The Manufacture of Bodies in Surgery Author(s): Stefan Hirschauer Source: Social Studies of Science, Vol. 21, No. 2 (May, 1991), pp. 279-319 Published by: Sage Publications, Ltd. Stable URL: https://www.jstor.org/stable/285264 Accessed: 16-09-2019 07:19 UTC

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This content downloaded from 134.93.236.161 on Mon, 16 Sep 2019 07:19:06 UTC All use subject to https://about.jstor.org/terms * ABSTRACT

This paper presents an ethnographic account of surgical operations as encounters of two disciplined bodies - a parcelled 'patient-body" and an aggregated 'surgeon-body'. It describes the practices of making bodies operable, of cooperating and of creating anatomical visibility by means of highly skilled manipulations and optical technology. The discussion relates features of surgical practice to two issues raised in science studies: (1) Ritual aspects of scientific work; how does a medical science deal with the life- world esteem for its object?; and (2) The relation of experience and representation; how do patients' bodies come to embody the properties of anatomical pictures? A constructivist interpretation is offered: the anatomical body is an accomplishment of the sculptural practice of operations.

The Manufacture of Bodies in Surgery

Stefan Hirschauer

The ethnographic and constructivist approach in social studies of science has so far mainly dealt with experimental natural sciences.1 Observational studies have investigated scientific practice within its social situatedness in the laboratory. This article focuses on an applied science which studies and treats human beings: surgery.2 It presents empirical results of an ethnographic study of surgical operations,3 in the form of a 'thick description'.4 This description tries to provide an insight into a situation in which a subtle manipulation of a material object (the human body) is accomplished in a close cooperation of highly skilled and technologically supported specialists, who together aim to enhance the visibility of the object. The description brings several points into focus which can be compared to features of experimental sciences. One question con- cerns ritual aspects of scientific work: how does a medical science deal with the life-world esteem for its object, which precludes that 'sacrifice' of bodies, which has been described for experimental

Social Studies of Science (SAG E, London, Newbury Park and New Del hi), Vol. 21 (1991), 279-319

This content downloaded from 134.93.236.161 on Mon, 16 Sep 2019 07:19:06 UTC All use subject to https://about.jstor.org/terms 280 Social Studies of Science sciences?' The handling of human bodies should require more continuity and more discontinuity to practices in everyday life. Another point concerns perception in surgery. In a recent article, Bryan Turner attributes the historical growth of anatomical know- ledge to the empiricist rigour of Vesalius and his followers: 'a revolt against Galenic deductivism'.6 In contrast, to Bruno Latour, 'science' begins with a turning away from direct observation to a preoccu- pation with extracted representations: 'If scientists were looking at nature, at economics, at stars, at organs, they would not see anything.'7 Instead of choosing one of these alternatives, we can better approach surgical perception by taking up a question Michael Lynch has raised: 'How do graphic properties merge with and come to embody the "natural object"?'8 Lynch describes how in the laboratory 'natural objects' (rats) are assimilated to the properties of an image-medium by making these properties crucial for the selective perception and manipulation of 'natural objects'. In surgery, of course, it is not 'docile images' (that is, data), but the practical use of images (anatomical drawings) in the production of 'docile bodies', that is at stake. So one has to follow another aspect of 'merging': the re-assimilation of 'natural objects' to images already produced. How do patients' bodies come to embody the properties of anatomical pictures? Concerning this question I propose that the authoritative facticity of the anatomy atlas is an accomplishment of the sculptural practice of surgery.

Approaching Surgery through Discursive Phenomena

A first way to approach the events in operating theatres is to look at the topics of the most important studies.9 Observational studies of operating theatres are surprisingly rare. In the context of his theory of role distance, Erving Goffman studied the operating surgeon's jocular presentation of self as a means of making subordinate members of the team accept the surgical hierarchy, and thus become part of an 'activity system'. J. Cassell, too, dealt with the relationship of the surgical profession to the surgeon as a person. She analyzed the personality traits and the professional 'ethos', the standardized emotional stances which the surgeons' work requires: certitude, resolve, arrogance and courage. Finally, Pearl Katz approached the operating theatre from an ethnological point of view and studied in great detail sterility procedures as rituals, which contribute to the

This content downloaded from 134.93.236.161 on Mon, 16 Sep 2019 07:19:06 UTC All use subject to https://about.jstor.org/terms Hirschauer: Manufacture of Bodies in Surgery 281 technical functioning of operations by clarifying the categories clean'/'dirty'. A second way of approaching the events in operating theatres is to look for surgical self-descriptions in books and articles or in interviews. Most written texts describe operating methods. In these descriptions, the persons of patient and surgeon seem to be absent from the events: in place of the patient, there are terms for organs, and instead of the surgeon a multitude of practices, which 'take place' or are 'carried out' in a particular sequence and with particular instruments:

Access is achieved via the perineum by means of a longitudinal incision in the raphe of scrotum. Both testicles are exposed and, after following the spermatic cord up to the anulus inguinalis superficialis, they are severed using clamps, with ligation of the spermatic cords

The anonymity of these practices, and the exclusive appeal to technical rationality, stand in contrast to the topics of the observa- tional studies: rituals and persons. In interviews I conducted with surgeons, the personality also appeared to be of only some anecdotal interest. It is, from the point of view of surgeons, a marginal topic. Two types of metaphors, which frequently appear in surgical self- descriptions, indicate surgical relevances. In a historical account, a surgeon describes four prerequisites of surgery as science:

1. anaesthetics, operating in an area free of pain; 2. asepsis, surgical action in a sterile field; 3. stypsis, and thus intervention in a preferably bloodless space; 4. strictly detailed systems of localization and a wide-ranging topographical anatomy, which enabled us to have a new overall view of the ground, the terrain of the operation."

The author writes that when asepsis had been established historically, 'the departure was sounded for the general attack on the large cavities of the body: truly a storm on heart, belly, brain! The heroic age of surgery had begun'.'2 Such affinities to military language are also present in basic terms of surgery such as 'tactics', 'invasive methods', 'invasion of germs'. And, of course, an 'operation' is also a 'planned movement of one side, limited in its goal, duration and space, mostly related to fighting'.'3 Another range of metaphors is derived from sports. In interviews, surgeons talked of the 'operating team', which should have the right 'team spirit', and of their 'daily form', which could depend on the amount of sleep they had had. Smirking, a surgeon assured me that a

This content downloaded from 134.93.236.161 on Mon, 16 Sep 2019 07:19:06 UTC All use subject to https://about.jstor.org/terms 282 Social Studies of Science five-hour operation was definitely a 'marathon'. An assistant was complaining of aching muscles: 'And then you're hanging on such a retractor for eight hours'. But she also said, 'That gives you some idea of what a body can endure'. Cassell quotes one surgeon as saying that 'surgery is a body contact sport', and another compared the permanent need for decision-making during an operation to a cyclist's need to keep in motion.'4 Cassell also refers to the specific 'thrill' of an operation: as during a match, the pulse-rate goes up and then falls again. The limitations of these metaphors are immediately obvious. Even though surgical, like military, operations are a matter of life and death, in surgery both sides agree that the patient's body shall be kept alive. The patient's consent in writing is not a declaration of war, and the 'invasion' is not a sudden attack but a controlled advance, trying to grasp organs as selectively as possible, especially in 'sparing' (schonendem), operating in the right layers. But the metaphors also have a core which can be of use for an apt sociological description of operations: it is the antagonism of bodies and the relation offorces of two sides which they emphasize. In what follows, I take up this trail. I do not claim to represent the participants' perspective in an unbroken way. I was neither in the surgeon's nor in the patient's position, and both are for different reasons very bad informants during an operation. So my point of view is a mixture of non-participant observation and a dual anticipation: an attempt at taking over the surgeon's view of the body, and a fantasy on what the patients would tell us if they could. The limitation of participation in surgery also has methodological advantages. As an observer, I was neither under anaesthetic like the patients, nor like the surgeons, whose concentration on the area of operation and dull daily routine seems to have put them under local anaesthetic towards many sensorial impressions in the operating theatre.'" When I describe them, too, as bodies, it is an attempt at filling the gap between surgical texts and observational studies by consistently applying the surgeons' point of view on themselves. The structure of my description is guided by the observation points in the operating theatre and in the operating department. I follow the surgeons through the scrub room and the patients through the preparation room. Then I surround the area of operation, and together with the anaesthetists I take over the patient's perspective. After this, I observe the operating team from an external point of view and finally, together with the surgeons, the area of operation. When the operation

This content downloaded from 134.93.236.161 on Mon, 16 Sep 2019 07:19:06 UTC All use subject to https://about.jstor.org/terms Hirschauer: Manufacture of Bodies in Surgery 283 is over, I look back in a more interpretive way on the described course of events. This is at the same time a look across the boundaries of the operating theatre: on how surgical practice is embedded in everyday rituals, and on the construction of the anatomical body.

Bodies in Preparation

The Locale

Operating departments in a clinic are located on a separate floor or section of a floor. Some can only be entered by passing through an air lock installed to keep out germs. The first door only opens when the second is closed. One then passes through the staff lock (Personals- chleuse), consisting of two rooms for dressing and undressing, respectively, and reaches a corridor. Instead of patients in morning gowns, nurses in blue and doctors in white coats, which are typical of the long, white corridors on the ward, here the sight is dominated by

FIGURE I Operating Table from the Beginning of the Twentieth Century

Note: Reproduced with kind permission of the Deutsche Museum, Muinchen (picture no. 44902).

