prenatal Indeterminacy. Health, Risk & Society, Forthcoming.

Gross, S. E. (2009b). Experts and ‘Knowledge that Counts’: A

Study into the World of Brain Cancer Diagnosis. Social Science &
Medicine, in Press.

Gross, S. E., & Shuval, J. T. (2008). On Knowing and

Believing: Prenatal Genetic Screening and Resistance to 'Risk-
Medicine'. Health, Risk and Society, 6(1), 549-564.

191
 Black Butterflies

Gunderman, R. B. (2005). The Medical Community's

Changing Vision of the Patient: The Importance of Radiology.
Radiology, 234, 339-342.

Hacking, I. (1982). Language, Truth and Reason. In M. Hollis

& S. Lukes (Eds.), Rationality and Relativism (pp. 48-66). Oxford:
Blackwell.

Hacking, I. (1992). "Style" for Historians and Philosophers.

Studies in the History and Philosophy of Science, 23(1), 1-20.

Hafferty, F. W. (1988). Cadaver Stories and the Emotional

Socialisation of Medical Students. Journal of Health and Social
Behavior, 29(4), 344-356.

Hahn, R. A., & Gaines, A. D. (Eds.). (1985). Physicians of

Western Medicine: Five Cultural Studies: Anthropological
Approaches to Theory and Practice. Dordrecht, the Netherlands:
Reidel.

Halpern, S. A. (1992). Dynamics of Professional Control:

Internal Coalitions and Crossprofessional Boundaries. American
Journal of Sociology, 97(4), 994-1021.

Haraway, D. (1997). Modest-Witness@Second-

Millenium.FemaleMan(c)-Meets-Oncomouse: Feminism and
TechnoscienceTM. New York: Routledge.

Haraway, D. J. (1991). Simians, Cyborgs, and Women : The

Reinvention of Nature. New York: Routledge.

Harvey, D. (1989). The Condition of Postmodernity : An

Enquiry into the Origins of Cultural Change. Cambridge, MA:
Blackwell.

192
 Sky E. Gross

Heil, J. (1988). Priviledged Access. Mind (new series), 97(386),

238-251.

Hindmarsh, J., & Pilnick, A. (2002). The Tacit Order if

Teamwork: Collaboration and Embodied Conduct in Anesthesia.
The Sociological Quarterly, 43(2), 139-164.

Hirose, S. (1972). Past and Present Trends of Psychiatric

Surgery in Japan. In E. Hitchkock & e. al. (Eds.), Psychosurgery
(pp. 349-357). Springfield, Ill.: Charles C. Thomas.

Hirschauer, S. (1991). The Manufacture of Bodies in Surgery.

Social Studies of Science, 21, 279-319.

Hitchcock, E. R., Laitinen, L., & Vaernet, K. (1972).

Psychosurgery; Proceedings. Springfield, Ill.,: Thomas.

Horgan, J. (1999). The Undiscovered Mind: How the Human

Brain Defies Replication, Medication, and Explanation. New York:
Touchstone.

Howell, J. D. (1995). Technology in the Hospital:

Transforming Patient Care in the Early Twentieth Century.
Baltimore, MD: John Hopkins University Press.

Huyn-Dornier, C. (1992). La Psychochirurgie: Vie et Mort d'une

Méthode. Université de Caen, Caen.

Hyman, S. E. (2000). The Millennium of Mind, Brain and

Behavior. Archives of General Psychiatry, 57(1), 88-89.

Jackson, F. (1982). Epiphenomenal Qualia. Philosophical

Quarterly, 32, 127-136.

193
 Black Butterflies

Jenike, M. A., Baer, L., & Ballantine, H. T. (1991).

Cingulotomy for refractory obsessive compulsive disorder. A long
term follow-up of 33 patients. Archives of General Psychiatry, 48,
548-555.

Jenks, C. (1995). The Centrality of the Eye in Western

Culture: An Introduction. In C. Jenks (Ed.), Visual Culture.
London: Routledge.

