Download - PHD ALL R1
-
8/2/2019 PHD ALL R1
1/215
Sky E. Gross
Table of ContentsContents
THE S TUDY OF THE HUMAN ANIMAL.........................................................................................................4 THE THREE PAPERS.................................................................................................................................7
Surgeons of the Mind...............................................................................................................8 Experts and 'Knowledge that Counts'...............................................................................9 The World of Brain Surgery .................................................................................................10
THE MIND-BODY PROBLEM AND CARTESIAN DUALISM..............................................................................12 Descartes and After ..............................................................................................................12 The Cartesian Fallacy ............................................................................................................14
INTRODUCING THE GNOSTIC SPLIT..........................................................................................................16 Phenognosis and Ontognosis.............................................................................................16 The Body and Embodiment: Closing the Great Divide..............................................18 Social Studies of Medicine and the Body ........................................................................19 The Discourses of Truth: Foucault and Beyond............................................................21
INTRODUCING REPLICATED BOUNDARIES..................................................................................................24 The Gnostic Split and Replicated Boundaries...............................................................24 Replicated Boundaries: The Professional Grounds......................................................26
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.................................................59 The Traps of Symbolics: Freeman and the Ice Pick ....................................................60
FROM THE MEDICAL INTO THE SOCIAL AND BACK AGAIN..........................................................................62 Social Control and the State...............................................................................................63 Dystopic Prospects: Psychiatry in Charge.....................................................................65
Back to Society: The Social Cure.......................................................................................66
Illegitimate Interests: The Costs of Mental Asylums...................................................68 THE HOMO VADUM..............................................................................................................................70
The Homo Vadum's Brain.....................................................................................................72 Corporeality, Pain and Phenognostic Truth....................................................................74 Madness and Ontognosis.....................................................................................................77 The Homo Vadum and Society ...........................................................................................78
CONCLUDING WORDS............................................................................................................................80 THE NEURO-ONCOLOGY CLINIC..............................................................................................................82
The Clinic: Spatial Characteristics.....................................................................................83 Schedules and Organisation of Time...............................................................................86 The Neuro-oncology Meeting..............................................................................................86 The Patients..............................................................................................................................87
The Consultation.....................................................................................................................88 Family Members......................................................................................................................89
1
-
8/2/2019 PHD ALL R1
2/215
Black Butterflies
SOMETHING ABOUT BRAIN TUMOURS......................................................................................................90 Types of Tumours...................................................................................................................90 Location of the Tumour and Functions Threatened....................................................91 Treatment ..................................................................................................................................93
INTRODUCTION......................................................................................................................................96 METHODOLOGY......................................................................................................................................97 A T THE CLINIC: THE DIAGNOSTIC PROCESS............................................................................................98 MEDICOSCIENTIFIC DIAGNOSIS...............................................................................................................100 THE WEB OF EXPERTISE......................................................................................................................102 ON THE ONTOGNOSTIC AUTHORITATIVENESS OF REPORTS.......................................................................104
The Sight of the Tumour: Radiology ..............................................................................106 Sorting Things Out: Histopathology ...............................................................................111 Figuring it out: Neuropsychology ....................................................................................113 Hands-on: The Clinical Report .........................................................................................114 The Patient .............................................................................................................................117 General Oncologists: Peripheral Experts......................................................................121 The Neurosurgeons and the Tumour Board: Peripheral Experts..........................123
MECHANISMS OF INTEGRATION..............................................................................................................124 Hierarchisation......................................................................................................................125 Sequencing.............................................................................................................................126 Negotiation.............................................................................................................................127 Peripheralising.......................................................................................................................129 Pragmatism............................................................................................................................130
CONCLUDING WORDS..........................................................................................................................134
PART V: THE BRAIN EXPOSED...............................................................137
ON NEUROSURGERY AND THE NATURE OF OBJECTIFICATION...................137
INTRODUCTION....................................................................................................................................137 METHODOLOGICAL NOTES....................................................................................................................140 THE SACRED BRAIN: THE MATTER OF THE GNOSTIC SPLIT...................................................................141 THE S TORY.........................................................................................................................................143
' Prelude'....................................................................................................................................143 The S-day .................................................................................................................................146 Under the Skin.......................................................................................................................150 The Peak of Surgery .............................................................................................................152 Closing up: The last stages...............................................................................................155 Just a Story ..............................................................................................................................156
LIMINALITIES AND REPLICATED BOUNDARIES...........................................................................................156 The OR as a Space of Multiple Liminalities..................................................................156 The Temple of Ontognosis: The OR................................................................................159 Keeping Phenognosis Out: Sterility ................................................................................159 Anaesthesia: Subduing Phenognosis.............................................................................161 Space and Liminal States...................................................................................................163 Going Native...........................................................................................................................164
GNOSTIC SHIFTS AND 'THEORIES OF MIND'...........................................................................................167 CONCLUSIONS......................................................................................................................................170
PART VI: CONLUDING WORDS...............................................................172
The Bounded Brain...............................................................................................................172 A Contemporary and Future Look onto the Gnostic Split ........................................175
2
-
8/2/2019 PHD ALL R1
3/215
Sky E. Gross
3
Macbeth: How does your patiendoctor?
Doctor . Not so sick, my lord,
As she is troubled with thick comfancies, That keep her from her rest.
Macbeth . Cure her of that.Canst thou not minister to a mindiseased,
Pluck from the memory a rootedsorrow,Raze out the written troubles of tbrainAnd with some sweet obliviousantidoteCleanse the stuff'd bosom of tha
perilous stuff Which weighs upon the heart?
Doctor . Therein the patientmust minister to himself.
Macbeth . Throw physic to
the dogs;I'll none of it.
Shakespeare, MacBeth Act V
scene iii
http://www.opensourceshakespeare.org/views/plays/characters/charlines.php?CharID=doctor-mac&WorkID=macbethhttp://www.opensourceshakespeare.org/views/plays/characters/charlines.php?CharID=macbeth&WorkID=macbethhttp://www.opensourceshakespeare.org/views/plays/characters/charlines.php?CharID=doctor-mac&WorkID=macbethhttp://www.opensourceshakespeare.org/views/plays/characters/charlines.php?CharID=macbeth&WorkID=macbethhttp://www.opensourceshakespeare.org/views/plays/characters/charlines.php?CharID=macbeth&WorkID=macbethhttp://www.opensourceshakespeare.org/views/plays/characters/charlines.php?CharID=doctor-mac&WorkID=macbethhttp://www.opensourceshakespeare.org/views/plays/characters/charlines.php?CharID=macbeth&WorkID=macbethhttp://www.opensourceshakespeare.org/views/plays/characters/charlines.php?CharID=doctor-mac&WorkID=macbeth -
8/2/2019 PHD ALL R1
4/215
Black Butterflies
Part I : Introduc: Introduc ing 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
1 The use of masculine pronouns and possessives was chosen arbitrarily the text refers to bothgenders
4
-
8/2/2019 PHD ALL R1
5/215
Sky E. Gross
known in the world-out-there, and in the world of the self?