This content downloaded from 134.93.236.161 on Mon, 16 Sep 2019 07:19:06 UTC All use subject to https://about.jstor.org/terms 284 Social Studies of Science uniformly muffled figures. Various rooms border on the corridor: a kitchen and a lavatory for the physical needs of the staff members, preparation rooms for narcotizing the patients, a recovery room, the operating theatres, scrub rooms in front of them, and occasionally a small laboratory for pathological and haematological analyses during the operation. The operating theatre is shielded from the world outside by heavy sliding doors and frosted glass windows. It contains fixed elements, like an intercom, fluorescent screens for X-ray plates, small cup- boards or shelves with dressing material, linen and instruments, as well as various supplies of electricity, compressed air, vacuum, laughing-gas, and so on. However, most items are mobile (for example, fitted with castors): the jack for the 'workbench', the operating table, in the middle of the room, above it the swivel lamp with several jibs, the trolleys with instruments, the respirator, the rubbish bin, the suction machine with its collection vessel for blood, the stands, the X-ray apparatus, the cold-light generator and the coagulator. Nurses and orderlies equally mobile are assigned to the operating theatre on a daily basis. This collection of materials, technology and staff is the infra- structure of operations, to use a military term: their logistics. Painstaking cleanliness is part of it, too. The operating theatre is protected from germs by a special filter in the air-conditioning system, and it is disinfected after every operation. The degree of sterility increases from the periphery to the centre both of the operating theatre and of the whole department. Accordingly, bodies moving towards the centre are also subject to the rule of asepsis. To achieve this, they are transferred to a state of disciplined and visually reduced appearance.

Turning the Surgeon into an Instrument

The surgeons reach the operating theatre through the staff lock and the scrub room. Stripped down to their underwear, they step in front of a connecting door, which can only be opened after cleaning one's hands with the disinfectant dispensed next to it. The parts of the uniform worn by everyone working in the operating department lie in sterile wrappings in the dressing room: blue linen trousers and short- sleeved shirts, blue slippers and green masks for one's mouth and nose as well as some headgear: ordinary caps for women; helmet-like

This content downloaded from 134.93.236.161 on Mon, 16 Sep 2019 07:19:06 UTC All use subject to https://about.jstor.org/terms Hirschauer: Manufacture of Bodies in Surgery 285

caps, which may also cover a beard, for men. The mask is tied behind one's head with a bow - a somewhat difficult operation on one's own body for the unpractised. Behind it one is at the same time hidden in an enclosure, which reflects the sound of one's breathing and speaking, and exposed through the nakedness of one's eye region. This ambivalent condition leads to a certain isolation of oneself. The disinfecting measures on the bodies of those working at the operating table continue in the scrub rooms. Instructions for the cleaning ceremony hang above the wash-basins. They prescribe five stages of cleaning, which involves various substances and cleaning techniques. Forearms, hands and fingernails have to be cleaned and disinfected for seven minutes altogether. The surgeons turn off the water and open the door to the operating theatre with their elbows, holding their forearms helplessly upright and away from their body and other non-sterile objects. In the operating theatre, nurses help the chief surgeon and the escorting assistant surgeons into their operating coats, which also cover their arms, and slip the light-coloured gloves over their hands. If surgeons, like nurses, do this by themselves, they take care to touch the first glove only from the inside, to avoid making it non-sterile with their still uncovered hand. They also avoid touching the sterile outer side of their coats. Sleeves and gloves must not be adjusted before they are wearing both gloves. This gear can be complemented by green paper aprons, if the operating gets 'moist' (that is, -especially bloody), or by leaden X-ray aprons, which are worn under the gowns. At the end of the dressing procedure, the bodies of those operating are largely muffled up - that is, visually reduced to the light gloves and the region of the eyes. One must learn to identify them as individuals by their eyes. Most of the naked skin visible in the operating theatre belongs to the uncovered hands and arms of the 'jumpers' (Springer). Unlike scrub nurses, they do not stand at the instrument tables, but move in and also outside of the operating theatre doing ancillary jobs. In contrast to the jumpers, the surgeons' mobility is restricted: once started, they cannot so easily leave work; they are almost tied to the patient's body, stand next to it rooted to the spot, only occasionally switching their standing leg. Besides, they have to keep wearing the heavy leaden aprons during the whole of an operation requiring radiography, whereas jumpers can take them off. The surgeons' mobility can further be hampered, when they stand hemmed in between equipment at the operating table. For example, a jumper has to release them from a position between respirator, coagulator and

This content downloaded from 134.93.236.161 on Mon, 16 Sep 2019 07:19:06 UTC All use subject to https://about.jstor.org/terms 286 Social Studies of Science the patient's body, before they can examine something under the microscope. For phone calls, too, nurses are sent as 'messengers'. But the surgeons' independence is not only restricted because they cannot move their body on their legs so freely any more; they are also denied various manual manipulations concerning their own body. They depend on others for swabbing sweat off their forehead, for 'feeding' with glucose when their blood circulation threatens to collapse, if blood splashes soil their mask and eyes and have to be dabbed away, and if glasses have to be adjusted or complemented by a magnifying device. In all these cases, a nurse's hands replace the operating tools extended from their bodies. When a nose or back itches, it shows how difficult it can be to explain something to a strange hand. The rules of asepsis distinguish two types of hands in the operating theatre: those whose owners are constantly taking care not to touch something non-sterile (stands, X-ray apparatus, parts of the patient) and, conversely, hands of participants who are on their guard not to move too close to the sterile zones around the patient's body and to contaminate them. The aseptic disciplining of the surgeon-body puts it in a state in which it becomes a suitable instrument for gaining access to the patient's body. The restricted mobility resembles the effect of wearing a diving-suit on shore or a spacesuit on earth. The specific medium the surgeon is rigged out for is sterile space.

Turning the Patient into an Object

Preparing the patient-body consists of disciplining it to become immobilized, and of reducing it visually to its relevant parts. The patients are washed, purged and clothed in a white gown on the ward. They are wheeled in their beds to the operating department by orderlies, and are channelled through the preparation room into the operating theatre. They will usually-look around apprehensively and are greeted in a friendly way by nurses introducing themselves by first names. In the beginning, the induction of narcosis is a two-layered business. Nurses and anaesthetists talk to the patients, asking them questions, calming them down, explaining, asking and requesting things: 'you'll just feel a prick, don't pull away, please'. Busy handling of the patient-body and of the technical equipment accompanies the talking.16 Wedge-shaped bolsters are pushed under parts of the body, the pulse is taken and noted down on the pillow with a pencil. The

This content downloaded from 134.93.236.161 on Mon, 16 Sep 2019 07:19:06 UTC All use subject to https://about.jstor.org/terms Hirschauer: Manufacture of Bodies in Surgery 287 patients are asked to climb from their bed on to a wheeled stretcher, which will later become the operating table. They are told to take an arm out of their gown and to put it on the armrest. They receive explanations as to why cannulae are inserted at the wrist and apologies for the pain it causes. This handling-and-commenting resembles a feature of medical examinations, which Katharine Young called an 'etiquette of touch'. '7 It makes possible and limits a 'dislodgement' of the patient's person from his/her body. In the preparation of narcosis, this dislodgement seems to happen to a larger extent, because the 'absence' of the patient is anticipated. Anaesthetists often talk to patients in an unnecessarily loud voice - as opposed to talking among each other as if they were already narcotized and therefore difficult to reach acoustically. Apart from this, the anaesthetists are often under pressure of time because the surgeons have already finished washing themselves, and for this reason may scarcely wait to see if patients have understood an explanation. So the handling of their bodies mostly remains incomprehensible to the patients. They are at the same time the centre of the situation and 'offside', and they can do nothing but give in to the take-over of their body. A patient said, conscious of her 'guilt', 'My pulse must surely be too fast'. The anaesthetist soothingly replied, 'Why should I get a racing heart?!' With a patient who was in fact hard of hearing, the following dialogue developed: one anesthetist asked 'May I just bend your arm over?' The patient did not understand her, and a second anaesthetist cracked a little joke, saying 'no'. Narcosis can be induced step by step, and can comprise a sedative premedication (administered on the ward), an injection and the inhalation prior to the intubation. The last words spoken to a patient are demands to breathe deeply, announcements like 'you'll slowly get tired now', and perhaps some kind of farewell like 'so long'. Then the layer of soothing talk disappears and only the cool grips are left. They can now be performed with increased speed and efficiency. 8 A kind of gestalt switch then occurs: as soon as the patients (as persons) are 'gone', the talking breaks off, the anaesthetist presses the respiratory mask on to the face, removes it after a short while, pulls back the head with a jerk, shakes the jaw, pushes the hook-shaped laryngoscope into the throat and the airway into the windpipe, so that its end extends from a corner of the mouth. While this is done, the patient- body is often jerking and writhing. What has not yet been done can now be carried out without time-consuming explanations: the tubus

This content downloaded from 134.93.236.161 on Mon, 16 Sep 2019 07:19:06 UTC All use subject to https://about.jstor.org/terms 288 Social Studies of Science is stuck to the cheeks with plaster or fixed with a leather strap, similar to a gag, the shirt is taken off, the legs are strapped on, a catheter is introduced, electrodes for the ECG are attached to the chest, small wet cloths are put on the eyes, an arm is shifted, the head is moved up again. Then the operating table with the patient-body is escorted by the anaesthetists and the respirator to the operating theatre and slid on to the jack. Further connections are sometimes laid in addition to the two cannulae in the arms: a cannula into the neck if a considerable loss of blood is anticipated a tube through the nose into the stomach so that during major abdominal operations the stomach does not distend and can empty itself through this exit. The surgeons may demand a different position of the patient-body. Then the limp and heavy body is adjusted in all directions: it is moved to the side or pulled towards the lower end of the table, and the open legs are hoisted up in slings. Once the patients are 'introduced', they are no longer talked with but, at most, talked about. They are represented linguistically by their names, which are stated together with age, diagnosis and operation in the narcosis records, and sometimes written on adhesive tape stuck on to the shoulder of the patient-body. One can come across it there as accidentally as one can read the name of the respirator: 'Sulla 808 V'. 'What's his name, by the way?' is not a rare question in the operating theatre. More important than this are the findings (in the form of texts and X-ray plates), which provide exact information on the patient-body. In contrast, reference in speech to the patient's person is of a strangely indefinite kind comparable to our style of talking about a third party without being sure s/he is out of earshot."9 Once the patient is reduced to a body, positioned and connected, this body is, in turn, reduced to the area of operation. Marked off sections and alienating covers intended to ensure sterility create a visual disfigurement of the body's gestalt. Around the planned incision the skin is thoroughly disinfected; so a belly may be coated with wide strokes or a vagina painted inside with soaked cotton-wool held by a pair of metal forceps. The colour of the skin is turned a strange orange-brown. Next, a rectangle of skin is dabbed dry, and green paper towels are placed around it and affixed to the skin, thus marking the area of operation as a strip of skin. Afterwards, blue linen is spread all over the patient-body, covering everything except the area of operation. It may be fixed to the patient's skin: to the belly with a clamp, to the inside of the thighs or to the labia with needle and thread. The coverings isolate parts of the body so that an abdomen or

This content downloaded from 134.93.236.161 on Mon, 16 Sep 2019 07:19:06 UTC All use subject to https://about.jstor.org/terms Hirschauer: Manufacture of Bodies in Surgery 289 a penis is already visually 'cut out'. The orange-brown strip of skin is then covered with a transparent plastic film. This sterile second skin makes this stretch of body look like the dull surface of a plastic doll. Finally, large blue sheets of linen are stretched across the body over the breast; they visually 'cut off' the head from the trunk. These sheets are usually fastened so high up to stands that they hide the whole area of the anaesthetist as if by a folding screen. So anaesthetists and surgeons have profoundly different views of the patient. Whereas the former are normally not able to see the area of operation, to the latter the head and together with it the patient's person have finally vanished behind the screen.