Joyce, K. (2005). Appealing Images: Magnetic Resonance

Imaging and the Production of Authoritative Knowledge. Social
Studies of Science, 35(3), 437-462.

Joyce, K. (2006). From Numbers to Pictures: The Development

of Magnetic Resonance Imaging and the Visual Turn in Medicine.
Science as Culture, 15(1), 1-22.

Joyce, K. (2008). Magnetic Appeal: MRI and the Myth of

Transparency. Ithaca, NY: Cornell University Press.

Kaimovitz, G. (1980). My Case Against Psychosurgery. In E. S.

Valenstein (Ed.), The Psychosurgery Debate: Scientific, Legal, and
Ethical Perspectives (pp. 506-519). San Francisco: W.H. Freeman &
co.

Katz, P. (1981). Ritual in the Operating Room. Ethnology, 20,

335-350.

Katz, P. (1999). The Scalpel's Edge: The Culture of Surgeons.

Boston, MA: Allyn and Beacon.

Katz, P., & Kirkland, F. R. (1988). Traditional Thought and

Modern Western Surgery. Social Science and Medicine, 26(12),
1175-1181.

194
 Sky E. Gross

Kaufman, S. R. (2000). In the Shadow of 'Death with Dignity':

Medical and Cultural Quandaries of the Vegetative State. American
Anthropologist, 102(1), 69-83.

Keating, P., & Cambrosio, A. (2003). Beyond 'Bad News': The

Diagnosis, Prognosis and Classification of Lymphomas and
Lymphoma Patients in the Age of Biomedicine (1945-1995). Medical
History, 47, 291-313.

Kelley, D., Richardson, A., & Mitchell-Heggs, N. (1973).

Stereotactic Limbic Leucotomy: Neurophysiologic Aspects and
Operative Technique. British Journal of Psychiatry, 123, 133-140.

Kendler, K. S. (2001). A Psychiatric Dialogue on the Mind-

Body Problem. American Journal of Psychiatry, 158, 989-1000.

Kerber, L. (1980). Women of the Republic: Intellect and

Ideology in Revolutionary America. Chapel Hill, NC: University of
North Carolina Press.

Kesey, K. (1973). One Flew over the Cuckoo's Nest. New York:
Viking Press.

Kevles, B. (1998). Naked to the Bone: Medical Imaging in the

20th Century. New York: Perseus.

Khin-Zaw, S. (1979). Do Philosophy and the Brain Sciences

need Each Other? Brain and Mind, 69, 167-173.

Kimball, C. P. (1970). Introduction of the Discussion on

Different Models of Mind-Body-Unity Model. Psychotherapy and
Psychosomatics, 18(1), 186-188.

195
 Black Butterflies

Klassen, P. E. (2001). Blessed Events: Religion and Homebirth

in North America. Princeton: Princeton University Press.

Klassen, P. E. (2001). Sacred Maternities and PostBiomedical

Bodies: Religion and Nature in Contemporary Home Birth. Signs,
26(3), 775-809.

Klein, M.-R., & Tardieu, G. (1949). La Leucotomie chez

l'Enfant et ses Indications. Seminaires des Hopitaux de Paris, 25(3),
113-114.

Kleinman, A. (1988). The Illness Narratives: Suffering,

Healing, and the Human Condition New York: Basic Books.

Kleinman, A. (1997). 'Everything that Really Matters': Social

Suffering, Subjectivity, and the Remaking of Human Experience in
a Disordering World. The Harvard Theological Review, 90(3), 315-
335.

Knight, G. C. (1969). Bifrontal Stereotactic Tractotomy: An

Atraumatic Operation of Value in the Treatment of Psychoneurosis.
British Journal of Psychiatry, 115, 257-266.

Knorr-Cetina, K. (1999). Epistemic Cultures: How the Sciences

Make Knowledge. Cambridge, MA: Harvard University Press.

Knorr-Cetina, K., & Amann, K. (1990). Image Dissection in

Natural Scientific Inquiry. Science, Technology and Human Values,
15(3), 259-283.