The 'I' (myself), the 'he' (the 'other'), or rather the 'they'
('society')?
Thus, this essay is about epistemology, in it asking how do
we know what we know. In looking at the world and at the self,
which kind of knowledge 'counts'? and And if one is considered
more authoritative than another, how much is this hierarchy
contingent upon cultural settings at both macro-level, and 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
essay: tackling, in the most plain-spoken way possible, the issue of
human understanding of the world and of himself within this world.
Before entering the analysis itself, there are twosome issues
that I would like to address. Both relate to my choice to study the'Western world'.
Much of anthropological attempts to understand human ways
and culture sought knowledge in social worlds other than the one
from which the discipline itself has sprouted from. This may be a
somewhat curious fact, considering it is itself the source of the
initial interest in and conceptualisation of - the issue. Whileacknowledging the value of these endeavours, I have chosen to
come back 'home', and to try to understand Western culture in its
own context, with its own dynamics, and with its own historical
development (each as defined by its own narratives).
One may oppose the reference to Western culture as if it
were one whole, and I must join these expressions of
discontentment. The Western world is indeed a mosaic of different
5
-
8/2/2019 PHD ALL R1
6/215
Black Butterflies
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 andpractical grounds: Biomedicine. This has been acknowledged by
endless works in the sociology and anthropology of medicine, now
well-accepted subdisciplines, and sources of many theoretical
innovations in the social sciences in general.
The power of biomedicine in the Western world can hardly be
overrated: it may be one of the most dominant, influential, and
highly regarded profession and body of knowledge. Its
authoritativeness over the individual and the social allows it to be
the source and the culmination of values assigned to Western
culture in the most general meaning of the term. Thus, it seemed
most promising to turn to this field as an empirical arena for the
development of a general theory of knowledge as it applies to
Western society, in its modern and postmodern manifestations.
In my seekingmy search for the most promising field of
study, I defined another vector of interest: the focal point within
which the Western modern individual defines his identity mind
and body, mind or body. There, many complexities began to arise:
am I a subject, looking at the world from my own private
perspective, defining Truth as it is sensed, thought of, felt, by me ,
as an conscious individual?; Or should I rather adopt a vision of myself as an object among objects, in a world defined by a general
(and scientific) consensus on which is True, and which is False?
Once having ascertained biomedicine's tendency to reinforce
the second way of defining Truth (adopting a body-centred, or
objectifying epistemology), I shall look at the ways in which it is
resisted by a sense of truth as held by the experiencing subject.
6
-
8/2/2019 PHD ALL R1
7/215
Sky E. Gross
These relations of power stood at the centre of my research in the
last years and will be placed at the centre of this essay as well. My
hope is to be able to convince the reader that these may form a
ground for a theory placing mind-body relations at a focal point inthe understanding of modern and postmodern Western
epistemological cultures.
The Three Papers
In the course of this essay, I will use three different ways to
substantiate, exemplify, and clarify the claims above. First, I will
propose a historical outlook on the ethical debate regarding
psychosurgery, the use of surgical, material means for treating the
mind; Second, I will bring the analysis of an in-situ work where I
observed the ways in which brain tumour diagnosis is reached,
when based on more or less objective forms of knowledge; And
third, I will lay down an analytical first-person narrative to bear on
the processes of objectification associated with brain surgery, as
experienced by the field-worker.
The sequencing will go from the macro, to the micro, to the
reflexive a representation of the theory itself, by which the 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
7
-
8/2/2019 PHD ALL R1
8/215
Black Butterflies
presentation of the methodology will be presented in each of the
three chapters, thereby avoiding redudancies and repetitions, as
well as making the compatibility between the work and the
methods explicitly evident.
Surgeons of the Mind
The first paper will serve as theoretical grounds for the
overall analysis proposed in this work. Thus, although heavily
drawing on philosophical insights, its aim will be to build a
framework for a social study of knowledge. In this, I will suggest a
conceptual framing whereby modern Western biomedical practice
and research sees two forms of knowledge coexist and fight for
authoritativeness: phenognosis (knowledge based on subjective
experience) and ontognosis (knowledge based on the enquiry of a
world-out-there).
Drawing on philosophical and theoretical insights from recent
works on discourse, the body, and social studies of medicine, this
paper will propose an analysis raising cultural aspects of 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 relatedtexts 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
8
-
8/2/2019 PHD ALL R1
9/215
Sky E. Gross
of the debate over psychosurgery will raise questions as to the
ways in which mind-body epistemologies affect conceptualisations
of humanhood and its association with self-consciousness (being a
subject) and the ability to accept objective truth (being sane). This historical analysis will allow a bird-eye, macro-level view of
the conceptual issues running throughout this work. It will assert
the social embodiment of the mind-body problem using a broad
perspective settled on the world of biomedicine. This will turn to
be essential to the understanding of the microdynamics
associated with the epistemological forces at hand, i.e.
phenognosis and ontognosis.
Experts and 'Knowledge that Counts'
Bringing these ideas to the realm of the clinical, this paper
will provide a closer, in situ , look into the life of a neuro-oncology
(brain cancer) clinic of a large hospital in Israel, based on a 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
9
-
8/2/2019 PHD ALL R1
10/215
Black Butterflies
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 thereports ( e.g. radiologists being aware of clinical evaluations before
finalising their reports); Peripheralising : turning to other expertises
to 'explain away' symptoms that do not fit with a well established
initial diagnosis ( e.g. asserting that a symptoms source was
orthopaedic rather than neurological); And pragmatism : using
information only as far as it provides sufficient grounds for
treatment decisions, leaving ambiguities unresolved. These five
mechanisms will here be presented in the context of the daily
work of the clinic, and associated with the theoretical thrust of this
work, i.e. , the relation of power between phenognosis and
ontognosis.
