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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

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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

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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

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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

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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

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cultures, whether defined as based on national aspects, religious

beliefs, gender attributes, social stratification, etc. There is,

however, one important institution, which can be said to hold

greater homogeneity in respect to its epistemological 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.

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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

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presentation of the methodology will be presented in each of the

three chapters, thereby avoiding redudancies and repetitions, as

well as making the compatibility between the work and the

methods explicitly evident.

Surgeons of the Mind

The first paper will serve as theoretical grounds for the

overall analysis proposed in this work. Thus, although heavily

drawing on philosophical insights, its aim will be to build a

framework for a social study of knowledge. In this, I will suggest a

conceptual framing whereby modern Western biomedical practice

and research sees two forms of knowledge coexist and fight for

authoritativeness: phenognosis (knowledge based on subjective

experience) and ontognosis (knowledge based on the enquiry of a

world-out-there).

Drawing on philosophical and theoretical insights from recent

works on discourse, the body, and social studies of medicine, this

paper will propose an analysis raising cultural aspects of 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

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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

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temporal dimension, and defining the discrepancy itself as a

diagnostic sign ( e.g. the degradation or amelioration of the

disease); Negotiation: adjusting diagnoses via a preliminary

exchange between experts and a consequent 'fine tuning' of 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

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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

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dimension; Matter has proper characteristics and attributes, such

as colour and shape; Matter is public and accessible to all,

including to scientific observation. The mind, in contrast, will have

no spatial extension, no attributes, and exists in the private 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

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dualism, or non-interactionism). This 'identity theory' will have

mind and body as two manifestations of the same phenomenon

thereby not claiming for a duality of substances but for a duality of

properties. 'Mind will appear when the question is 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.

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Spirit cannot affect matter and matter cannot affect spirit.

In order to make have these assertionsthem 'make logical

sense', one would have to give uprelinquish at least one of these

assertions. This is, in the broadest terms, the basis for the

different philosophical approaches described earlier:

The body would not be material (idealism);

The mind would be material (materialism);

Mind and body would not interact (non-causal dualism: e.g .identity theory, or ephiphenomenalism);

Spirit can affect matter and vice-versa (causal

interactionism).

With the development of modern science, idealism has lost

most of its vigour. With the evolution of experimentalism and the

focus on pragmatism in the development of technologies,

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

less or more extreme version seemed to have led 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

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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

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knowledge (observed), or between subjective and objective

knowledge (Ornstein, 1972; Young, 1990). This 'hard' problem

rightfully earned its appellation. The subjective/objective split

presupposes a form of consciousness encompassing a set of 'truths' (often referred to as qualia ) inaccessible to scientific

inquiry: the sight of the colour red, the sensation of an itching toe,

or a tooth ache which whose actuality could never be disputed by

a dentist. Arguably, no progress of science will ever allow being,

feeling, or aching in the place of another, and no map of the brain,

however elaborate, will be able to convey subjective experience

(Damasio, 1994; Edelman, 2000; Searle et al. , 1997). As Nagel

(1974), in his famous article "What is it like to be a Bat?"

eloquently notes, true knowledge of 'what it is like' is an

epistemological privilege reserved to the sentient subject, i.e ., to

the bat itself: Only a bat would know 'what it feels like' to see with

sounds, and only a particular bat would know what it feels like to

be this particular bat (Jackson, 1982; Heil, 1988; Gertler, 2001).

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

site where one turns acquired knowledge (of the world, of oneself)

into which he/she will define and often declare to constitute the

'Truth',. This, regardless of whether the source is the world-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.

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

materialistic approach to the easy problem portraying the world

as essentially material. With phenognosis, on the other hand, I will

adopt the notion of experience as addressed in the context of 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

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machine' it is rather the experiencing, first-person, faade of the

machine. While the body may be without mind, the mind cannot

be without body: both empirically and philosophically, perception,

action, cognition, emotion are all 'embodied phenomena'.

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

the organism: it keeps the visible spectacle

constantly alive, it breathes life into it and

sustains it inwardly, and with it forms a

system" (Merleau-Ponty, 1945 in Lanigan,

1995a: 203).

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

while the body may be regarded as a mere physiological and

natural entity (an 'objective body'), it will, once experienced, turn

into a 'phenomenal body'- unified with (rather than distinct from)

this physiological entity. The phenomenal body, thus, must be

viewed as one with the objective body: experience is experience

of the body, rather than an entity IN the body.

Social Studies of Medicine and the Body

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

have taken up these leads and engendered considerable research

on the existential and phenomenological groundings of the self

and its relation to 'the body'. This was associated with an 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

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understood from the standpoint of bodily being-in-the-world."

(Csordas, 1994:143).