Knorr-Cetina, K. D. (1981). The Micro-sociological Challenge

of Macro-sociology: Towards a Reconstruction of Social Theory and
Methodology. In K. Knorr-Cetina & A. V. Cicourel (Eds.), Advances
in Social Theory and Methodology: Towards an Integration of Micro-

196
 Sky E. Gross

and Macrosociologies (pp. 1-47). London: Routledge and Kegan

Paul.

Koenig, B. (1988). The Technological Imperative in Medical

Practice: The Social Creation of a "Routine Treatment". In M. Lock
& D. R. Gordon (Eds.), Biomedicine Examined. Dordrecht: Kluwer.

Koestler, A. (1967). The Ghost in the Machine. London:

Penguin.

Kolb, B., & Whishaw, I. Q. (2003). Fundamentals of human

neuropsychology (5th ed.). New York: Worth Publishers.

Kolker, A., & Burke, B. M. (1994). Prenatal Testing: A

Sociological Perspective. Wesport, CT: Bergin & Garvey.

Koupernik, C. (1977). Section: Halte a la Psychochirurgie.

Concours Medical, 99(22), 3561-3562.

Kucharski, A. (1984). History of Frontal Lobotomy in the

United States, 1935-1955. Neurosurgery, 14(6), 765-772.

Kuhn, T. S. (1970). The Structure of Scientific Revolutions ([2d

ed.). Chicago: University of Chicago Press.

Landzelius, K. M. (2001). Charged Artifacts and the

Detonation of Liminality: Teddy-Bear Diplomacy in the Newborn
Incubator Machine. Journal of Material Culture, 6(3), 323-344.

Landzelius, K. M. (2003). Humanizing the Impostor: Object

Relations and Illness Equations in the Neonatal Intensive Care
Unit. Culture Medicine and Psychiatry, 27, 1-28.

197
 Black Butterflies

Lanigan, R. L. (1991). The Human Science of Communicology:

A Phenomenology of Discourse in Foucault and Merleau-Ponty.
Pittsburgh: Duquesne University Press.

Lanigan, R. L. (1995a). Communicology. In L. Embree (Ed.),

The Encyclopedia pf Phenomenology. Norwell, NM: Kluwer
Academic Publishers.

Lanigan, R. L. (1995b). Phenomenology. In T. Enos (Ed.), The

Encyclopedia of Rhetoric. New York: Garland Publishing.

Larson, M. S. (1977). The Rise of Professionalism: A

Sociological Analysis. San Francisco: University of California Press.

Latour, B. (1993). The Pasteurization of France. Cambridge,

MA: Harvard University Press.

Latour, B. (1996). Aramis or the Love of Technoscience.

Cambridge, MA: Cambridge University Press.

Latour, B. (1999). Pandora's Hope: Essays on the Reality of

Science Studies. Cambridge, MA: Harvard University Press.

Leder, D. (1992). The Body in Medical Thought and Practice

(Vol. 43). Dordrecht: Kluwer Academic Publishers.

Leder, D. (1992). A Tale of Two Bodies: The Cartesian Corpse

and the Lived Body. In D. Leder (Ed.), The Body in Medical Thought
and Practice. Dordrecht: Kluwer Academic.

Leibowitz, I. (1982). Body and Mind- The Psychophysical

Problem. Tel Aviv: Ministry of Defense Publications.

198
 Sky E. Gross

Leigh Star, S. (1989). Regions of the Mind: Brain Research

and the Quest for Scientific Certainty San Francisco: Stanford
University Press.

Levine, J. (1983). Materialism and Qualia: The Explanatory

Gap. Pacific Philosophical Quarterly, 64, 354-361.

Light, D. (1980). Becoming Psychiatrists : the Professional

Transformation of Self (1st ed.). New York: Norton.

Lishman, W. A. (1992). What is Neuropsychiatry? Journal of

Neurology, Neurosurgery and Psychiatry, 55(11), 983-985.

Lock, M. (1997). Decentering the Natural Body: Making

Difference Matter. Configurations, 5, 267-292.