The World of Brain Surgery
In this essay, I will try to show how issues of objectification
can be discussed from the viewpoint of the objectifying party.
Resisting a dichotomy between physician-objectifying and
ethnographer-humanising, I will portray objectification as being of
a fluctuating nature, rather than a necessary by-product of
professional tendencies, epistemological bases, practical
necessities, and processes of socialisation. With this in mind, I will
propose a further look into the settings within which these
discursive dynamics take place and come about through artefacts,
space, symbols, etc. I will first briefly portray my relationship with
Ivan, a brain cancer patient whom I have followed over a period of
eighteen months, and then focus my attention on my observation
of the brain surgery he had to undergo. As it is presented from a
first-person perspective, this account will provide a glance into the
10
-
8/2/2019 PHD ALL R1
11/215
-
8/2/2019 PHD ALL R1
12/215
Black Butterflies
Part II: The Argument and its TheoreticalII: The Argument and its Theoretical ComplexComplex
The Mind-Body Problem and Cartesian Dualism 22
Descartes and After
"Cogito ergo Sum"
(I think therefore I am)
In these few words, Ren Descartes (1596-1650) offered his
definition of the mind as an entity outside of the realm of matter.
More specifically, he would define how mind and matter were
distinct: Matter has a spatial extension, i.e. , it has a place and a2 Note: some of the material presented here is borrowed from my own Master's Thesis
12
-
8/2/2019 PHD ALL R1
13/215
Sky E. Gross
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 worldof 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.
Much like Descartes himself, philosophers adhering to dualist
views conceive of the problem as based on the relations between
two distinct ontological entities (entities that 'are' in the world).
Monists, however, will speak of one dominant substance: this
being either material (materialists) or spiritual (idealists)
(Schimmel, 2001).
Dualist explanations, in turn, can be subdivided into
interactionist or non-interactionist ('parallelism'). As Descartes saw
mind and body as interacting entities (more specifically through
the 'pineal gland', an organ located deep within the brain), one
could define him as an interactionalist (Schimmel, 2001). Leibnitz
(1646-1716), in contrast, would see mind and body existing in
parallel, without having one affecting the other (non-causal
13
-
8/2/2019 PHD ALL R1
14/215
Black Butterflies
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 approachedfrom a subjective angle, and 'matter' when approached
objectively. Trying, like monists and 'substance dualists' do, to ask
whether water is water or H 2O, makes no sense to the 'property
dualist': these are not two phenomena, but rather two ways of
looking at one phenomenon (Kendler, 2001).
'Functionalism' will hold a somewhat related concept: the
mind-brain relationship would be comparable to drive-car
relationship, that is, rather than one being a by-product of the
other, there would be between the two a relation of function to
matter (Ben Zeev, 1996). An additional important dualist theory is
referred to as 'epiphenomenalism'. According to this view, mental
phenomena will be but a by-product of material substance, a
Hegelian 'foam on the wave' of brain activity. With the rising
power of brain research, these views, along with clear-cut
materialism, have become ever more pervasive.
The Cartesian Fallacy
The mind-body conundrum can be defined around the logical
fallacy arguably entailed by Cartesian dualism. Benjamin (1988),
for instance, brings us four prepositions, each considered 'true' prima facie , yet logically incompatible with the others:
The human body is material.
The mind is spiritual.
Mind and body interact.
14
-
8/2/2019 PHD ALL R1
15/215
Sky E. Gross
Spirit cannot affect matter and matter cannot affect spirit.
In order to make have these assertionsthem 'make logical
sense', one would have to give uprelinquish at least one of these
assertions. This is, in the broadest terms, the basis for the
different philosophical approaches described earlier:
The body would not be material (idealism);
The mind would be material (materialism);
Mind and body would not interact (non-causal dualism: e.g .identity theory, or ephiphenomenalism);
Spirit can affect matter and vice-versa (causal
interactionism).
With the development of modern science, idealism has lost
most of its vigour. With the evolution of experimentalism and the
focus on pragmatism in the development of technologies,
positivism has gained much strength. With it, materialism in its
less or more extreme version seemed to have led 20 th century's
Western thought. This until recently, when modern physics
(notably quantum theory) raised questions as to the ontological
exclusivity of 'matter'. This, aAlong with more general trends of
New Age culture, this seems to have revitalised concepts
regarding 'mind' as a powerful entity, or to the very least, as a
consequential actor in the 'world', were it the world of 'nature' or
the world of the 'social'. This process will stand at the very centre
of much of this current work.
The accumulation of scientific knowledge leaves little doubt:
there is to the very least some correlation between the mental and
the cerebral. The question remains as to the idea of a causal
15
-
8/2/2019 PHD ALL R1
16/215
Black Butterflies
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
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
16
-
8/2/2019 PHD ALL R1
17/215
Sky E. Gross
knowledge (observed), or between subjective and objective
knowledge (Ornstein, 1972; Young, 1990). This 'hard' problem
rightfully earned its appellation. The subjective/objective split
presupposes a form of consciousness encompassing a set of 'truths' (often referred to as qualia ) inaccessible to scientific
inquiry: the sight of the colour red, the sensation of an itching toe,
or a tooth ache which whose actuality could never be disputed by
a dentist. Arguably, no progress of science will ever allow being,
feeling, or aching in the place of another, and no map of the brain,
however elaborate, will be able to convey subjective experience
(Damasio, 1994; Edelman, 2000; Searle et al. , 1997). As Nagel
(1974), in his famous article "What is it like to be a Bat?"
eloquently notes, true knowledge of 'what it is like' is an
epistemological privilege reserved to the sentient subject, i.e ., to
the bat itself: Only a bat would know 'what it feels like' to see with
sounds, and only a particular bat would know what it feels like to
be this particular bat (Jackson, 1982; Heil, 1988; Gertler, 2001).
Facing an outside world, this first-person standpoint is the
site where one turns acquired knowledge (of the world, of oneself)
into which he/she will define and often declare to constitute the
'Truth',. This, regardless of whether the source is the world-out-
there agreed upon by several individuals or ones own
hallucinatory world. This first-persons position is also the focal
point where facts become meanings and where data become
experience, this again, regardless of whether the meaning
assigned to a phenomenon seems objectively acceptable or
based on some sort of psychological distortion (Edelman and
Tononi, 2001; Metzinger, 2003). This locus of 'Truth', based on 'I
know', 'I think', 'I feel' (phenomenological Truth), will often be
challenged and questioned by a claim for Truth based on 'There
is', or 'This is' (ontological Truth), a claim most often originating
from the world of science and biomedicine.