FIGURE 2 The Vanishing Patient

10 11

7

12 14 9

Note: The patient is also 'gone' in this schema from a surgical textbook. S/he is referred to as No. I ('patient'), whereas No. 13 indicates the 'area of operation'; 2-6 indicate the operating staff, 7-12 parts of the equipment. Source: G. Heberer, W. Kole and H. Tscherne, Chirurgie (Berlin: Springer, 1986), 18.

Bodies in Action

The preparation of the bodies has two consequences. First, their visual shape is narrowed and they are parcelled out into regions. The disappearance of everyday bodies also implies the persons' anony- mity. Second, the bodies are partially or completely distanced from the persons and their free disposal of themselves, so that patient and

This content downloaded from 134.93.236.161 on Mon, 16 Sep 2019 07:19:06 UTC All use subject to https://about.jstor.org/terms 290 Social Studies of Science surgeon both lose autonomy and become dependent in various ways. This dependence is the basis of afunctional extension of the bodies in the course of an operation. It goes together with an increase in their physical forces, which counteracts their subjection to the effects of narcosis or the rules of asepsis. The differences in this increase establish an immense imbalance of forces: the surgeon-body, equip- ped with instruments and supported by helping hands and the technology of the operating theatre, opposite a powerless patient- body now controlled by the anaesthetists. Externalized organs support its functions, which leads to an increase in its passive forces. In contrast to this, the functional extension of the surgeon-body consists of an incorporation of executive organs, whose performance is hierarchically controlled. In view of the invasion of this 'mega- organism', the life of the patient-body seems to have retreated to the anaesthetists' side of the screen.

Anaesthetics: Defending Life

Narcotizing patients is 'controlled poisoning' (as an anaesthetist put it to me). It overcomes the resistance and vital forces of the patient- body. Consciousness and sensitivity to pain are chemically elimin- ated, the muscles' reaction of resistance to pain is forestalled, the patient-body's own respiration is blocked by the relaxation of the diaphragm and the costal musculature. A narcosis can differ in its depth, ranging from loss of consciousness over loss of sensations and relaxation of muscles to cardiopulmonary collapse. Somewhere along this line between the waking state and death is the so-called 'tolerance stage' of optimum relaxation for surgery. On the other hand, the patient-body is kept alive by the anaes- thetists, and they help to increase its resistance against the surgical invasion, or to use an expression from athletics: its staying power. To some extent, the weakened self-support of the body and the representations of itself possible in the waking state are replaced as functions and signs of life by the anaesthetists. There is an inverse relationship: in place of the patient's closed eyes others are opened; a new system of control makes up for their loss of control. The watchfulness and tension the patient-body loses is gained by the bodies of those working in the operating theatre. They are supported by its technical equipment. In contrast to the visual reduction of the patient-body under the

This content downloaded from 134.93.236.161 on Mon, 16 Sep 2019 07:19:06 UTC All use subject to https://about.jstor.org/terms Hirschauer: Manufacture of Bodies in Surgery 291 sheets, the technical equipment achieves a kind of extension into the space behind the screen. From the angle of the patient-body, the result of laying connections and of being moved around appears like this: muscles and joints, which move it and hold it together, are now located in the wheels of the stretcher, in the tilting mechanisms at the head and foot of the table, in the straps around the legs, the hinges of the armrest, the lifting mechanism of the jack, pedal-operated by the anaesthetists. The fluids circulating in the body are collected extern- ally or supplied from the outside: urine empties through a catheter into a second bladder under the left arm, the stomach through a tube in the nose into a container, blood is sucked off through a tube and flows into a vessel at the base of the head. As soon as this container is filled above a certain level, stored blood is supplied to the body through a cannula at the neck. A water bag and possibly other solutions dripping into the patient-body at its wrist are hanging above it. The lung of the patient-body is standing diagonally behind its head and breathing for it, sucking and clapping. Finally, the utterances of the body also appear isolated from it as acoustic signals emitted by the respirator or optical signals appearing on its monitor. Technically amplified, the heart of the patient-body is now flashing and bleeping. The life of the patient-body seems to be externalized and can be threatened by many errors. Somebody unfamiliar with the new boundaries of the body can endanger its life by turning switches, accidentally pulling cords and tubes off or out, or by getting too close to sheets of linen. To the anaesthetists, the signs of life indicate a patient's 'state', which has to be continually controlled to maintain the delicate equilibrium of the various circulations. Compared with the evidence of verbal exchanges, which may begin with, say, 'how are you feeling?', the body's dumbness presents a problem. The evidence of machine-produced values takes their place, supported by the evid- ence of clinical signs. The patient's signs of life are largely visualized. One has to 'keep an eye' on them. Laboratory results of regular blood analysis are presented on computer printouts carried into the operating theatre by orderlies. The monitor of the respirator shows the pulse rate, and also the jagged line of the ECG led from the patient's skin by electrodes. Besides that, there are a number of digital displays for respiratory minute volume, tidal volume, respiratory rate, lung pressure, oxygen content, and the like. One must read all these values to see how the patient is 'feeling', what s/he 'needs': water, blood, oxygen . ..

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The pulse rate is conveyed acoustically, so that its acceleration, which would indicate the patient's waking up again, is registered immediately. The continual bleeping can be adjusted to be more or less piercing, or it can be turned off altogether if the surgeons are irritated by it. In addition, the respirator sends out acoustic alarm signals if certain parameters exceed or fall below pre-set limits: if the content of oxygen is too low, the respiratory minute volume too small, the lung pressure too high. The alarm signal indicates not only a threat to a vital function but also the fading of the narcosis. It alerts the vigilant anaesthetist to restore the intermediate state of narcosis. Clinical signs, established by physical contact with the patient, complement the machine-produced values. Anaesthetists put their hand on the patient's carotid, measure the blood pressure at his/her arm, additionally listen to the pulse with a stethoscope, check the tension of the lower jaw, register a tear or groaning and check the pupils again and again. Having been asked a question about the depth of the narcosis, an anaesthetist lifted the patient's eyelid and said, 'She isn't quite asleep, they're not fully contracted yet'. Surgeons, too, can point to clinical signs with utterances like 'he's hiccuping', 'anaesthetics clearly pressing now', 'he is slow, this is just a mild stream'. Or (surgeon): 'Listen, is he getting enough oxygen?', (anaesthetist): 'Yes, he is quite pink here', (surgeon): 'Well, over here he isn't so pink rather more blue-blooded'. The patient's signs of life do not stand on their own, but are assessed in the light of anamnestic data collected before the operation. So the curve of the ECG may look fairly grotesque at the beginning, and an anaesthetist knowing the patient has no heart condition will immediately locate the problem in loosened electrodes and adjust them until the curve is 'right'. During another operation, an anaesthetist reacted to the frequently recurring acoustic alarm signal by turning it off again and again. She was irritated by it and explained, 'She is just too slow, I'd have to adjust it differently, that would make it stop bleeping all the time'. When handing a patient-body over to colleagues, anaesthetists pass on small pieces of information about, for instance, a patient being a jogger', his having had slight hypertension for three years, her problems with a certain medicine, and so on. On the basis of life signs, a narcosis is dynamically 'steered'. The respiratory minute volume is modified, atropine is injected into a cannula, the valves of the infusion are adjusted, the oxygen content is reduced after measuring the pH value, rattling is stopped with a

This content downloaded from 134.93.236.161 on Mon, 16 Sep 2019 07:19:06 UTC All use subject to https://about.jstor.org/terms Hirschauer: Manufacture of Bodies in Surgery 293 suction tube, a switch is turned to allow for more voluntary ventilation of the patients themselves. As with the use of the stethoscope, anaesthetists sometimes prefer to use their hands when dealing with respiration. Especially at the beginning and at the end of the narcosis, 'when the patient is coming round', they make use of a pair of hand-operated bellows. The patient-body is then directly connected to the activity of the anaesthetist's body. Anaesthetists breathe with their hands for the patient. In dramatic moments, when life is about to disappear completely and mouth-to-mouth resuscitation becomes necessary, they even do this with their own lungs. Monitoring a machine, which itself monitors the body functions; being alerted by this same machine and by the surgeons; and in turn alerting them: the anaesthetists form a central element in a system of surveillance which defends the patient's life. They appear as inter- mediaries between patients and surgeons. Their dual task consists in keeping the patient-body alive and maintaining its functional interconnectedness against the surgical separations, but also in removing as many expressions of life as possible for the surgeons because they would obstruct these separations. The narcotic discip- lining of the patient-body makes this work easier, too. It is particularly beneficial to proper and calm incisions. The patient- body's fidgeting would make this altogether impossible, and scream- ing would strain the already tensed nerves of the surgeon-body. But even such remaining expressions as hiccuping, jerking and pressing have to be countered by the anaesthetists. They hand the patient- body over to the surgeons and present an efficient and suitable object to be operated on.