Lock, M. (2002). Twice Dead: Organ Transplants and the

Reinvention of Death. Berkeley: University of California Press.

Lopez-Ibor, J. J., & Lopez-Ibor Alino, J. J. (1975). Selection

Criteria for Patients who should Undergo Psychiatric Surgery. Paper
presented at the Proceedings of the Fourth World Congress of
Psychiatric Surgery, Madrid, Spain.

Lupton, D. (1994). Medicine as Culture: Illness, Disease and

the Body in Western Societies. London: Sage.

Lynch, M. E. (1985). Discipline and the Material Form of

Images: An Analysis of Scientific Visibility. Social Studies of
Science, 15(1), 37-66.

199
 Black Butterflies

Lynch, M. E. (1988). Sacrifice and the Transformation of the

Animal Body into a Scientific Object: Laboratory Culture and
Ritual Practice in the Neurosciences. Social Studies of Science,
18(2), 265-289.

Lynch, M. E., & Woolgar, S. (Eds.). (1990). Representation in

Scientific Practice. Cambridge, MA: MIT Press.

Lyotard, J. F. (1984). The Postmodern Condition : A Report on

Knowledge (Vol. 10). Minneapolis: University of Minnesota Press.

Macmillan, M. (1996). Phineas Gage's Contribution to Brain

Surgery. Journal of the History of the Neurosciences 5(1), 56-77.

Malizia, A. L. (1997). The Frontal Lobes and Neurosurgery for

Psychiatric Disorders. Journal of Psychopharmacology, 11, 179-
187.

Marchand, L., Rondepierre, J. P., Constans, J. P., & Oules, J.

(1949). Apercus sur la Psychochirurgie des Maladies Mentales: Les
Lesions Causees par la Lobotomie Prefrontale. Annales Medico-
Psychologiques, 107, 513-554.

Mark, V. H., & Ervin, F. R. (1970). Violence and the Brain.

New York: Medical Dept.

Marti-Ibanez, F., Sackler, R. R., Sackler, A. M., & Sackler, M.

D. (1954). The Philosophy of Organicism in Psychiatry. Journal of
Clinical and Experimental Psychopathology, 15(3), 179-190.

Martin, E. (1994). Flexible Bodies. Boston, MA: Beacon.

Martin, E. (2000). Mind-Body Problems. American Ethnologist,

27(3), 569-590.

200
 Sky E. Gross

Mattingly, C. (1998). In Search of the Good: Narrative

Reasoning in Clinical Practice. Medical Anthropology Quarterly,
12(3), 273-297.

Mattingly, C. (2008). Reading Minds and Telling Tales in a

Cultural Borderland. Ethos, 36(1), 136-154.

Mayer-Gross, W. (1949). A Propos de la Théorie de l'Effets de

la Leucotomie sur les Symptomes Psychotiques. Encéphale, 28,
317-323.

McDonald, K. M. (1995). The Sociology of Professions. New

York: Sage.

McGovern, C. M. (1985). Masters of Madness : Social Origins

of the American Psychiatric Profession. Hanover, NH: The University
Press of New England.

McNay, L. (1991). The Foucauldian Body and the Exclusion of

Experience. Hypathia, 6, 125-139.

Merino, J. G. (2000). Neurology and Psychiatry: Closing the

Great Divide (letter to the editor). Neurology, 55, 602-603.

Merleau-Ponty, M. (1962). Phenomenology of Perception (C.

Smith, Trans.). New York: Routledge.

Metzinger, T. (2003). Being No One: The Self-Model Theory of

Subjectivity. Cambridge, MA: MIT Press.

Midgley, M. (1996). One World, but a Big One. Journal of

Consciousness Studies, 3(5-6), 500-514.

201
 Black Butterflies

Mishler, E. G. (1981). Social Contexts of Health, Illness, and

Patient Care. Cambridge, UK Cambridge University Press.

Mishler, E. G. (1984). The Discourse of Medicine: The

Dialectics of Medical Interviews. Norwood, NJ: Ablex.