17
-
8/2/2019 PHD ALL R1
18/215
Black Butterflies
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 thehard problem, emphasising the irreducibility of the subjective into
material elements.
The Body and Embodiment: Closing the Great Divide
Phenomenology has its basis in philosophy and finds itself at
the centre of much contemporary work in the philosophy of mind,
namely in the field of neurosciences. For instance, one may find
such a view in Bennett and Hacker's famous essay, "Philosophical
Foundations of Neurosciences":
"A human being is a psychophysical unity,
an animal that can perceive, act
intentionally, reason, and feel emotion, a
language-using animal that is not merely
conscious, but also self-conscious
not a brain embedded in the skull of a
body" (Bennett and Hacker, 2003:3) [my
emphasis, S.G.]
The Cartesian mind-body split has ever been the subject of
philosophical attempts to either deny its existence or dissolve itsproblematic 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 willonly exist as far as it is embodied: the mind is not the 'ghost in the
18
-
8/2/2019 PHD ALL R1
19/215
Sky E. Gross
machine' it is rather the experiencing, first-person, faade of the
machine. While the body may be without mind, the mind cannot
be without body: both empirically and philosophically, perception,
action, cognition, emotion are all 'embodied phenomena'.
"[The body] is in the world as the heart is in
the organism: it keeps the visible spectacle
constantly alive, it breathes life into it and
sustains it inwardly, and with it forms a
system" (Merleau-Ponty, 1945 in Lanigan,
1995a: 203).
In other words, for phenomenologists such as Merleau-Ponty,
while the body may be regarded as a mere physiological and
natural entity (an 'objective body'), it will, once experienced, turn
into a 'phenomenal body'- unified with (rather than distinct from)
this physiological entity. The phenomenal body, thus, must be
viewed as one with the objective body: experience is experience
of the body, rather than an entity IN the body.
Social Studies of Medicine and the Body
Scholars, notably in the fields of the social studies of science,
have taken up these leads and engendered considerable research
on the existential and phenomenological groundings of the self
and its relation to 'the body'. This was associated with an ongoingeffort to account for possible gaps between 'sentience' and
'science' at the level of the self , a self problematised as dual (mind
vs. body) by external expert knowledge (most notably by medical
practitioners, dealing directly with the 'body in pain', or the
'experiencing flesh'). These works generally sought to merge the
bodys objective faade with the less tangible subjective
experience of which it serves as the locus. This would lead to theunderstanding of culture and experience "insofar as these can be
19
-
8/2/2019 PHD ALL R1
20/215
Black Butterflies
understood from the standpoint of bodily being-in-the-world."
(Csordas, 1994:143).
Along tangential lines, feminist literature took on the task of
revealing conflicts between sentient knowledge on the one hand,
and biomedically based knowledge on the other, often relating
epistemology to constructions of gender ( e.g. Root and Browner,
2001). According to these views (which were generally put under
the umbrella of a 'sociology of the body'), culture, as a system of
thought both external to the individual and concurrently present
within the individual, represents the body in a way that is socially
contingent (Martin, 1994). While agreeing with this basic premise,
scholars of 'embodiment' will claim that the sociology of the body
does not take into account the lived-experience of the body, a fact
that eventually only reinforces ideological and political dualisms.
In relation to the context of gender, these very works will be
claimed to adopt a 'mentalist discourse' (seeing 'mind' as being
superior to 'body') by which men are the 'mind', that is, related to
public realm, while women are the 'body' and belong to the
private sphere (Williams and Bendelow, 1996; Webb, 1998).
Thus, sociologies of embodiment ( e.g. Shilling, 1993;
Crossley, 1995; Turner, 1996; Lupton, 1994; Williams, 1996) have
shown how much 'we are our bodies' and how much of the mind-
body split remains unchallenged by current sociological work
(Nettleton, 2006). Thomas Csordas, one of the leading scholars inthe 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
20
-
8/2/2019 PHD ALL R1
21/215
Sky E. Gross
and nature to a way of living or inhabiting
the world through one's acculturated body."
(Csordas, 1994: xiv).
Overall, while ascertaining the presence of epistemological
conflicts in micro-settings where third-person and first-person
views collide (IT vs. I), even these 'embodiment'-oriented
undertakings showed little concern for the changing hierarchies
between the two forms of Truth (subjectively experienced vs.
objectively accountable) as broad discursive forces. For instance,
while Turner (1992) brings up the distinction between leib (the
lived body) and korper (the physiological body), he uses it as to
show the preciousness of the leib over the korper as a source and
grounds for culture. Still, the relationship between the two as
'Truths' is never analysed as such.
Throughout this work, I will seek to provide such a
complementary outlook, using Foucaults (1986) notion of
discursive practices as entailing human desire for 'Truth' about the
world and about the self. In an attempt to do so, I will first propose
a theoretical framing and then attempt to work the theory into the
canvas of the social settings from which individual cases were
drawn from: the history of psychiatry, the clinic, and the surgery
room.
The Discourses of Truth: Foucault and Beyond
Biomedical and scientific discourses generally comply with
ontognostic views whereby Truth would be accessible through the
unravelling of the world of material essences. Medical knowledge
is essentially of a reductionist nature, paying little or no attention
to the subjective aspects of disease. This ontognostic
epistemology is, in turn, associated with the foundation of apowerful ethos, the establishment of an authoritative system of
21
-
8/2/2019 PHD ALL R1
22/215
Black Butterflies
rhetorics, and the drawing on highly evocative symbolic elements -
all of which serving to support its discursive supremacy.
Biomedicine has had indeed notable success in achieving this
demarcation as highly respectable, trustworthy, and distinctive
from other social spheres, such as religion, politics, and economics
(Gieryn, 1983, 1999; Mizrachi et al. , 2005). This distinction persists
within a particular power structure where a hegemonic regime of
truth is established, defining the forms of knowledge considered
admissible while dismissing competing claims for Truth (Foucault,
1972, 1980, 1986; Armstrong, 1983). This will ipso-facto place
non-scientifically based knowledge including phenognosis - in a
subordinate position (Foucault, 1982). Phenognosis, however,
should not be seen as comprising mere 'leftovers' of this
biomedical ontognosis. When considering the development of
post-modernism, the linking of subjectivity with power relations
will reveal that it may indeed constitute a rising discursive force.