Cooperating as a Surgeon-Body

The number of people present (and awake) during the operations I observed varied between five and nine, not counting mere onlookers attracted to spectacular operations. Some jumpers only entered the theatre to perform a few tasks, and then disappeared again. The assistant and the instrument nurse were also exchanged in the course of longer operations. For anaesthetists, this was possible when the patient was 'gone': a change of staff in the presence of the body seemed easier than in the presence of the person. The spatial distribution of the various persons depends on the

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patient-body, brought in position in the middle of the room. The bodies are placed and moved in relation to each other. The members of the operating team beleaguer the area of operation and have their own domains: the surgeon acts in the centre, the (first) assistant opposite him/her on the fringe, a second assistant if present beside the surgeon, the instrument nurse next to the first or in place of the second assistant. Her domain is the instrument trolleys at the foot of the operating table, whereas the two (or more) anaesthetists are, as described above, in charge of head and arms. Even farther away from the inner circle of action are the jumpers on the fringe of the operating theatre.20 The location in relation to the operating area corresponds to the surgical hierarchy; those in places 'with restricted visibility' have no say, those with the best view do. The exact position of the operating team depends on the location of the area of operation on the patient-body. The team can be crowded around the belly, an arm or between the legs. It can also change position in the course of an operation in order to improve lighting conditions or access. Such movements are not restricted to the operating team; the patient's head or legs are also automatically lowered or lifted. Movements of bodies against each other can also appear in the operator's instructions announcing a change of position, such as, 'I must go down again, legs up.' Cooperation among the individual parts of the operating team is characterized by division of labour and hierarchic organization. The assistants' hands with their retractors and steady blood staunching mainly ensure good vision, so they support the operator's eyes, whereas the instrument nurse must constantly keep an eye on what will be the next instrument to be placed into the operator's hand. She stands behind the instrument table with the operating set selected for the particular operation; instruments for cutting, hold- ing, retracting, blood-staunching and suturing, all arranged in ordered rows on sterile cloths. She handles them at a high speed and often observes and performs several hand movements simultan- eously, placing instruments into the operator's hands or receiving some from them. There is a permanent circulation. The nurses usually know which instruments are needed when a demanding hand is stretched out towards them, or they react to brief commands like 'let me have a Richardson', 'suture', 'scissors', 'swab', 'heparin'. Apart from instruments, the nurse receives parts of the body, for example superfluous skin or amputated organs, which she sometimes keeps as preparations. However, she throws most of these bits as well as swabs

This content downloaded from 134.93.236.161 on Mon, 16 Sep 2019 07:19:06 UTC All use subject to https://about.jstor.org/terms Hirschauer: Manufacture of Bodies in Surgery 295 or cloths soaked with blood across the table into the rubbish bin. A few things will end up on the floor, like objects the surgeons carelessly drop or which they themselves throw in the direction of the waste bin.

FIGURE 3 Tbe Surgeon's 'Tools', Seen AnatomncaUiy

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k esl eg ex t'uW

brewm. ei,l m. awdM*s bu1, es

Source: J. Sobotta and H. Becher, Atlas der Anatomie des Menschen (Miinchen: Urban & Schwarzenberg, 1988), Bd. 1, Abb. 446.

The instrument nurse supplies the operator, and is in turn supplied by the jumpers. This results in a chain of command and manual assistance: suture material is handed from the non-sterile to the sterile zone of the operating theatre, and scrub nurses and jumpers act as pivots between the two zones. Materials and instruments (almost like people) are therefore wrapped twice. The outer wrapping may only be touched by one of the nurses, the inner wrapping only by the other

This content downloaded from 134.93.236.161 on Mon, 16 Sep 2019 07:19:06 UTC All use subject to https://about.jstor.org/terms 296 Social Studies of Science nurse. Many instruments come to rest on the patient-body. Because of the sterile sheets it can be used as an additional table, to have some instruments always at hand. Such an instrumentalization of the patient-body also takes place in another cycle, when a wire is attached to a leg to turn it into the earth for electric operating. Surgeon and assistant cooperate in a very small space, always working under each other's close supervision. Assistants are the surgeons' 'right-hand'. In some respects, they can be replaced in this role by less flexible but more enduring instruments, for example by Martinarme, retractors with many joints, fixed to the table. However, they cannot be replaced in their role as junior staff trained at the operating table, who one day will replace the operator. At the beginning and end of operations, they are brought into play more extensively. The autonomy they are allowed in their assistance of the operator largely depends on their experience. Trainee hands are told 'Don't pull away! Over here!'; they are given a tap and receive gestural demonstrations as to the direction of a hand movement or, without further ado, a retractor will be taken away and its proper use will be demonstrated to them. There are at times up to eight hands in the area of operation. They move above, below and beside each other in this cramped space, taking turns and complementing each other, pulling, cutting or sucking something off. The operator's hands take the lead; they are more dextrous because more experienced in certain movements than the other hands, which complement the surgeon-body as additional 'right' and 'left' hands. Instruments have to be 'at hand' like persons. Some take part in the work even without hands: hanging out of the wound holding something, or spreading something apart, clamping it or pulling it aside. In the area of operation, a hand holds a pair of tweezers, another one supplies an electric current to its end for blood staunching. If an additional hand is needed, a simple request like 'can somebody just hold here' may be uttered, without any particular addressee. Whereas there are washed and unwashed hands with regard to sterility, the functioning of an operating unit involves four types of hands: leading, assisting, instrumenting and running hands. Like the patient-body, the surgeon-body appears to be functionally extended, in contrast to the visual reduction of its individual members. Similar to the way in which a corporation is treated as a 'legal person', the operating team acts as a 'surgical body'. Since it belongs to several persons, its eyes and hands must be co-ordinated by words and

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gestures. The strict hierarchy simplifies this: dreaming eyes or eyes wandering aimlessly about are yelled at and orientated back to the events in the operating area: 'You musn't let loose before I've got the thing', 'Doctor, the good time is over now! No, like this, otherwise he's gone'. An alarm sounds if the patient's respiration comes to a halt, and alarm signals can be heard whenever a cog in the works of the operating team is out of order and threatens to stop the whole apparatus. Normally, however, the surgeon-body with its rhythmic activity functions like a machine: no words being said, instruments slide into hands snapping shut. Surgical hierarchy concerns not only some persons' subordination, but also the subordination of personal boundaries to the functioning of the surgeon-body. The operator can reach out for the assistant's hand as if he were adjusting a tool, or he can wipe splashes of blood off his forehead on the nurse's shoulder beside him, apparently without any need to apologize for this use of another person's body. Even the assistants' ears can be used in this way: often the surgeon explains a surgical problem to them only in order to develop his thoughts.2' Below the level of verbal and gestural co-ordination, the unity of the surgeon-body is also produced corporally. The height of the table is adjusted to fit the height of the surgeon, and, if necessary, assistants have to adjust themselves. Finally, standing so close to one another- more so than in a lift - also creates an emotional unity of the surgeon- body. The waxing and waning of attention or the disquiet of some part of the surgeon-body is 'contagious'. Therefore emotional discipline is exercized, when the person's hostility is postponed, and anger about the failure of some part is subdued to avoid any amplification of the disorderly feeling by emotional feedback. However, the hierarchic structure of the surgeon-body also leads to a nervous division of labour. Whereas the operator takes care of the necessary level of attention and of the synchronization of the changes in tension, tolerant nurses, grumbling assistants and psychologically more subtle anaesthetists provide the nerves of the surgeon-body.22

Looking into the Patient-Body

Visibility of the area of operation is the main criterion for the optimum spatial positioning of the bodies. As described above, the patient-body is visually reduced to the area of operation, and the surgeon-body is concentrated on its hands and eyes. This arrangement provides

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FIGURE 4 Looking into the Patient-Body

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Source: Front cover of Andreas Vesalius, De humani corporis fabrica epilome (Amsterdam, 1642).

This content downloaded from 134.93.236.161 on Mon, 16 Sep 2019 07:19:06 UTC All use subject to https://about.jstor.org/terms Hirschauer: Manufacture of Bodies in Surgery 299 apart from sterility - a situational focus for those present in the room. It visually supports the (mental) reduction to a part of the body and intensifies the concentration on the piece of body below the operating lighting. It consists of a special diffuse light, ensuring that the surgeon's head does not cast a shadow over the area of operation. So the surgeons see neither their own nor the patient's head, which may help to discipline the imagination that they themselves could be this other body.23 Before the first incision, the area of operation is often palpated to make sure this move is well-positioned. Then the incision is sometimes drawn on to the body, so the scalpel must only follow the indicated path.24 And finally, some surgeons perform a 'dry run' before particularly long and bending incisions, almost like a golfer swinging his club before the actual stroke. After all these preparations - separation of the head, cutting out of a section by means of linen, palpating the area of operation and drawing on it - the incision of the skin is no longer a social incision for those working at the patient- body. Conversations continue without interruption, and will only break off later. Wounding somebody has become wounding some body, and so it appears undramatic. The incision evokes a sign of life from the patient-body: it is bleeding. This hinders those operating in their work, because it reduces the degree of visibility of the target organ which had just been achieved. The outflow of blood is therefore continually ligatured. Trying to overcome this obstacle to visibility leads to a number of non-visual perceptions in the operating theatre: warm and sticky splashes on one's skin, the gargling of the suction machine, the sizzling electric cauterizer, which sends out drifts of smoke and spreads a burnt stench, at times covering the specific odour of blood. After the incision, a step-by-step occupation of the patient-body takes place. The surgeon-body extends itself into the flesh: with fingers, clamps, suction tubes and cutting instruments. One layer after the other is removed, camp is pitched, and the expedition continues. The visual reduction by textiles reveals itself as one step in a process of targeting,25 which is now realized by instrumental means. The operator surrounds an organ, trying to spare the neighbouring parts of the body. Layers of skin and tissue obstructing the view are cut through and spread apart. Operating becomes a sequence of looking and cutting, of manipulations providing visibility for further manipulations. One must see to cut, and one cuts to see more. Furthermore, organs are shifted for the sake of increased visibility;

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retractors spread the wound apart, gauze pushes organs aside, sleeves help to shift organs out of the wound. Besides this, optical instruments support the surgical gaze; reflecting instruments, pairs of magnifying glasses, microscopes, forehead mirrors and lamps. But hands remain the most important instruments for viewing. Bare hands can, for example, make something out and then stretch some tissue to make it more transparent, or they identify nerves by way of their tensile strength. 'Blunt' dissection involves stretching, tearing or shifting tissue with one's fingers, during 'sharp' dissection hands serve as holders for the scalpel, scissors or the electric cauterizer. Vessels, skin, tissue and bones are tackled differently depending on the way in which they resist: the skin is treated with the scalpel, the yellow layer of fat and the peritoneum with scissors, muscles with the cauterizer. Thus, the practice of operating appears to be a versatile craft. It resembles building or carpentry in the way bones are sawed, drilled, chiselled and screwed together; tailoring, where skin and tissue of different consistency are cut apart and sewn together; the work of sailors, when various knots are tied; and a butcher's trade, when muscles and innards are carved up. To develop their competent handling of instruments, assistants are sometimes told to try their less dextrous hand, too, because this can be favourable, for example, for tying a knot and also when making an incision: from left to right with a scalpel, from right to left with scissors. There are methods to turn hands into steady instruments: surgeons lean against the 'bench', press their elbows against their body and rest their wrists and little fingers on the patient-body when they are performing subtle manipulations, comparable to laying one's hand on the writing surface when writing. The scalpel is then held like a pencil. Dissection, which is the precision work of making objects visible, is at the same time classifying work. The flesh is dense and compact, stuck together and impenetrable. First, one has to identify something in a crevice opening up, in the depths of a wound or on a bloody surface. During the search for a spermatic duct, someone utters 'I can't see anything', and an assistant is told, 'now, this is the transversus perinei profundus'. In the case of microsurgery, this identifying work can take hours, in which whitish and red cords are identified as particular nerves and vessels and lifted out of their bloody surroundings by slings and numbered clamps. Another film seems to be spread out on the patient-body like an overlay: the anatomic film.