Mizrachi, N., & Shuval, J. T. (2005). Between Formal and

Enacted Policy: Changing the Contours of Boundaries. Social
Science & Medicine, 60(7), 1649-1660.

Mizrachi, N., Shuval, J. T., & Gross, S. (2005). 'Boundary at

Work': Alternative Medicine in Biomedical Settings. Sociology of
Health and Illness, 27(1), 20-43.

Moerman, D. E. (1979). Anthropology of Symbolic Healing.

Current Anthropology, 20(1), 59-80.

Mol, A. (1998). Missing Links, Making Links: The Performance

of some Atheroscleroses. In M. Berg & A. Mol (Eds.), Differences in
Medicine: Unraveling Practices, Techniques and Bodies. Durham,
NC: Duke University Press.

Mol, A. (2002). The Body Multiple: Ontology in Medical

Practice. Durham, NC: Duke University Press.

Moniz, E. (1936a). Tentatives Operatoires dans le Traitement

de Certaines Psychoses. Paris: Masson et Cie.

Moniz, E. (1936b). Les Premieres Tentatives Operatoires dans

le Traitement de Certaines Psychoses. Encephale, 31(1), 1-29.

Moreira, T. (2000). Translation, Difference and Ontological

Fluidity: Cerebral Angiography and Neurosurgical Practice (1926-
1945). Social Studies of Science, 30(3), 421-446.

202
 Sky E. Gross

Moreira, T. (2004). Coordination and Embodiment in the

Operating Room. Body and Society, 10(1), 109-129.

Moreira, T. (2006). Heterogeneity and Coordination of Blood

Pressure in Neurosurgery. Social Studies of Science, 36(1), 69-97.

Murphy, R. F. (1990). The Body Silent. New York: Norton.

Nagel, T. (1974). What is it Like to be a Bat? The Philosophical

Review, 83, 435-450.

Nagel, T. (1986). The View from Nowhere. New York: Oxford

University Press.

Nettleton, S. (2006). The Sociology of Health and Illness.

Cambridge, MA: Polity Press.

Okhuni-Tierny, E., Angrosino, M. V., Becker, K., Daar, A. S.,

Funabiki, T., & Lorber, M. I. (1994). Brain Death and Organ
Transplantation: Cultural Bases of Medical Anthropology. Current
Anthropology, 35(3), 233-244.

Ornstein, J. H. (1972). Reduction and Reality: Some

Misconceptions about Science. In J. H. Ornstein (Ed.), The Mind
and the Brain: A Multi-Aspect Interpretation (pp. 71-98). Hague:
Martinus Nijjhoff.

Parsons, T. (1971). System of Modern Societies (Foundations

of Modern Sociology) New York: Prentice Hall.

Pickering, A. (Ed.). (1992). Science as Practice and Culture.

Chicago: The University of Chicago Press.

203
 Black Butterflies

Pilnick, A., & Hindmarsh, J. (1999). 'When You Wake Up, It

Will All Be Over': Communication in the Anesthetic Room Symbolic
Interaction, 22, 345-360.

Polanyi, L. (1985). Telling the American Story: A Structural

and Cultural Analysis of Conversational Storytelling. Norwood, NJ:
Ablex.

Polanyi, M. (1998). Personal Knowledge. London: Routledge.

Popper, K. R. (1965). The Logic of Scientific Discovery. New

York: Basic Books.

Popper, K. R., & Eccles, J. C. (1977). The Self and its Brain:
An Argument for Interactionism. Berlin: Springer.

Porot, M. (1947). La Leucotomie Prefrontale en Psychiatrie.

Annales Medico-Psychologiques, 105, 119-142.

Porter, R. (1993). The Rise of Physical Examination. In W. F.

Bynum & R. Porter (Eds.), Medicine and the Five Senses (pp. 179-
197). Cambridge, NY: Cambridge University Press.

Porter, T. (1995). Trust in Numbers: The Pursuit of Objectivity

in Science and Public Life. Princeton, NJ: Princeton University
Press.