Along tangential lines, feminist literature took on the task of

revealing conflicts between sentient knowledge on the one hand,

and biomedically based knowledge on the other, often relating

epistemology to constructions of gender ( e.g. Root and Browner,

2001). According to these views (which were generally put under

the umbrella of a 'sociology of the body'), culture, as a system of

thought both external to the individual and concurrently present

within the individual, represents the body in a way that is socially

contingent (Martin, 1994). While agreeing with this basic premise,

scholars of 'embodiment' will claim that the sociology of the body

does not take into account the lived-experience of the body, a fact

that eventually only reinforces ideological and political dualisms.

In relation to the context of gender, these very works will be

claimed to adopt a 'mentalist discourse' (seeing 'mind' as being

superior to 'body') by which men are the 'mind', that is, related to

public realm, while women are the 'body' and belong to the

private sphere (Williams and Bendelow, 1996; Webb, 1998).

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

Crossley, 1995; Turner, 1996; Lupton, 1994; Williams, 1996) have

shown how much 'we are our bodies' and how much of the 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

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and nature to a way of living or inhabiting

the world through one's acculturated body."

(Csordas, 1994: xiv).

Overall, while ascertaining the presence of epistemological

conflicts in micro-settings where third-person and first-person

views collide (IT vs. I), even these 'embodiment'-oriented

undertakings showed little concern for the changing hierarchies

between the two forms of Truth (subjectively experienced vs.

objectively accountable) as broad discursive forces. For instance,

while Turner (1992) brings up the distinction between leib (the

lived body) and korper (the physiological body), he uses it as to

show the preciousness of the leib over the korper as a source and

grounds for culture. Still, the relationship between the two as

'Truths' is never analysed as such.

Throughout this work, I will seek to provide such a

complementary outlook, using Foucaults (1986) notion of

discursive practices as entailing human desire for 'Truth' about the

world and about the self. In an attempt to do so, I will first propose

a theoretical framing and then attempt to work the theory into the

canvas of the social settings from which individual cases were

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

room.

The Discourses of Truth: Foucault and Beyond

Biomedical and scientific discourses generally comply with

ontognostic views whereby Truth would be accessible through the

unravelling of the world of material essences. Medical knowledge

is essentially of a reductionist nature, paying little or no attention

to the subjective aspects of disease. This ontognostic

epistemology is, in turn, associated with the foundation of apowerful ethos, the establishment of an authoritative system of

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rhetorics, and the drawing on highly evocative symbolic elements -

all of which serving to support its discursive supremacy.

Biomedicine has had indeed notable success in achieving this

demarcation as highly respectable, trustworthy, and distinctive

from other social spheres, such as religion, politics, and economics

(Gieryn, 1983, 1999; Mizrachi et al. , 2005). This distinction persists

within a particular power structure where a hegemonic regime of

truth is established, defining the forms of knowledge considered

admissible while dismissing competing claims for Truth (Foucault,

1972, 1980, 1986; Armstrong, 1983). This will ipso-facto place

non-scientifically based knowledge including phenognosis - in a

subordinate position (Foucault, 1982). Phenognosis, however,

should not be seen as comprising mere 'leftovers' of this

biomedical ontognosis. When considering the development of

post-modernism, the linking of subjectivity with power relations

will reveal that it may indeed constitute a rising discursive force.

In the 1979 Stanford Lectures, Foucault stated that what

troubled him since his first book was:

"In what way are those fundamental

experiences of madness, suffering, death,

crime, individuality connected, even if we

are not aware of it, with knowledge and

with power? I am sure I'll never get 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

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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

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(and in general culture, most particularly in art and literature), to

pave the way toward a destabilisation of the grounds upon which

ontognosis drew its force. Grand ontological and metaphysical

accounts lost grace to local, negotiated, and provisional forms of knowledge, thereby allowing experience to ascend as a legitimate

source of Truth.

Still, although overwhelmingly rooted in phenomenological

thought, more radical postmodernism will reject the whole idea of

Truth, including if ever considered - phenognosis (Bourdieu,

1992; Dickens and Fontana, 1994). Thus, while postmodernist

thought may have notable affinities with ideas associated with the

concept of phenognosis, one cannot stress enough the

distinctiveness of the two worlds of notions, whereby stands the

value of the proposed reconceptualisation. This issue shall be

clarified as this analysis develops.

Introducing Replicated Boundaries

The reconceptualisation of the mind-body conundrum will

serve to assert the sociocultural correlates of the philosophical

problem, both at the macro-level and at the micro-level, both

synchronically and diachronically. This work has led to the

formulation of a theoretical framework for the understanding of

such processes: the definition of replicated boundaries.

The Gnostic Split and Replicated Boundaries

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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

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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

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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

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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.

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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

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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.

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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.

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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

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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;

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Huynh-Dornier, 1992; Snaith, 1994; Berrios, 1997; Sabbatini,

1997).