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Dissection aims to present organs in the isolating style of an anatomic atlas. The drawings show neatly separated organs; in the patient-body this state must first be produced by isolating them with the knife. Surgeons call this 'exposition' or 'making anatomy' (Anatomie herstellen). Whereas, to a layperson, this procedure increasingly disfigures 'the body'- as it is known from everyday life - for the surgeon exposition creates 'the body'- as it is known from the anatomy book.26 When the exposition is completed, the target organ can be operated on: nerves are anastomozed, prostheses implanted, organs resected, tumours extirpated, bones screwed together. There is a multitude of different operations. A few of them shall be mentioned here because of the specific consequences of technologies and procedures for the surgeon-body and the patient-body. Several optical technologies are applied in surgery. So before most operations, the patients are X-rayed (often in combination with the use of a contrast medium) to reduce the strain on their body and to orientate oneself. It is said that one has to know 'where we are here', and if one does not know the answer, 'one has to move cautiously'. During operations on the throat a forehead lamp is attached to the operator's head, as for a miner. The gaze then runs parallel to the light beam. The lamp is connected to a cold-light generator by a flex running from the back of the operator's head; so the surgeon-body, too, is connected to the technology in the operating theatre. Technologies which separate the eye and the hand have even more considerable effects on the surgeon-body. With an endoscope (for example, when sterilizing the Fallopian tubes) the inflated belly can be inspected without making a large incision. The surgeon's staring gaze, brought about by the instrument, is only directed by the hand which operates the endoscope. The assistant's view can be made to run exactly parallel by an additional optical system. The division of labour of the surgeon-body can also distribute hand and eye among different persons, as when the searching operator focuses the endoscope on a haemorrhage and a 'blind' assistant carries out his instructions for the manual work of sucking blood through a canal of the endoscope. X-ray filming during an operation can also make the operators lose sight of their hands. When a pacemaker is implanted, the surgeon's hands manipulate the end of a tube in the area of the patient's collarbone while their eyes are turned away from their hands and focus on a monitor showing the movements of the tip of the tube near

This content downloaded from 134.93.236.161 on Mon, 16 Sep 2019 07:19:06 UTC All use subject to https://about.jstor.org/terms 302 Social Studies of Science the patient's heart. Their gaze is no longer fixed on their hands, but it merely follows the effects of their movements on the tip of the instrument in the visual field. The area of operation seems to be shifted from the patient-body to the screen. Everybody's attention is directed towards it almost as in competent typewriting, when people can fix their eyes on the characters on the sheet rather than on the keyboard. 'Closed' heart surgery and endoscopic operations have the advan- tage of leaving hardly any trace of surgical work on the patient-body, only very small scars. Plastic surgery has the opposite effect. It reconstructs damaged parts of the body and also makes cosmetic changes to the body surface. Specially extensive are the changes to the geography of the organs which happen in autogenous transplanta- tions on transsexuals. Surgeons shift pieces of skin or use micro- surgery for 'free' transplantations across larger distances. The patient-body becomes a stock of material, some of which is useful, whereas other parts cannot be used and are amputated. The skin of the penis is used for a vagina and the skin of the vagina is used for a penis, the scrotum for labia and vice versa. Parts of the labia may become nipples, pieces from the intestines may be used for a vagina, skin from the back of the foot and forearm as well as costal cartilage is taken for a penis. In the course of such operations, the organs dealt with undergo less of a gestalt change by the use of coverings, but more of an instrumental dissolution. So a scrotum is transformed into a trapezium; a penis is turned inside out, and divided into skin and shaft; the shaft is split into urethra and spongy bodies; they are 'mobilized' (that is, separated from the body), whereas the skin is used for an emerging neovagina. Plastic surgery of the breast involves competition between the ideal of leaving no traces and visibility during the operation. The construction process conceals itself by hiding the scars; below the prosthetically enlarged breast or closer to perfection in the armpit. However, the latter involves complicated blood-staunching measures and difficult visibility; to improve lighting conditions, a fibreglass lamp is inserted into the wound. The differences between operations can only be hinted at here. Common to all of them is the retreat from the patient-body. Towels and sponges soaked with blood are pulled out of the belly, instruments are counted aloud in order not to leave a foreign body behind. The loss of blood and temperature is checked, a drainage system is installed, and the body is put together again with sutures;

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one layer after the other is closed, the plastic film is removed, and suddenly one can recognize the wound again: the belly, for example, reappears, and with it the boundaries of the wound. The disfigured part of the body comes to light again when the sheets are pulled away (unless it was amputated or changed by plastic surgery). When the surgeon-body moves up again through more shallow layers towards the skin, it relaxes and lets off steam through the vent of casual conversations or silly jokes,27 which, together with careless touching, begin to soil everything. In contrast to signalling talk under high tension in the critical phase, conversations can now be about the latest football match, hospital gossip or the next operation, about patients who have to be 'at hand':28 'OK, you can order the varicose veins from El now', or 'Do we get the knee-joint here?', (assistant): 'the stomach is first', (surgeon, ironically): 'the stomach has refused its consent to the operation'. Sheets are collected, the operating room is tidied, and the patients are wheeled out towards the recovery room. There they will be heaved on to their beds, and leave the operating department in the direction of the intensive-care unit or the ward. They belong to the majority of people who do not 'stay on the table',29 and get their body back. The surgeons, too, regain their autonomy. They throw their gloves into the rubbish bin, begin to remove their disguises and leave the operating theatre for the scrub room and staff lock. It is pleasant to feel one's own clothes on one's own skin again.

Discussion: The Inhabited and the Anatomical Body

The operating theatre has now been left behind, and the narrow spatial and temporal focus of this observational study will also be extended in what follows, in order to achieve a more comprehensive understanding of the operative events in the context of phenomena outside of the theatre. I shall take up two issues from my description which need further clarification. The first is the relationship between the patient's body and the patient's person, which surgery - as a medical science - has to consider because of the life-world esteem for its object. In this respect, surgery has ritual dimensions which differ from those described for the natural sciences. The second question concerns the relationship of disciplined bodies to the disciplinary knowledge which is most relevant in surgery: in which way are objects and anatomical representations surgically interconnected?

This content downloaded from 134.93.236.161 on Mon, 16 Sep 2019 07:19:06 UTC All use subject to https://about.jstor.org/terms FIGURE S An Eighteenth-Century Amputation without Narcosis (St Tbomas's Hospital, London)

Source: Reproduced from A. H. Murken, 'Die alteste Disziplin der Heilkunde', in Bluliges Handwerk Chirurgie (Munster: Westfliisches Museumsamt, 1989), 39.

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The Territories of the 'Self'

Neither the observational studies mentioned at the beginning nor the surgical descriptions of operations deal with the patient's person. This topic seems to be rendered irrelevant by the administration of narcosis, which moves the patient's person out of his/her body and leaves it in front of the closing doors of the operating theatre. On the basis of classic definitions of a 'social situation',30 the patient is not a participant, because she/he is - although physically present - not involved in reciprocal perception. On the other hand, the patient- body has a particular, person-like status in the operating theatre. As mentioned above, patients are neither referred to by their names, nor - like physically absent patients - by expressions for organs. Indefinite reference in speech makes them appear to be in an ambiguous state of presence and absence. In Goffman's opinion,3' the participants regard the patient-body like a sacred object, irrespective of its owner's status. But this 'sacredness' of the body cannot be located in itself, nor solely in the medical perspective on it. It is rooted in its relation to the person inhabiting it: its character is that of a loan with a temporary status as an object. The patient-body is, as it were, a 'virtual participant'. This remainder of the patient's person can be detected in the narcosis and in the sterility precautions. The induction of narcosis presented itself as a two-layered task. One part dealt with the body and marginalized the patients as participants; the other part took them into account as persons by constantly talking to them. It is easy to imagine how imperative such comments would be during the operation, if patients were 'masters of their senses':32 the surgical invasion would have to be accompanied by an endless stream of announcements, explanations, soothing talk and, above all, apol- ogies. A body cut open and laid bare internally with organs hanging out or dragged out - is more than naked. Its inhabitant would be seized with fear and dismay, but would also react with a different social affect already required for states of lesser disarray of one's appearance: shame. Patients may lose all sorts of organs in the operating theatre; without narcosis they would lose their face. So what seems to sever patients as persons from the social situation also serves to protect them as persons. This also protects the surgeons from complementary feelings of shame or guilt,33 which are also suggested to them by legal definitions of operations as bodily injury. But in the operating theatre this injury