Porteus, S. D. (1955). Some Common-Sense Implications of

Psychosurgery. British Journal of Medical Psychology, 28, 167-176.

Pratt, M. L. (1986). Fieldwork in Common Place. In J. Clifford

& G. E. Marcus (Eds.), Writing Culture: The Poetics and Politics of
Ethnography (pp. 27-50). Berkely: Universty of California Press.

204
 Sky E. Gross

Pressman, J. D. (1988). Sufficient promise: John F. Fulton

and the Origins of Psychosurgery. Bulletin of the History of
Medicine, 62(1), 1-22.

Pressman, J. D. (1998). Last Resort : Psychosurgery and the

Limits of Medicine. Cambridge, UK: Cambridge University Press.

Price, B. H., Adams, R. D., & Coyle, J. T. (2000). Neurology

and Psychiatry: Closing the Great Divide. Neurology, 54(1), 8-14.

Puech, P. (1949). Psychochirurgie - Indications et Resultats.

Presse Medicale, 2, 115-118.

Rabinow, P. (1996). Making PCR: A Story of Biotechnology.

Chicago: University of Chicago Press.

Reiser, S. J. (1978). Medicine and the Reign of Technology.

New York: Cambridge University Press.

Reiser, S. J. (1991a). The Clinical Record in Medicine, Part I:

Learning from Cases. Annals of Internal Medicine, 114(10), 902-
907.

Reiser, S. J. (1991b). The Clinical Record in Medicine, Part II:

Reforming Content and Purpose. Annals of Internal Medicine,
114(10), 980-985.

Rohrer, T. (2007). The Body in Space: Dimensions of

Embodiment. In T. Ziemke, J. Zlatev & R. Frank (Eds.), Body
Language and Mind I: Embodiment. New York: de Gruiter.

Rollin, H. R. (1990). The Dark before the Dawm. Journal of

Psychopharmacology, 4(3), 109-114.

205
 Black Butterflies

Root, R., & Browner, C. H. (2001). Practices of the Pregnant

Self: Compliance with and Resistance to Prenatal Norms. Culture
Medicine and Psychiatry, 25, 195-223.

Rose, N. (1985). The Psychological Complex: Psychology,

Politics and Society in England 1869-1939. London: Routledge.

Rosenberg, C. E. (1999). Meanings, Policies, and Medicine: On

the Bioethical Enterprise and History. Daedalus, 128(4), 27-46.

Rosenberg, C. E., & Golden, J. L. (1992). Framing disease :

studies in cultural history. New Brunswick, N.J.: Rutgers University
Press.

Rouvroy, C. (1954). Réflexions sur la Légitimité et les

Indications de la Psychochirurgie. Acta Neurologica et Psychiatrica
Belgica, 54, 359-367.

Rudin, E., & Zimmerman, R. (1978). Psychiatric Treatment:

General Implications and Lessons from Recent Court Decisions in
California. Western Journal of Medicine, 128(5), 459-466.

Ryle, G. (1949). The Concept of Mind. London: Hutchinson.

Sabbatini, R. M. E. (1997). The History of Psychosurgery.

Brain and Mind, 1(2), 1-15.

Sachdev, P., & Sachdev, J. (1997). Sixty Years of

Psychosurgery: Its Present Status and its Future. Australian & New
Zealand Journal of Psychiatry, 31(4), 457-464.

Sacks, O. (1985). Man Who Mistook His Wife for a Hat and
Other Clinical Tales. New York: Summit Books.

206
 Sky E. Gross

Sargant, W. (1976). Long-Stay Mental Hospital Population.

British Medical Journal 1(6003), 221.

Sartre, J.-P. (1956). Being and Nothingness (H. E. Barnes,

Trans.). New York: Philosophical Library.

Scambler, G., & Higgs, P. (Eds.). (1998). Modernity, medicine

and health: medical sociology towards 2000. New York: Routledge.

Scheflin, A. W., & Opton, E. M. (1978). The Mind

Manipulators. New York: Paddigton Press.