In the 1979 Stanford Lectures, Foucault stated that what
troubled him since his first book was:
"In what way are those fundamental
experiences of madness, suffering, death,
crime, individuality connected, even if we
are not aware of it, with knowledge and
with power? I am sure I'll never get theanswer; 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 herethat Foucault may have had the question misspelled: what if these
22
-
8/2/2019 PHD ALL R1
23/215
Sky E. Gross
experiences were not pre discursive, 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 thephenognostic authoritativeness of human experience?
Thus, although, according to Szakolczai (2000), Foucaults
own lifework can be defined as revolving around this issue of
discursive subordination, both his writing and more recent
literature has, by and large, omitted the option of a symmetrical
opposite, by which phenognosis itself would serve as grounds for
legitimacy and, therefore, for power. When at all acknowledging
subjective forms of knowledge, these works rather deal with them
in oppositum to the hegemonic power/knowledge, that is, through
the challenges it may present to the material-ontological bases of
biomedicine, science, and modern Western social order ( e.g.
Eisenberg, 1977; Rosenberg and Golden, 1992; Rosenberg, 1999;
Mizrachi et al. , 2005).
Traditionally then, phenognosis, as a consequent discursive
formation in and on itself, rarely seems to be deserving particular
interest, again making the relationships of power between
phenomenological and ontological forms of knowledge critically
understudied. This lack of attention remains somewhat enigmatic
considering recent historical developments.
The second half of the 20 th century witnessed a gnostic shift
in the form of hierarchical changes in the statuses of the two
forms of knowledge. This shift had both roots and repercussions
within what social sciences have traditionally referred to as the
rise of the postmodern (Lyotard, 1984; Harvey, 1989). This
postmodern era would see critiques of science joining existential,
phenomenological, and relativist influences in the social sciences
23
-
8/2/2019 PHD ALL R1
24/215
Black Butterflies
(and in general culture, most particularly in art and literature), to
pave the way toward a destabilisation of the grounds upon which
ontognosis drew its force. Grand ontological and metaphysical
accounts lost grace to local, negotiated, and provisional forms of knowledge, thereby allowing experience to ascend as a legitimate
source of Truth.
Still, although overwhelmingly rooted in phenomenological
thought, more radical postmodernism will reject the whole idea of
Truth, including if ever considered - phenognosis (Bourdieu,
1992; Dickens and Fontana, 1994). Thus, while postmodernist
thought may have notable affinities with ideas associated with the
concept of phenognosis, one cannot stress enough the
distinctiveness of the two worlds of notions, whereby stands the
value of the proposed reconceptualisation. This issue shall be
clarified as this analysis develops.
Introducing Replicated Boundaries
The reconceptualisation of the mind-body conundrum will
serve to assert the sociocultural correlates of the philosophical
problem, both at the macro-level and at the micro-level, both
synchronically and diachronically. This work has led to the
formulation of a theoretical framework for the understanding of
such processes: the definition of replicated boundaries.
The Gnostic Split and Replicated Boundaries
24
-
8/2/2019 PHD ALL R1
25/215
Sky E. Gross
If indeed the mind-body problem does stand at the basis of
social phenomena, how can one discern, detect, or recognise its
manifestations? How are phenognosis\ontognosis reflected in the
institutional, symbolic, interactional, spatial, professional,epistemological spheres?
The systems of classification we hold ordinate the creation of
boundaries at many layers of cultural phenomena (Abbott, 1995),
thus forming 'replicated boundaries'. In broad terms, replicated
boundaries refer to the presence of epistemological groundings
here, as a relation between two forms of knowledge- which will
replicate themselves in several spheres concurrently, and still
keep structural similarities. These spheres may include both lay
and professional epistemologies and practices, and may
encompass beliefs, classifications, actions, symbols, etc . If, for
instance, one finds a process of subordination of one form of
knowledge to another, this will come about in the subordination of
one professional sphere to another ( e.g. one group of
professionals losing their status), in changes in the ways in which
space is distributed ( e.g. forming a panoptical advantage in
spaces where the more powerful form of knowledge is exercised),
and so on.
The cases at hand will be used to illustrate this concept, and
assert that ontognosis' failure to conquer and subordinate
phenognosis led to a rejection of the latter from the territories of the former; and that this was followed by the creation of robust
limits to forestall any 'leaking' of the phenognosis into ontognosis'
terrains. I shall further claim that these bounding limits will not
remain within the layer of the abstract, and will have powerful
manifestations inat several layers simultaneously: the splitting of
brain and mind in the professional layer ( e.g. neurology vs.
psychiatry), in the layer of the spatial organisation of biomedical
25
-
8/2/2019 PHD ALL R1
26/215
Black Butterflies
areas ( e.g. where the operation room becomes a well-bounded
ontognostic shrine), in the symbolic layer ( e.g. the apparatus used
to keep each form of knowledge distinct in social settings), the
conceptual layer ( e.g. in the case of brain tumours - the conceivingof oneself as either body or mind) and in the more general
discursive layer, where definitions of authoritativeness remain
crucial ( e.g. hierarchies of sources of information in the forming of
diagnosis).
The phenomenon of replicated boundaries will accompany us
throughout the analysis, in which I hope to be able to establish it
as a valuable theoretical concept.
Replicated Boundaries: The Professional Grounds
Professions constitute social fields where particular
organisations of knowledge are often manifested in a most
palpable way. In the course of this study, I have thus chosen to lay
special attention to the professional developments of the fields
where the mind\body split would come about most noticeably, that
is, biomedicine, and most particularly, neurology ('the profession
of the brain') and psychiatry ('the profession of the mind').
The rise of the professions is related to the processes of
secularisation in Western society around the late eighteenth and
nineteenth centuries (Parsons, 1971; Goldstein, 1994). Parsons(1971:145) sees the professionalisation as a "criteria of cultural
legitimacy", and sees it as the "single most important component
in the structure of modern societies". Foucault (1982) joins him in
pointing to the importance of the professions in Western modern
societies. Associated with the interest in professions and the
attempts to define the phenomenon has always been the study of
knowledge and of epistemological subordination. As claimed byMcDonald (1995: 160), professions are knowledge-based
26
-
8/2/2019 PHD ALL R1
27/215
Sky E. Gross
occupations and therefore the nature of their knowledge and the
occupations strategies in handling their knowledge base are of
central importance. For Foucault, for instance, the unbreakable
link between abstract knowledge and the profession would bebased on the idea of the 'gaze', most often present in discourses
related to the practice and epistemological grounds of medicine
(Goldstein, 1994).