This content downloaded from 134.93.236.161 on Mon, 16 Sep 2019 07:19:06 UTC All use subject to https://about.jstor.org/terms 306 Social Studies of Science appeared to be entirely undramatic, owing to the numerous inter- ruptions of contact between surgeon and patient. Usually, the surgeons do not accompany the narcotizing of the patients, much as general practitioners do not observe the patients' undressing. And narcosis itself ensures that the injury happens outside of their relationship: in a transitory time of 'lesser reality', because it is not shared with the patient. But the latent theme of social affects is also present in the various sterility measures; washing one's hands, covering one's face and the patient's head and his/her entire body. The screen creates anonymity and functions like a reverse folding screen, covering the naked face instead of the naked body. Distance from the body of everyday life is also distance from disorderly affects. They shall not disturb34 the surgeons any more when they are making an incision -'with a blend of arrogance and innocence'35 -into an anonymous, dumb and disfigured body. Katz has analyzed sterility procedures as rituals, and interpreted their function as the removal of ambiguity from objects which do not easily fit in the schema of sterile/non-sterile.36 The ritually affirmed, complete separation of the operating theatre from everyday situa- tions enables surgeons to deal with the body in a matter-of-fact way, free from passion and disgust. So Katz, too, regards sterility procedures as related to affects; one could say: as part of a situational condition of the 'medical gaze'.37 However, her interpretation leaves two questions unanswered. Why does the operating theatre need so much symbolic distinction? And what is, after all, the local signif- icance of the distinction between the clean and the dirty? One can answer this question more specifically than by referring to the general function of rituals, without only affirming the bacter- iological rationality of asepsis:38 the symbolic function of sterility procedures is primarily related not to the boundaries of the operating theatre but to those of the patient. So, although the blood is not free from bacteria, blood-stained instruments are treated as 'sterile' because 'being clean' is to be understood relative to the patient-body. It differentiates anything belonging to this body from foreign germs.39 Sterility procedures continually separate the 'own' from the 'foreign' body. They thus keep apart categories which are also relevant in everyday situations. Goffman talks of 'territories of the self', whose final and clearest boundary is the skin.40 To touch it accidentally outside of an intimate relationship calls for an apology. Although in the operating theatre the patient's skin is covered and thus rendered invisible, everybody present treats a diffuse zone

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around the operating table as if it constituted this boundary, of which one should normally stay clear. There are repeated remarks, directions and reminders concerning the respect for this boundary: words preventing accidental contact where later apologies would have no addressee. Sterility procedures reconstruct the injured skin as a zone-like boundary between persons.4' They restore this territory for somebody who cannot defend it, and thereby constitute an intensification of the 'etiquette of touch' described by Young.42 When looking at the relationship between the patient's body and the patient's person, it becomes clear why the operating theatre is also symbolically delimited. The sterility zones of the theatre and the department as a whole reconstruct the injured skin as a protective wrapping - so, entering the operating theatre is tantamount to entering the patient. Anybody who undertakes to enter this wrapping must neutralize the 'dirt' of their own person by a disguise which renders them anonymous.43 In contrast to the 'sacrifice' of animals in experimental sciences,44 the ritual dimension of surgery is due not to sacralization but to a protection against desacralization in the course of transforming patients into objects that are as 'natural' as possible. It may be legitimate in the study of natural sciences to suppose a 'natural object' as starting-point. In medical sciences one must consider that the 'original material' is itself a cultural object, already constructed in everyday rituals as a bearer of universal significances. But this is not the only cultural object which is a relevant point of reference for surgical practice.

The Anatomical Discipline

Even though the everyday owner of the body cannot be ousted completely, an extensive occupation takes place during operations. The operating theatre gave the impression of a puppet theatre, featuring an object with no will of its own. Dislodging the patient's person makes it possible to release the body from everyday rituals, which differently esteem and protect different parts of the body (for instance, face, breasts, elbows, genitals). In everyday life they are means of presentation of self, cause for attributions of identity, modest covering, and so on. Goffman talks of the 'ritual segmen- tation' of the body.45 At the beginning of operations, an undiffer- entiated equal treatment of parts of the body takes its place:46

This content downloaded from 134.93.236.161 on Mon, 16 Sep 2019 07:19:06 UTC All use subject to https://about.jstor.org/terms 308 Social Studies of Science unashamed exposure, visual reduction by cloths, disinfection and incision. Then the ritual segmentation is dominated by the anato- mical one. In the medical system of values, there are 'vital' and

FIGURE 6 The Anatomical Segmentation of the Body

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'dispensable' parts of the body, and in practical surgical work there are differences in the material, which in plastic surgery determine its usefulness'. The occupation of the patient-body by these new distinctions is based on disciplinary knowledge, whereas I have so far stressed the occupation by disciplined bodies: in many respects the events in the operating theatre correspond to the 'art of the human body', which 'in one mechanism renders it the more obedient the more useful it is and vice versa'.47 According to Foucault, disciplinary institutions create an apparatus which codes activities, localizes bodies in a parcelled and hierarchic enclosure and connects them to instruments; so individual bodies become elements of a complex machine co- ordinated by command signals. If one characterizes the patient as a 'virtual participant',48 one must regard the parts of the operating team as 'members' absorbed in 'organic solidarity' thus taking Durk- heim at his word.49 This discipline regulates the relationship of bodies to themselves and to each other. The question arises as to how it is connected to that other 'discipline' with a specific knowledge as a medical subject. Foucault regards 'man as a machine' as being historically described in two ways: anatomically-metaphysically and technologically-polit- ically. The link between the analyzable and the manipulable body is docility.50 Then how do surgeons and patients learn anatomy? And how is the patient's body related to anatomical representations of it? On the one hand, the education of surgeons consists of a training of their own body, which has to practise its manual skills and to internalize the aseptic taboos of touching: 'it becomes second nature to you because you always shrink back' (a urologist). On the other hand, surgeons like other medical students learn the abstract body of anatomy from books with texts and illustrations. They swot it up bone after bone and nerve after nerve and they are examined on whether they know it by heart. They only encounter concrete bodies in the form of corpses, which owing to the high esteem for living patients are used to develop their anatomical knowledge. So surgeons acquire two bodies in their education: their own trained body and the ingrained abstract body. The abstractness of the second is due to its having been learnt from dead substitutes like books and corpses. Neither the images with their exaggerated colours, attracting the eye, nor the corpses (mostly of old people), uniformly brownish pink, their absence of blood and incipient decomposition, look much like a live body.51 Therefore

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anatomy must largely be acquired on the job, through the practice of operating.52 In two respects the patient-body becomes the base of a disciplinary education: as a constant memory aid of the abstract body, which is so easily forgotten, and as a visual aid for an anatomical demonstration. During an operation, a junior surgeon learns to use the anatomy atlas in the broken ground of the flesh. The difficult task of recognizing anatomical structures in the visual complexity of the concrete body,53 forces every student of surgery into the disciplinary differentiation of the field. One can know the whole body of anatomy, but one cannot know all about the anatomy of the patient-body, only about the body regions of urology, gynaecology, orthopaedics, heart surgery, thoracic surgery, oral surgery, neurosurgery, and so on. These subdisciplines have covered the body abandoned by the patient with their network of territorial boundaries.54 'Knowing about' these regions of the body, which grows out of acquiring an anatomical view in surgical practice, combines the anatomical knowing that of the visible, and the anatomical knowing how of making something visible. Knowledge and skill are tied to each other. On the one hand, the knowledge emerges out of dissection; on the other hand, it structures dissection as an instruction for viewing and cutting. The body of the anatomic atlas, with its clear- cut divisions, different colours, numbered and labelled structures, is present in the surgeon's mind. So it guides the anatomical imag- ination necessary to anticipate what is waiting for me after the next incision behind this cover. In the process of operating, both the impressions gained of the concrete body and the single images, which make up the abstract body, are only of transitory relevance.55 Perception in surgery is a continuous superimposition of one over the other: a permanent cross-fading of experience and representation. A precondition for this is the low, 'iconic' level of abstraction of anatomical pictures, compared to most representations in exper- imental sciences. Nevertheless they do represent the practices that constituted the image. As Lynch puts it, they 'reflect the disciplinary organization of scientific labour as much as they do the organization of natural objects and relationships'.56 For example, they reflect the main instrumental means of looking: pictures of the human body which are based on the work of a scalpel are typically 'sharper' than X-ray or ultrasound images. So anatomical pictures document products of dissecting labour, and thus also provide an idealized account of what has been done. But they also provide a schedule for what is to be done, and what the 'natural object' should look like.

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FIGURE 7 llMustration from an Anatomic Atlas: The So-called 'Kidney Situs'

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body, which in the beginning is not visible at the patient-body, is looked for in it and constructed at the patient-body in the course of the constant attempts to produce its visibility. One 'leafs through' the three-dimensional patient-body to find the two-dimensional struc- ture of anatomical pictures. Section after section, the proper anatomy of the ideal body is engraved on these layers. One inscribes the structures which a normal, proper body should have into the patient- body. One removes the idiosyncrasies of its 'illness', and on the way to this goal one performs exposition and dissection to shape the structures of the anatomical body out of the raw material. In this respect, plastic operations, such as 'sex changes', are operations par excellence, with the anatomical perspective coming into its owni. Not only is the change in the anatomical geography 'plastic', so are the normalizing 'repair' of organs and, even before this, their 'expos- ition'. The anatomical body is the result of a sculptured practice. So the relationship between patient-body and anatomical body is reflexive: they are models for one another. On the one hand, the concrete body is a didactic model, from which the abstract body is learnt; on the other hand, the anatomical body is an aesthetic model, which is an example to the patient-body and its treatment. Focused on the issue of representation, this means: in surgery 'transference' happens not only between pictures, but between pictures and 'natural objects'.58 This results in a reflexivity of similitude: 'there is no ultimate reference point. Representational relations are symmetric and can be reversed and extended without limit'.59 In this harmonious circularity, surgical practice takes place. It explores a body which it must already presuppose and take for granted, and it standardizes itself by means of its decontextualized anatomical knowledge. The development of surgery to an increasing capacity is tied to this reflexivity. The 'new surgery' of endoscopy increases the selectivity of targeting. This is achieved with an optical instrument which puts the surgeon-body at a distance and simultaneously allows its gaze to venture forward to the target organ. The subdiscipline of plastic surgery, however, has gone in the direction of mobilizing target organs and allowing them to overcome distances. Plastic surgery has worked for centuries with 'sliding flaps' and 'rotation flaps' (that is, locally shifted pieces of skin), and then it began to transfer 'advancing flaps' to more distant parts of the body.60 Today it also carries out many free transplantations, which overcome the local rootedness of organs, at first within an individual. With the allogenic transplan- tations of the last few decades, plastic surgery has moved beyond the

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territory of the individual body and exchanges organs in a growing market. As a circulating spare part, 'a kidney', for example, no longer leads an existence as nothing but an anatomical illustration.