Scheper-Hughes, N., & Lock, M. (1987). The Mindful Body: A

Prolegomenon to Future Work in Medical Anthropology. Medical
Anthropology Quarterly, 1(1), 6-41.

Schimmel, P. (2001). Mind Over Matter? - Philosophical

Aspects of the Mind-Body Problem. Australia and New Zealand
Journal of Psychiatry, 35, 481-487.

Schutz, A. (1970). On phenomenology and social relations:

Selected writings. Chicago: The University of Chicago Press.

Searle, J. R. (1998). Mind, Language, and Society: Philosophy

in the Real World. New York: Basic Books.

Searle, J. R., Dennett, D. C., & Chalmers, D. J. (1997). The

Mystery of Consciousness. New York: New York Review of Books.

Seli, T., & Shapiro, C. M. (1997). Neuropsychiatry: The Mind

Embrained? Journal of Psychosomatic Research, 43(4), 329-333.

Shilling, C. (1993). The Body and Social Theory. London Sage

Publications.

207
 Black Butterflies

Shorter, E. (1997). A History of Psychiatry : From the Era of

the Asylum to the Age of Prozac. New York: John Wiley & Sons.

Silbermann, M., & Ransohoff, J. (1954). Medico-legal

Problems in Psychosurgery. Am Journal of Psychiatry, 110(11),
801-808.

Silverman, W. A. (2001). Neurosurgical Exorcism. Paediatric

and Perinatal Epidemiology, 15, 98-99.

Smith, A. C., & Kleinman, S. (1989). Managing Emotions in

Medical School: Students' Contact with the Living and the Dead.
Social Psychology Quarterly, 52(1), 56-69.

Snaith, R. P. (1994). Psychosurgery: Controversy and

Enquiry. British Journal of Psychiatry, 165, 582-584.

Snaith, R. P. (1997). Surgery for mental illness has been

proved effective. British Medical Journal, 314(7073), 75.

Stone, J. L. (2001). Dr. Gottlieb Burckhardt--The Pioneer of

Psychosurgery. Journal of the History of the Neuroscience, 10(1),
79-92.

Sugar, O. (1978). Changing Attitudes Towards Psychosurgery.

Surgical Neurology, 9, 331-335.

Sugar, O. (1980). Surgery for the Mind. Journal of Medical

Ethics, 6(3), 115-116.

Swayze, V. W. (1995). Frontal Leukotomy and Related

Psychosurgical Procedures in the Era before Antipsychotics (1935-
1954): A Historical Overview. American Journal of Psychiatry,
152(4), 505-515.

208
 Sky E. Gross

Synott, A. (1992). Tomb, Temple, Machine, and Self: The

Social Construction of the Body. British Journal of Sociology, 43(1),
79-110.

Szakolczai, A. (2000). Reflexive Historical Sociology. London:

Routledge.

Szasz, T. S. (1977). Aborting Unwanted Behavior: The

Controversy on Psychosurgery. The Humanist, 37, 7-11.

Thompson, J. B. (1995). The Media and Modernity.

Cambridge, MA: Polity Press.

Thornquist, E. (1997). Three Voices in a Norwegian Living

Room: An Encounter from Physiotherapy Practice Medical
Anthropology Quarterly, 11(3), 324-351.

Toombs, K. S. (1990). The Meaning of Illness: A

Phenomenological Account of the Different Perspectives of
Physician and Patient. Dordrecht: Kluwer Academic Press.

Torrey, E. F. (1975). The Death of Psychiatry (1st ed.). Radnor,

PA: Chilton Book Co.

Tsementzis, S. A. (2000). Differential Diagnosis in Neurology

and Neurosurgery. New York: Thoeme Stuttgart Editions.

Turner, B. (1992). Regulating Bodies. London: Routledge.

Turner, B. S. (1996). The Body and Society: Explorations in

Social Theory. London: Sage.

Turner, V. (1969). The Ritual Process: Structure and Anti-

Structure Chicago: University of Chicago Press.

209
 Black Butterflies

Turner, V., & Turner, E. (1978). Image and Pilgrimage in

Christian Culture: Anthropological Perspectives. New York:
Columbia university Press.