Medicine holds several ''core generating traits" (Larson,
1977) that enable it to be referred to as a profession, rather than a
mere occupation. First, it holds a body of abstract knowledge
which must be mastered by its members; Second, it holds a
degree of exclusivity in the relevant field of practice and
knowledge; Third, it is autonomous in the definition of its practice;
And finally, it holds a 'service ideal', that is a disinterested practice
that is based on altruistic rather than self-centred objectives
(Wilensky, 1964; Goldstein, 2001).
The need for professions to bind bindisolate themselves from
other forms of culture and to gain power through knowledge
involves processes of 'boundary-work'. There are several ways in
which biomedicine, as an ideal type of profession may 'do'
boundary-work (Gieryn, 1983, 1999; Mizrachi et al., 2005): First by
expanding its authority or expertise into domains claimed by other
professions or occupations; Secondly, by creating a clearer
contrast between itself and its rivals; Thirdly, by monopolisation of professional authority and resources; Finally, by labelling rivals as
pseudo or amateurish and exclude them from its turf.
Along related lines, Halpern (1992)willhas claimed that the
resolution of jurisdictional (and knowledge-related) conflicts
between professions may entail three possible forms: the control
of one profession over a field of jurisdiction; split jurisdiction; and
27
-
8/2/2019 PHD ALL R1
28/215
Black Butterflies
subordination (Halpern, 1992). These relations find themselves
replicated on several layers, hence my proposed definition of
replicated boundaries. This involves symbolic, rhetorical and
professional modes of boundary formation around and in parallelto 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 the non-scientific
are related to a battle on the hierarchy of these two kinds of
truths.
28
-
8/2/2019 PHD ALL R1
29/215
Sky E. Gross
Part III:III: Surgeons of the MindSurgeons of the Mind
Frontal Lobotomy and the Mind-Bodyand the Mind-Body
ProblemProblem The first section of this work, the story of psychosurgery, will
serve as a case-study where the key concepts of 'ontognosis' and
'phenognosis' are taken to their extreme. The boundaries between
the two forms of knowledge will come about at the level of
temporal developments as well as at the level of professional
dynamics. Its value as a basis for analysis is manifold: First, the
case reflects a daring attempt to bridge Cartesian dualism acting
29
-
8/2/2019 PHD ALL R1
30/215
Black Butterflies
upon matter to alter the realm of the mind-- making this chasm
remarkably explicit. Furthermore, it relates to the cultural
significance of the brain in biomedical thought. Finally, one cannot
overrate what is at stake here: i.e. , notions of humanhood,experience, existence, and consciousness (Kleinman, 1997). This
may account, at least partially, for the fact that, while over the
years many medical procedures were eagerly embraced only to be
consequently rejected, few arose as lively debates and as much
moral outrage as psychosurgery's.
Introduction
"It is better [] to have a simplified
intellect capable of elementary acts than an
intellect where there reigns disorder of
subtle synthesis. Society can accommodate
itself to the most humble laborer, but it
justifiably distrusts the mad thinker".
Walter Freeman, psychosurgeon, 1942
(cited in Kucharski, 1984:766)
Drawing on insights from a range of recent works on
discourse, the body, and social science of medicine, I will suggest
here an integrative analysis of the cultural and philosophical
aspects of mind-body dualism in modern and postmodern Western
society. I will picture this chasm, now broadly referred to as
Cartesian, through the study of the practice of frontal 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 certain epistemological
3 Lobotomy is but one psychosurgical technique yet, as it is of common usage to refer to the latter bythe former, and as it was the most practiced form of psychosurgery, I will use both terms alternately.
30
-
8/2/2019 PHD ALL R1
31/215
Sky E. Gross
assumptions associated with the Gnostic Split have led to the
overwhelming acceptance of the technique within modern
medicine of the 1940s-1960s, and how these have increasingly
become depicted as 'outrageous' within a more recent post-modern bioethical debate. More specifically, I will then relate this
transformation to the placing of human subjectivity above
observable functioning as the ultimate goals of medical and social
practices.
Lobotomy in Mind: Methodology
A Historical Approach to the Study of Replicated
Boundaries
"Sociological explanation is necessarily
historical. Historical sociology is thus not
some kind of sociology; rather it is the
essence of the discipline" (Abrams, 1982:2).
Historical analysis is often most resourceful when tackling
central interests of sociology (Abrams, 1982). It enables a drawing
of infinite changes and shifts in the relations of the subject matter
with other contexts. Boundaries can be understood as a belonging
to a process through time: their locations are drawn and redrawn,
at times strengthened, at others weakened. This and more, the
two sides of the borders are ever changing, both defining and
being defined by the boundary, or the relationship with the 'other'.
This is why a proper study of boundaries should involve a temporal
vector, as well as a study of the set of changing relationships
between two entities, were it professional, sociocultural, or
epistemological entities.
31
-
8/2/2019 PHD ALL R1
32/215
Black Butterflies
Still, this analysis will remain sociological in its nature: I will
seek the theoretical drawing on a historical case, and not a
detailed description, or critical reconstruction of an event.
Psychosurgery is brought here as a "historical individual" inWeber'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 articlespublished since the 1930's, the selection criterion being their
referring to terms related to psychosurgery or to its main
practitioners. I have included both French and English sources
collected in two central libraries in Paris, and four in Israel. This
revealed 384 articles and 14 major book publications. I interpreted
the texts along a chronological thread, as well as through several
overarching themes: the criteria for the evaluation of theprocedure; the rhetorical devices employed; positive/negative
32
-
8/2/2019 PHD ALL R1
33/215
Sky E. Gross
stances; and finally, the drawing on symbolic aspects of medical
practice. I then defined the debate as rotating around a number of
issues.
First was the inadequateness of theoretical and empirical
bases- using a method of trial and error on groups of patients
diagnosed with etiologically, nosologically, and symptomatically
diverse mental pathologies.
Second were the procedure's mutilating aspects and the
irreversibility of its effects as it inflicted great damage to both
affective, cognitive, and physical functioning by the severance of
brain tissue not targeted by the procedure.
Third were issues of obtaining informed consent from mental
patients, some going as far as claiming the latter to be infeasible
in the case of such extreme mental transformation: in terms of
personality, the patient giving his consent may not be the same
person going through the postoperative phase.
A fourth matter included questions of human
experimentation, with practitioners having limited tools to predict
the outcomes and calculate the risks of such an intervention.