Surgical and Ethnographic Practice

The 'applied science' of surgical operations also presented itself as science practically accomplished. In comparison with the laboratories of the natural sciences, in the operating theatre there is less room for 'experiments'. But surgery, too, constructs facts. Its object, 'the body', has not only a history of medical classification and interpre- tation,6" it is also grounded in a specific practice of the discipline. When looking in the body for the images which have been made of it, surgery aims at enhanced visibility not in pictures, but in the 'original material' itself. The instrumentality of its looks makes surgery a specific practical accomplishment of the 'medical gaze', which Foucault described as a union of the 'listening' gaze of the clinician with its authority for deciphering symptoms, and the 'pointing' glance of the pathologic anatomist.62 In the nineteenth century this had constituted an anatomical-clinical experience, in which an observing, local circumscribed gaze was always outdone by an absolute gaze armed with 'logic', which integrated all perceptions. The surgical gaze of the twentieth century tries its utmost to overcome the local circumscription of the eye. It is less armed with logic and language than with optical technology and an arsenal of cutting instruments which enhance its visual acuity. Not only does disease provide it with an analysis of the body, but also the scalpel. These qualities of instrumentality, imaginativeness and plasticity let modern surgery sometimes come into conflict with its social environment. Its object, the body of patients, oscillates between the normative body of anatomy and the everyday shape of the body and the ritual demands on it. Because of this, the surgical 'will to know' often 'ethically' reminds itself of the high esteem for persons and normal bodies as its life-world ties, which it is tempted to leave behind. But the dislodgement of the patient's person occurs not only in surgery. It can be found in ordinary medical examinations and also in psychological examinations, in which the patient is asked to produce emotions and memories, which are analyzed by an anonymous analyst together with the remaining 'resistances' of the patient.

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Apparently it is a basic feature of sciences whose objects are human beings that the object always has to be conquered against the specific resistance of living and sense-making individuals. Ethnographic science studies, too, try to gain access to a foreign territory. It is not the bodies or souls of individuals, but a web of symbols, practices and interaction that constitutes social fields. They are entered for a limited period, and the fleeting perceptions are captured in language by painstaking descriptive work. One tries to profit from the naivete63 of one's status as a novice. The product of the descriptive work mediates between this presence and the absent readers of one's own scientific home ground. However, the perspective of the inhabitants of the social field is not simply copied, but a translation is made. Their interpretations are not only 'preserved' in another language, but they undergo a 'vivisection of sense'. In this respect, my description also finally dislodged the inhabitants of the field. We can only gain methodological legitimation for this procedure of 'creating recog- nizability by disfigurement' in the same way as other scientists who study human beings. They devote themselves to their objects: whether they humbly discipline their own body or patiently listen to free associations after a long self-analysis, or whether they enter social fields, pedantically observing and recording in order to produce texts like this.

* NO TES

Like a surgical operation, the work of writing this article has been teamwork. I wish to thank Klaus Amann, Karin Knorr, Jens Lachmund and five anonymous reviewers of this journal for sociological comments, Ullrich Specht and Anke Bartsch for medical advice, and Gisela Baumann for her translation. The study was supported by the Deutsche Forschungsgemeinschaft and the Friedrich-Naumann-Stiftung.

1. B. Latour and S. Woolgar, Laboratory Life: The Social Construction of Scientific Facts (London & Beverly Hills, CA: Sage, 1979); K. Knorr-Cetina, The Manufacture of Knowledge: Toward a Constructivist and Contextual Theory of Science (Oxford: Pergamon Press, 1981); M. Lynch, Art and Artifacts in Laboratory Science (London: Routledge & Kegan Paul, 1982). 2. I shall be using 'surgery' as a collective term for various surgical disciplines, including some which have become differentiated from their 'mother discipline'. I am speaking of an 'applied science' to point out that surgery today is more than the mere

This content downloaded from 134.93.236.161 on Mon, 16 Sep 2019 07:19:06 UTC All use subject to https://about.jstor.org/terms Hirschauer: Manuifacture of Bodies in Surgery 315 handicraft outside the realm of recognized medicine which it was in the nineteenth century. Several biomedical sciences are influential in surgery and in turn profit from the advance of surgical technology. 3. Over a period of 12 months, I observed surgical, urological, gynaecological and plastic operations in four West German clinics in Hamburg, Heidelberg and Bielefeld. The circumstances in these clinics as well as individual operations differed from each other (for example, in the strictness of sterility precautions, the technical equipment available and used or the surgical procedures). I disregard some of these details in my description. 4. C. Geertz, 'Thick Description: Toward an Interpretive Theory of Culture', in his The Interpretation of Cultures: Selected Essays (New York: Basic Books, 1973), 3- 30. 5. M. Lynch, 'Sacrifice and the Transformation of the Animal Body into a Scientific Object: Laboratory Culture and Ritual Practice in the Neurosciences', Social Studies of Science, Vol. 18 (1988), 265-89. 6. B. Turner, 'The Anatomy Lesson: A Note on the Merton Thesis', The Sociological Review, Vol. 38 (1990), 1-18, at 8. 7. B. Latour, 'Visualization and Cognition: Thinking with Eyes and Hands', Knowledge and Society: Studies in the Sociology of Culture Past and Present, Vol. 6 (1986), 1-40, at 16. 8. M. Lynch, 'Discipline and the Material Form of Images: An Analysis of Scientific Visibility', Social Studies of Science, Vol. 15 (1985), 37-66, at 43. 9. E. Goffman, Encounters: Two Studies in the Sociology of Interaction (Har- mondsworth, Middx: Penguin, 1961), 102-17; P. Katz, 'Ritual in the Operating Room', Ethnology, Vol. 20 (1981), 335-50; J. Cassell, 'On Control, Certitude, and the "Paranoia" of Surgeons', Culture, Medicine and Psychiatry, Vol. 11 (1987), 229-49. See also R. Wilson, 'Teamwork in the Operating Room', Human Organization, Vol. 12 (1954), 9-14. For dramatic descriptions of historical operations, see J. Thorwald, Das Jahrhundert der Chirurgen (Stuttgart: Steingriiben, 1956). Brilliant literary descriptions are given by the poet-surgeon R. Selzer, Mortal Lessons: Notes on the Art of Surgery (New York: Simon & Schuster, 1974). Selzer's book contains inner monologues of the operating surgeon, homages to the individuality of organs and remarks on a philosophy of flesh. 10. W. Eicher, 'The Inverted Penis Skin Technique in Male-to-Female Trans- sexuals', in Eicher; F. Kubli and V. Herms (eds), Plastic Surgery in the Sexually Handicapped (Berlin & Heidelberg: Springer, 1989), 91-97, at 91. 11. H. Schipperges, 5000 Jahre Chirurgie: Magie - Handwerk - Wissenschaft (Stuttgart: Franck, 1967), 82. 12. Ibid., 72. 13. Der grosse Brockhaus, Kompaktausgabe (Weisbaden: Brockhaus, 1984), Vol. 16, 70. 14. Cassell, op. cit. note 9, 232. 15. Note that, in contrast to my metaphorical expression, the anaesthetization of surgeons posed a real problem in the history of surgery: surgeons were in danger of anaesthetizing themselves by inhaling the evaporating ether, which was used in the so- called 'rag and bottle' technique: a piece of gauze placed over the patient's face was moistened with some drips from a bottle filled with ether or chloroform: see G. Welty, 'The Emergence of the Modern Mode of Medical Production', Humanity and Society, Vol. 9 (1985), 377ff.

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16. Using the concepts of Anselm Strauss and his colleagues, one can speak of a combination of 'machine work' and 'sentimental work': A. Strauss, S. Fagerhaugh, B. Suczek and C. Wiener, Social Organization of Medical Work (Chicago, IL & London: The University of Chicago Press, 1979). 17. K. Young, 'Disembodiment: The Phenomenology of the Body in Medical Examinations', Semiotica, Vol. 73 (1989), 43-66. 18. Strauss et al., op. cit. note 16, hinted at the participation of patients as co- workers in their own treatment. But in the preparation of surgery, most patients have little or no experience and routine, and so their 'loss' as co-workers is more of a gain for the anaesthetists. 19. The expressions which I could record were never 'Mr/Mrs So-and so', seldom - and more often used by anaesthetists -'he/she' (er/sie), and as a rule 'the patient' and 'him/her' (der/die, er/hier), especially in talk between surgeons and anaesthetists. But it could also happen that parts of the respirator were referred to as 'he'. (On the personification of instruments and organs, see also Selzer, op. cit. note 9.) Occasionally there were simple elliptical phrases such as 'is clearly pressing now', or 'has hyperventilated'. Physically absent patients were usually referred to by expressions for organs or types of operations (see below). 20. As a merely observing 'guest', I could choose my position relatively freely, and unless I was talking with the anaesthetists, I was mostly standing at the foot of the table next to the nurse. I was cautioned by her (the nurses were all women) several times not to move too close to the sterile zone, but I was also a by-stander with bare hands, and as such frequently employed as a jumper: to fetch threads or rubber gloves, to push a footstool somewhere, to hold a pair of scissors or a flex, or to fetch the senior physician in an emergency. A good position for the observation of the operating field was a footstool behind the anaesthetist's screen. 21. A surgical textbook expressly states the usefulness of such thinking aloud, and contends that it is not necessary for the 'addressees' to understand what is being said: R. M. Kirk, Chirurgische Techniken (Stuttgart & New York: Thieme, 1978), 1. Goffman (op. cit. note 9, 112) assumes that such thinking aloud of the surgeon is a demonstration, reassuring the other team members of his self-confidence. 22. Goffman (op. cit. note 9, 108 and 113) attributes 'anxiety management' and ,moral maintaining' to the chief surgeon, but his observation of an operating team with an operator taking care that all members keep their heads seems exceptional to me. Cassell (op. cit. note 9) describes the surgeon's character as 'paranoid': operators project their 'split-off' insecurities on to their environment, because their work under conditions of insecurity and the compulsion to reach decisions requires the demonstration of security and resolve. This psychological structure must probably be regarded as an incorporation of the nervous division of labour. It follows that - for psychological studies - one should also look at the personality of assistants and nurses. 23. Contact with oneself and subjective fantasies, which are at the centre of psychological work, have little room in operating. Wilson (op. cit. note 9, 12) puts it in these words: 'Inspection, not introspection, is the imperative in operating room activity'. 24. Abdominal incisions can also be sketched before the body is covered with sheets, because otherwise the operator might become disorientated on the visually distorted abdomen. 25. Selzer (op. cit. note 9, 37) describes this as follows: ... . the surgeon makes his