Umbach, W. (1976). Indications et Limites d'une Chirurgie du

Comportement. Neurochirurgie, 22(6), 579-584.

Valenstein, E. S. (1980a). Review of the Literature and

Postoperative Evaluation. In E. S. Valenstein (Ed.), The
Psychosurgery Debate: Scientific, Legal, and Ethical Perspectives
(pp. 141-163). San Francisco: W.H. Freeman & co.

Valenstein, E. S. (1980b). The Psychosurgery Debate :

Scientific, Legal, and Ethical Perspectives. San Francisco: W. H.
Freeman.

Valenstein, E. S. (1986). Great and Desperate Cures : The

Rise and Decline of Psychosurgery and Other Radical Treatments
for Mental Illness. New York: Basic Books.

Van der Geest, S. (2005). 'Sacraments' in the Hospital:

Exploring the Magic and Religion of Recovery. Anthropology and
Medicine, 12(2), 135-150.

Van der Geest, S., & Finkler, K. (2004). Hospital

Ethnography: Introduction. Social Science and Medicine, 59, 1995-
2001.

Van Gennep, A. (1960). The Rites of Passage. Chicago:

University of Chicago Press.

Walters, T. (2004). Body Worlds: Clinical Detachment and

Anatomical Awe. Sociology of Health and Illness, 26(4), 464-488.

210
 Sky E. Gross

Webb, D. (1998). A 'Revenge' on Modern Times: Notes on

Traumatic Brain Injury. Sociology, 32(3), 541-555.

Weber, M. (2001 [1930]). The Protestant Ethic and the Spirit

of Captalism. London: Routledge.

Weiner, R. D. (1984). Does ECT Cause Brain Damage? .

Behavioral and Brain Sciences, 7, 1-53.

Wertheimer, P. (1948). La Lobotomie Préfrontale: Essai de

Psychochirurgie. La Presse Médicale, 41, 496-498.

White, R. T. (1998). Evidence-Based Medicine Offers Little

Support for Psychosurgery. Australia and New Zealand Journal of
Psychiatry, 32, 460-463.

Whitty, C. W. M., Duffield, J. E., & Tow, P. M. (1952). Anterior

Cingulectomy in the Treatment of Mental Disease. Lancet, 1, 475-
481.

Wilensky, H. L. (1964). The Professionalization of Everyone?

American Journal of Sociology, 70(2), 137.

Williams, G. (2008). The Genesis of Chronic Illness: Narrative

Re-construction. Sociology of Health and Illness, 6(2), 175-200.

Williams, S. J. (1996). The Vicissitudes of the Embodiment

across the Chronic Illness Trajectory. Body and Society, 2(2), 23-
47.

Williams, S. J., & Bendelow, G. A. (1996). The `Emotional'

Body. Body and Society, 2(3), 125-139.

211
 Black Butterflies

Wilson, R. (1954). Teamwork in the Operating Room. Human

Organization, 12, 9-14.

Wiltshire, J. (1999). Ethnography and Oliver Sacks: The

Anthropologist on Mars. Postcolonial Studies, 2(3), 389-402.

Witz, A. (1992). Professions and Patriarchy. London:

Routledge.

Young, A. (1981). The Creation of Medical Knowledge: Some

Problems in Interpretation. Social Science and Medicine, 15, 379-
386.

Young, I. (1990). Throwing Like a Girl and Other Essays in

Feminist Philosophy and Social Theory. Bloomington: Indiana
University Press.

Young, K. (1997). Presence in the Flesh. Cambridge, MA:

Harvard University Press.

Young, R. M. (1970). Mind, Brain and Adaptation in the 19th

Century: Cerebral Localization and its Biological Context from Gall
to Ferrier. Oxford: Oxford University Press.

Youngner, S. J. (1989). "Brain Death" and Organ Retrieval: A

Cross-Sectional Survey of Knowledge abd Concepts among Health
Professionals. Journal of the American Medical Association, 261,
2205.

212