Another issue was the immense power accorded to the
psychosurgeon in social and political spheres: Critics, in fact, oftenassociated the procedure with contemporary Hitlerian concepts of
euthanasia and eugenics.
And finally was the theme of abuses and aberrations
observed through the implementation of the different procedures,
including interventions on children as young as four year old
(Valenstein, 1980a, 1980b; Kucharski, 1984; Bouckoms, 1988;
33
-
8/2/2019 PHD ALL R1
34/215
Black Butterflies
Huynh-Dornier, 1992; Snaith, 1994; Berrios, 1997; Sabbatini,
1997).
Browsing through the literature, one typically finds depictions
of the debate assuming an evolving movement from an inferior to
a superior moral and ethical world (accepting and then rejecting
the technique), from inferior to superior technology (the use of
better instruments), and scientific understanding (knowing more
about the brain). This will eventually represent psychosurgery as a
mere by-product of a darker era in medicine and psychiatry. Here,
I will seek to portray psychosurgery as neither justifiable nor
condemnable, and will insist that the procedures ascribed
legitimacy is in line with other sociocultural developments, namely
specific epistemological shifts. I will propose a more
contextualised, less presentist view, which will describe not just
past-proponents but also contemporary critics arguments as
equally contingent upon the particular Zeitgeist within which they
took form. The focus will be thus on transitions in the depiction
rather than usage -- of the procedure, and on broad
epistemological --rather than mere technological -- aspects of
these developments. Indeed, while historical accounts of the
technological and scientific contingence of the abandonment of
psychosurgery ( e.g. reference to the introduction of drug therapy)
may account for the decline in the use of the technique, they offer
little to the understanding in the shift in the debate itself and the
values it brings forth. True, lobotomy may have lost its place to
psychoactive drugs, yet debates over its legitimacy morally,
ethically, epistemologically carry on, a fact which cannot be
explained away by the pointing to scientific advances. I suggest
the story must be told otherwise.
On Psychosurgery
34
-
8/2/2019 PHD ALL R1
35/215
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 prominentneurologists 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 asone of medicine's greatest promises: In the US of the 1940s, many
35
-
8/2/2019 PHD ALL R1
36/215
Black Butterflies
would consider it unethical not to propose lobotomy to some
patients. In fact, both asylum psychiatrists and neurosurgeons
viewed it as no less than a breakthrough in the scientific
understanding of the mind. By 1960, tens of thousands of psychosurgical interventions were conducted worldwide, most
particularly in the US, but also in Continental Europe, the UK, and
Japan (Hirose, 1972; Donnelly, 1978; Kucharski, 1984). Between
1942 and 1954, 10,365 were counted in the UK. Until mid 1941,
more than 18,600 operations were performed in the US (Swayze,
1995). Globally, according to Silverman (2001), since 1945 the
number of lobotomies doubled each year: from 240 in 1945, to
more than 5,000 in 1949.
A meta-study of 10,000 lobotomies performed in the UK
between 1942 and 1954 shows that 41% were fully cured or
greatly improved, 28% had little improvement, 25% seemed not to
be affected by the operation, 2% saw their symptoms aggravated
and 4% would die as a result of the procedure. Indeed, a great
part of the studied literature shows a distribution of approximately
a third of 'favourable' results (where symptoms disappeared
altogether or at least greatly improved), a third of 'medium'
results (where some improvement can be observed) and a third of
failures (no change, or the patient's condition has worsen). Still,
and although already in the 1930s most professional widely and
openly acknowledged the ill effects of the operation, both
physicians and family members tended to consider the
postoperative patient as better off, or even cured.
Essentially, psychosurgery offered a source of hope for the
deliverance of the mentally ill from the misery of their existence.
This enthusiastic embrace, however, soon waned. By 1960,
psychosurgery did not only lose grace, but also acquired a
gruesome image as one of medicine's darkest episodes. Fewer
36
-
8/2/2019 PHD ALL R1
37/215
Sky E. Gross
and fewer neurologists showed interest in the technique, research
grew scarce, and its uses were to be confined to the darker rooms
of mental asylums. From a symbol of scientific progress,
psychosurgery came to be regarded as the craft of mad scientistswith ill-defined intentions of mind-control at best, and of pure
sadism at worse.
In the popular press, changes in the attitude towards
psychosurgery were evident (Diefenbach et al. , 1999). The first
publications, initiated in 1936, were brief medical reports,
becoming increasingly detailed by 1941. The tone was largely
positive, the descriptions overstating the practices miraculous
effects . Between 1945 and 1954, the press became progressively
more critical, with a rising number of negative reports. It is only in
the late fifties that a strong polarisation occurred, with a typical
depiction of the practice as a form of menticide or mental
euthanasia (e.g. Baruk, 1953, 1956; Umbach, 1976; Chorover,
1974, 1979). With the rise of anti-institutional and 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,
37
-
8/2/2019 PHD ALL R1
38/215
Black Butterflies
invariably seen as destructive and abusive, is still clearly present
in a wide range of texts. When considered, ideas of brain control
and psychiatric abuses of power are woven into a fearsome tale of
the terrible consequences an unrestrained science may have. Thepractice 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 faade. This, I shall claim, will place psychosurgery within
the unquestioned ontognostic truth-basis of medical and scientific
work, thus forming a solid ground of legitimacy.
'Prehistorical' Sources
Although often ignored in historical accounts of the
development of the practice, the roots of psychosurgery can be
said to go as early as 1890 with the experiments of the Dutch
scientist Friedriech Golz. Golz reported the effect of the ablation of
the brain cortex in laboratory dogs, and suggested that this
operation had a calming effect on the subjects.
38
-
8/2/2019 PHD ALL R1
39/215
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, transformingher from an excited patient to a calmer
dement schizophrenic.
Four surgical operations were conducted on Frau B. in the
course of the next fourteen months. Almost 15 grams of her brain
tissue were removed. Each operation seemed to have had a
calming effect on the patient. As Burckhardt himself put it:
39
-
8/2/2019 PHD ALL R1
40/215
Black Butterflies
Though her intelligence seems to have
been lost, she is now calmer and less
dangerous. (Burckhardt 1890, in Stone,
2001:83)
Of the other patients to go under Burckhardts scalpel, one
will not survive the operation, and another will commit suicide
shortly after. The positive effects on the subjects' hallucinations
and agitated behaviour did not, however, convince the psychiatric
community of the beneficial potential of this avant-garde
procedure. Burckhardt suffered from harsh criticism and was
forced to bring his experiments to an end, although claiming:
I will not let myself be discouraged and I
hope neither will my colleagues, but rather,
they will use my experiences and go the
way of cortical extirpations and achieve
continued better and improved results. (in
Stone, 2001: 85)
Burckhardt died convinced of the potential hiding behind this
new technique, stating he could have turned asylums chronic
population into calm and satisfied mental patients.