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incision, expecting a particular organ to be exactly where he knows it to be. He has seen it there, in just that single place, over and again. He has aimed his blade for that very spot, found the one artery he seeks, the one vein, captured them in his hemostats, ligated them, and cut them safely; then on to the next, and the one after that, until the sick organ falls free into his waiting hand - mined'. 26. In Selzer's words: 'Here are the twin mounds of the kidneys, the apron of the omentum hanging in front of the intestinal coils. One lifts it aside and the fingers dip among the loops, searching, mapping territory, establishing boundaries' (op. cit. note 9, 95). 27. Katz (op. cit. note 9, 348) and Wilson (op. cit. note 9, 10), too, hint at the relaxing function of wisecracking, which trivializes the dangers and ceremoniousness of operations. Goffman (op. cit. note 9, 109ff) views joking behaviour primarily as part of the presentation of self of the chief surgeons. Their 'good guy informality' is a display of role distance, subtly persuading the other members to subordinate themselves to their personal self-control. 28. Apart from the phase of an operation, the amount of talk depends on how well the members of a team get on. Some operations go by with hardly any word spoken, others contain detailed explanations for assistants. A well-founded analysis of talk in the operating theatre would have to be based on audiotapes. 29. 'Staying on the table' means staying within the area of competence of the staff, as D. Sudnow discovered: 'In the hospital setting . . . "dying" takes on its central significance insofar as death is considered likely on the current admission, for it is then that the hospital, its personnel, and its activities are directly involved in the affair of the death': see D. Sudnow, Passing On: The Social Organization of Dying (Englewood Cliffs, NJ: Prentice-Hall, 1967), 71. 30. Goffman defines a social situation as an 'environment of mutual monitoring possibilities, anywhere within which an individual will find himself accessible to the naked senses of all others who are "present", and similarly find them accessible to him': E. Goffman, 'The Neglected Situation', in P. P. Giglioli (ed.), Language and Social Context (Harmondsworth, Middx: Penguin, 1972), 61-66, at 63. 31. Goffman, op. cit. note 9, 1 1 1. 32. This is the case for operations under local or spinal anaesthesia. However, the patient's view is then barred with a screen. On the horror of a patient who accidentally gets a view of his bowels, see Selzer, op. cit. note 9, 25. 33. Selzer (ibid., 24) confesses: 'Even now, after so many voyages within, so much exploration, I feel the same sense that one must not gaze into the body, the same irrational fear that it is an evil deed for which punishment awaits'. 34. Selzer (ibid., 101) retrospectively describes the subjective side of operating as follows: 'The surgeon cannot weep. When he cuts the flesh, his own must not bleed. Here it is all work. Like an asthmatic hungering for air, longing to take just one deep breath, the surgeon struggles not to feel. It is suffocating to press the feeling out'. 35. Selzer, ibid., 37. 36. Katz, op. cit. note 9. 37. M. Foucault, The Birth of the Clinic: An Archaeology of Medical Perception (London: Tavistock, 1973). 38. Sterility is an ideal which can be perfected endlessly. The actual extent of sterility procedures varies between clinics and individuals. Moreover, it seems to vary between different parts of the surgeon's body: when a falling instrument touches the (sterile) gown below the waistline, it receives far more attention than the surgeon's (non-sterile)

This content downloaded from 134.93.236.161 on Mon, 16 Sep 2019 07:19:06 UTC All use subject to https://about.jstor.org/terms 318 Social Studies of Science eye-region almost coming into contact with the operating field. In her study of a hospital sterilizing unit, Barbara Rawlings has shown how the problem of endless perfectibility is treated by the participants: they treat behavioural rules as standing for 'sterility', and 'if the rules are followed, then standards of sterility will be maintained, and people will have done all they can do'. When the rules in this way provide for the accountability of the participants' actions, they acquire a bureaucratic ritual meaning. One could speak of a ritualistic mastering of 'rationalization'. See B. Rawlings, 'Coming Clean: The Symbolic Use of Clinical Hygiene in a Hospital Sterilizing Unit', Sociology of Health and Illness, Vol. 11 (1989), 279-93. 39. The patient-body is also protected from some germs on and inside of itself: consider disinfection of the skin and special precautions during operations on the intestines. 40. E. Goffman, Relations in Public: Microstudies of the Public Order (Harmondsworth, Middx: Penguin, 1971), 51ff. 41. A further indication of this substitution can be seen in Katz's own observation that the operating staff make the crudestjokes about the patient's body and person, but never about the sterility rituals (op. cit. note 9, 348ff). 42. Young,. op. cit. note 17. 43. I am not postulating here 'persons', or even 'subjects', as entities outside of social construction. Instead, I want to point at a local difference between operating theatres and everyday life. The 'person' is constructed outside of surgery, but it is taken into account in the theatre. 44. Lynch, op. cit. note 5, describes how in the laboratory 'natural animals' are rendered into 'analytical animals' and acquire in their careful 'sacrifice' a trans- cendental meaning, similar to religious rituals. 45. Goffman, op. cit. note 40, 62. 46. Medicine generally shows a tendency towards this, but it is particularly strong in the operating theatre. So Joan Emerson points out the need for signals of neutralization during gynaecological examinations. She talks of the 'balance' between an everyday and a medical perspective, which gynaecologists have to maintain with respect to the female genitals. See J. P. Emerson, 'Behavior in Private Places: Sustaining Definitions of Reality in Gynaecological Examinations', in H. P. Dreitzel (ed.), Recent Sociology, No. 2 (London: Macmillan, 1972), 74-87. 47. M. Foucault, Surveiller et punir. naissance de la prison (Paris: Gallimard, 1975), 139. 48. In a way, the patient is a virtual participant in the same sense as the potential inhabitants of the central tower in Bentham's Panopticon (ibid., 201ff): one cannot be absolutely sure, whether she/he is present or absent. 49. E. Durkheim, De la division du travail social (Paris: Alcan, 1902), 101. 50. Foucault, op. cit. note 47, 138. 51. Referring to the handiwork on corpses, medical students report that when starting autopsy lessons, they needed long showers afterwards in spite of the 'chemical purity' of the corpses: 'My hands became strange to me, somehow unclean and severed in my consciousness'. If one wanted to follow up this phenomenon, a comparison could be made between the 'acquisition of medical hands' and D. Sudnow's detailed study of the 'acquisition of jazz hands', in his Ways of the Hand (New York: Harper, 1978). 52. According to Wilson (op. cit. note 9, 13), the growing tendency in the 1950s to regard 'on the job education' as necessary is also the reason why hardly any operating

This content downloaded from 134.93.236.161 on Mon, 16 Sep 2019 07:19:06 UTC All use subject to https://about.jstor.org/terms Hirschauer: Manufacture of Bodies in Surgery 319 theatre is built as an amphitheatre any more. 53. 'It's a difficult area, hard to orientate yourself, and then the structures look very much alike. You think some cord is a certain nerve and then it isn't, and the other way around' (a junior surgeon talking about the thyroid gland). 54. And they compete for domains: for example, surgery and gynaecology for the female breast. 55. This is the case because being 'on the map' or 'off the map' depends on which layers of the body one is working in: cf. G. Psathas, 'Organizational Features of Direction Maps', in Psathas (ed.), Everyday Language (New York: Wiley, 1979), 200- 13, at 208. 56. Lynch, op. cit. note 8, 38. 57. This norm is largely aesthetic: 'One does try to get a nice situs, to create a really clear overall view there. So you don't want to have a jumble of intestines lying around and a lake of blood. But you want to keep track of things and act according to a precise plan: when and what to dissect, and you can dissect something beautifully, and you can dissect it chaotically. You know, a really nice situs is simply something aesthetic, something you're really pleased about' (a surgeon). 58. Michael Lynch and Steve Woolgar speak of 'transferences' between serially organized displays: see their 'Sociological Orientations to Representational Practice in Science', Human Studies, Vol. 11 (1988), 88-116, at 104. 59. Lynch & Woolgar (ibid., 105), referring to Foucault's This is not a Pipe (Berkeley, CA: University of California Press, 1982). 60. They are based on the following principle: a piece of skin which is to be transplanted is at first left at its original place, which is only given up after the detached part of this piece has grown onto the new location. The risk involved in trying to overcome large distances - between two legs or between a face and an elbow - can be reduced in this way. 61. See C. Gallagher and T. Laqueur, The Making of the Modern Body (Berkeley, CA: University of California Press, 1987). 62. Foucault, op. cit. note 37. 63. One of the well-known Dutch graphic artist, M. C. Escher's, most important innovations in the discipline of perspective was his discovery that curved vertical lines represent our spatial perception better than straight ones. He tells how he was drawing a village in southern Italy and used curved lines to draw the church spire and monastery wall just because he saw them curved, although he knew well and believed that they were straight 'in reality': see B. Ernst, Der Zauberspiegel des M. C. Escher (Berlin: Taco, 1986), 50. As I cannot draw, I have tried to produce such descriptions.

Stefan Hirschauer is a collaborator at the Center for Science Studies at the University of Bielefeld, and sub-editor of the Zeitschrift fur Soziologie. He has published on the social construction of sex and gender, and on the history of gender categories. Currently, he is finishing an ethnographic investigation in the treatment programme for transsexuals. Author's address: Centre for Science Studies, University of Bielefeld, Postfach 8640, 48 Bielefeld 1, FRG.

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