Browsing through the literature, one typically finds depictions

of the debate assuming an evolving movement from an inferior to

a superior moral and ethical world (accepting and then rejecting

the technique), from inferior to superior technology (the use of

better instruments), and scientific understanding (knowing more

about the brain). This will eventually represent psychosurgery as a

mere by-product of a darker era in medicine and psychiatry. Here,

I will seek to portray psychosurgery as neither justifiable nor

condemnable, and will insist that the procedures ascribed

legitimacy is in line with other sociocultural developments, namely

specific epistemological shifts. I will propose a more

contextualised, less presentist view, which will describe not just

past-proponents but also contemporary critics arguments as

equally contingent upon the particular Zeitgeist within which they

took form. The focus will be thus on transitions in the depiction

rather than usage -- of the procedure, and on broad

epistemological --rather than mere technological -- aspects of

these developments. Indeed, while historical accounts of the

technological and scientific contingence of the abandonment of

psychosurgery ( e.g. reference to the introduction of drug therapy)

may account for the decline in the use of the technique, they offer

little to the understanding in the shift in the debate itself and the

values it brings forth. True, lobotomy may have lost its place to

psychoactive drugs, yet debates over its legitimacy morally,

ethically, epistemologically carry on, a fact which cannot be

explained away by the pointing to scientific advances. I suggest

the story must be told otherwise.

On Psychosurgery

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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

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would consider it unethical not to propose lobotomy to some

patients. In fact, both asylum psychiatrists and neurosurgeons

viewed it as no less than a breakthrough in the scientific

understanding of the mind. By 1960, tens of thousands of psychosurgical interventions were conducted worldwide, most

particularly in the US, but also in Continental Europe, the UK, and

Japan (Hirose, 1972; Donnelly, 1978; Kucharski, 1984). Between

1942 and 1954, 10,365 were counted in the UK. Until mid 1941,

more than 18,600 operations were performed in the US (Swayze,

1995). Globally, according to Silverman (2001), since 1945 the

number of lobotomies doubled each year: from 240 in 1945, to

more than 5,000 in 1949.

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

between 1942 and 1954 shows that 41% were fully cured or

greatly improved, 28% had little improvement, 25% seemed not to

be affected by the operation, 2% saw their symptoms aggravated

and 4% would die as a result of the procedure. Indeed, a great

part of the studied literature shows a distribution of approximately

a third of 'favourable' results (where symptoms disappeared

altogether or at least greatly improved), a third of 'medium'

results (where some improvement can be observed) and a third of

failures (no change, or the patient's condition has worsen). Still,

and although already in the 1930s most professional widely and

openly acknowledged the ill effects of the operation, both

physicians and family members tended to consider the

postoperative patient as better off, or even cured.

Essentially, psychosurgery offered a source of hope for the

deliverance of the mentally ill from the misery of their existence.

This enthusiastic embrace, however, soon waned. By 1960,

psychosurgery did not only lose grace, but also acquired a

gruesome image as one of medicine's darkest episodes. Fewer

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and fewer neurologists showed interest in the technique, research

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

of mental asylums. From a symbol of scientific progress,

psychosurgery came to be regarded as the craft of mad 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,

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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.

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This report led to the more ambitious (and controversial)

experiments of Gottlieb Burckhardt, the head of a large Swiss

mental asylum. He put forward the idea that the creation of a

barrier -in the form of a surgical cutting through nervous tissue -between the cortex (conceived as responsible for the reception

and processing of sensory information) and the lower areas of the

brain (the 'motor areas') will relieve some of the pathological

behaviour of mental patients: and most particularly, behaviour

that involved the patients lack of control over themselves (Stone,

2001).

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

dangerous and difficult " patient of the asylum. This 51 year old

woman, diagnosed with schizophrenia, was impulsive and violent.

She has been hospitalised for the last 16 years, mainly in isolation.

She once almost strangled to death one of the nurses, and did not

seem to be responsive to any kind of treatment known at the time.

Suffering from chronic diarrhoea and of a lack of proper hygienic

manners, she had to be assigned with two nurses around the

clock. She was particularly difficult to maintain under control as

she spent many of her days screaming in the halls of the asylum.

Burckhardt (1890, in Stone, 2001:83) then began to wonder

whether it would make any sense to:

"extract this impulsive emotional element

from her brain mechanism, 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:

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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

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I shall claim here that the boundaries created between

neurology and psychiatry represent replicates of layers of broader

sociocultural boundaries in Western thought: the boundaries

between objective and subjective. They reassert an ethos, a 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

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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

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century saw two groups of psychiatrists beginning to emerge:

while the more psychoanalytically-oriented would insist on a

'psychogenetic' (originating from psychological processes)

explanation of mental illness, another substantial group will 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

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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

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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