It was not until the 1930s that psychosurgery began to
resurge. Yet, its origins in Burckhardt's work were, perhaps mostconveniently, 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
40
-
8/2/2019 PHD ALL R1
41/215
Sky E. Gross
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 wayof thinking the world. Thus pure reason becomes pure objectivity,
pure science: neurology as a mainstream biomedical and scientific
endeavour on the one end; and the fuzzy, the emotional, the
soiled, the subjective psychiatry on the other. Inside the category
of pure reason reigns order and inner classification, and outside:
chaos.
Neurology of the mid-1930s was among the most prestigious
and fast-growing academic fields (Abbott, 1988; Pressman, 1988).
Comprising a rather small group of physicians, neurology sought
an alliance with psychiatry, a more commonly practiced, albeit
less prestigious, form of medicine (Abbott, 1988; Gelfand, 2000).
By the 1920s, a unification of the fields was undertaken, to the
benefit of both professions. As knowledge on the anatomy and
structure of the brain began to accumulate, 'neuropsychiatry' of
the early 20 th 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 psychiatrys managing know-how, to neurology
as an expertise founded on complex and abstract knowledge
(Alexander and Selesnick, 1997; Seli and Shapiro, 1997).
Psychiatry was to rely on subjective, introspective accounts, or
symptoms. Neurology, on the other hand, could attain diagnoses
41
-
8/2/2019 PHD ALL R1
42/215
Black Butterflies
through quantifiable, communicable, and scientifically reliable
signs (Audisio, 1968; Price et al., 2000). The disciplinary
separation of what will become the fields of psychiatry and
neurology is strongly correlated with the distinction made betweenphysical and mental pathology. As more and more once believed
to be mental disease, have found their physical basis in brain
pathology, neurology has grown to encompass an enlarging group
of brain (and central nervous system) pathology. Indeed, over the
years, diseases such as aphasia and epilepsy have been relocated
from the blurry field of psychiatry to the more medical-like field of
neurology. The physical nature of disease will be attributed to any
brain-related pathology which physical basis can be understood
and clearly tagged. The psychic nature of disease will be
attributed to any mental syndrome for which no apparent
'physical' cause could be found. The former group of diseases will
belong to neurology as a medical expertise, while the latter will be
left in the hands of psychiatrists, then conceived as mental asylum
practitioners, mainly directing day-to-day life conditions for mental
patients (more 'technicians' than 'experts'). Medical treatment for
actual 'psyche-related' disease will be inconceivable, since the
basic definition of such a disease is related to the absence of
known brain-pathology.
In other words, the separation between mental and
therefore non-medical disease, and physical and therefore
treatable within medicine disease, shaped the separation of
psychiatry from neurology, turning psychiatry into a mere nursing
specialisation. This process is not a simple labour separation
process, as the epistemological bases of both of the fields were
deeply affected by this psychophysic separation. One of the
effects is the large group of psychiatrists leaning towards new
psychoanalytical stances, growing apart from the medical model
that has excluded them and marginalised their practice. Early 20 th
42
-
8/2/2019 PHD ALL R1
43/215
Sky E. Gross
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 persistin its search for the organic and neurological bases of mental
illness. While the former abandoned any aspirations regarding the
integration into the more mainstream medical model, the latter
will strengthen its efforts to differentiate itself from the
'philosophical therapy' to resemble a more scientific model of
medicine. This quest will be the main drive of psychiatric research
into organic-based cures to mental illness, cures that were
believed to be able to form a bridge over the ever growing gulf
between psychiatry and neurology.
Thus, the areas of professional jurisdictions gradually aligned
themselves around a distinct, though implicit, principle: the
gnostic split. While neurology adhered to purely scientific
ontognosis, psychiatry remained in an awkward position: treating
psyche-related illness, yet holding on to an organic epistemology.
Psychiatry suffered from a lack of clarity as to its basis of
legitimacy, hanging in the midst between ontognostic and
phenognostic grounds, leading to a severe identity crisis present
to this day (Armor and Klerman, 1968; Torrey, 1975; Light, 1980;
Merino, 2000). At the time, however, relentless efforts were made
to medicalise (and thus 'truthicise' or 'make true') psychiatry.
Psychosurgery stood at the very centre of this task.
Building the Heroic Ethos
"Doctors are different in nature. One kind
adheres to the old principle: first do not
43
-
8/2/2019 PHD ALL R1
44/215
Black Butterflies
harm; The other one says: it is better to do
something than nothing. I certainly belong
to the second category". (Gottlieb
Burckhardt, lobotomy pioneer)
This statement raises one of the central points contrasting
the Hippocratic notion of medical ethics with the kind of ethic
proclaimed by psychosurgeons. The 'primum non nocere ' principle
cannot hold in the face of horrifying mental suffering, and
Burckhardt, Moniz, and others felt they 'had to do something'. This
'something' took form in what was to become the psychosurgical
intervention.
While one can place some of sciences legitimacy within the
ethos of a pure and disinterested search for Truth, the mere
practicability and applicability of a scientific development may be
of no lesser significance (Gieryn, 1983, 1999). In practice, early
20 th 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 medicalpractice: the holding of measures that were both heroic and
therapeutic.
The Founding Tale
"For the physical therapy of mental
disorders they [the neuropsychiatrists] hadthe malaria treatment of neurosyphilis and
44
-
8/2/2019 PHD ALL R1
45/215
Sky E. Gross
prolonged sleep. Electroencephalography
was in its infancy, shock therapy by insulin
and metrazol almost coincided with
leucotomy, radioactive isotopes wereunknown, and control of the autonomic
system by pharmacological means was just
beginning. The introduction by Moniz of
cerebral angiography in 1927, and of
psychosurgery in 1936 brought about a
revolution in diagnosis and treatment, the
eventual extension of which is not yet in
sight". Freeman (1956:771).
An examination of the founding texts reveals that
psychosurgery's quest for scientific legitimacy involved a
rhetorical portrayal of the practice's bir