ENTRAR            

THEORETICAL

The surgical operation. Rite of passage in a hospital context
Javier González Requejo^1
1Enfermero quirúrgico. Hospital del Oriente de Asturias, Arriondas (Principado de Asturias), España

Mail delivery: Avda. del mar 69-1ºC, 33011 Oviedo (Asturias), España

Manuscript received by 17.12.2007
Manuscript accepted by 20.03.2008

Index de Enfermería [Index Enferm] 2008; 17(3): 201-204

How to cite this document

Abstract

The ritual is to analyze belongs to the field of health/disease. This is a surgical intervention, an act everyday without any apparent significance beyond the purely technique.
The history of surgery is as old as man. In civilizations like Egyptian or pre-Columbian find evidence of interventions including skull. For Laín Entralgo "Cranial trepanation executed from the Palaeolithic in the most diverse places on the planet was undertaken with two different purposes, sometimes combined with each other: the surgical and magic." This ritual takes place today in a hospital setting, which is in line with the model defined Total Institution by Goffman.
The process takes place at the Hospital del Oriente de Asturias, whose job as a surgical nurse block for six years, which provides a participant observation of the same.
The main contribution of this paper is its ability to uncover the meanings of surgical procedure from an anthropologic perspective. This may serve as the basis for applying critical thinking and asking about our professional actions, because things mean more than they seem.
Key-words: rites of passage, surgery, hospitalization.

Introduction

    Juan A.G. goes to an emergency service at the Hospital del Oriente de Asturias complaining of abdominal pain, fever and vomiting since the previous day.It is accompanied by his wife Aurora G.R.
    In the admissions service, after exposing his illness he is instructed to wait in the room to do so, while are attending to other patients. After a short space of time, a nurse comes to finding him and interrogates about their discomfort in one of the boxes Emergency (spaces intended for exploration of patients, separated among them by curtains). His wife remains in the waiting room, because it does not is allowed access. While the nurse helps to remove its clothing, he is asked about possible allergies, habits regarded as toxic and other diseases that he has endured.
    Once dressed in a nightgown of hospital are valued his vital signs, and is done a blood test. The nurse indicates that immediately will explore him the doctor. He again repeats the interrogation that he is been made in admissions and that has expanded nurse. The doctor extends questions about everything kind of details like the look and the frequency of his feces and vomits. Then it begins to explore manually Juan, touching where it hurts him the most and observing his reactions. After this, he is transferred to perform an ultrasound Abdominal. At the return of proof, the doctor spoke with him and his wife for inform them that the suffering of Juan was caused by an inflammation of the Appendix bowel and that it must be removed to avoid complications that could affect his life.
    Juan authorizes signing the written consent and is prepared his pre-operative; this consisted in a radiograph thorax, electrocardiogram and analytical blood. His watch is removed, his ring and his underwear too, which are stored together the rest of their garments.
    While awaiting entry into the operating room is accompanied by his wife, rather less nervous that him.
    I tell him to Aurora that this is a surgery very simple and short duration, but she does not seem calm. He only wants to remove the pain that the painkillers have failed to eliminate.
    One hour after Juan is led the operating theatre. Its passage through the exchanger of stretchers leads to the anteroom of the  operating room, where he is received by two nurses and one assistant, dressed all them with a uniform different from  the Emergency personnel, and of course, the Juan gown.
    While a nurse interrogates him about wearing a ring or removable prothesis, the auxiliary has put a cap on his head and electrodes around in the chest.
    The anaesthesiologist informs him about the type of anaesthesia that will implement. Juan insists that "does not want learn anything" and the anaesthetist fails in its attempt to tender a minor anaesthesia.
    Once prepared the operating room, Juan is introduced in it. He is placed in the surgical table, and their vital signs are monitored, before been anesthetized. Then begins the surgery and his appendix is removed.
    The operation is over, and then Juan is moved to the reanimation room. While, the surgeon has informed Aurora the course of the intervention. She remains in the waiting room for relatives outside the surgical block; Aurora is accompanied by her brother, who has come because of the serious illness of Juan.
    Juan remains in the reanimation room for two hours, here is monitored by a nurse who controls his vital signs while he asks for painkillers. After the process, he is taken off the surgical head-cap and the electrodes of his chest, after this hi is sent to the plant.
    Once transferred to the Hospitalization ward, Juan is transferred to "his" bed, and it changes the gown by one cloth (the previous was a paper one) equals to his roommate, Joseph, operated a leg 6 days ago. In the room he is received by Aurora and his brother, in addition to the family of the other patient.
    Juan, in spite of his hunger (he goes without eating an entire day), can take neither food nor drink up to passed six hours.
    In the evening he receives the visit of more relatives who bring him chocolates and magazines to read. His wife remains with him until the night. The following day he continues receiving visits of relatives and neighbors who, certainly, bring him more gifts. His activity in the hospital limits itself to seeing the television, to reading the press and to chatting with his companion. Occasionally he escapes to smoking to the relatives' waiting room.
    His routine in the ward is invariably the following one:
    6.30-control of arterial tension and temperature
    7.00-adorn of the bed
    8.00-breakfast and medication
    9.00-10.00 - medical visit
    11.00-13.00- cure of surgical wound
    13.30-food and medication
    15.30-control of arterial tension and temperature
    16.00-medication
    17.00-lunches
    20.00-dinner and medication
    21.00-control of tension and temperature
    Two days later is high of in the Hospital and returns to his house, where relatives and neighbors receive him with more gifts.

Symbols of the ritual

    Attending to the E.sapir's distinction among symbols of condensation and symbols of reference, we indicate the following symbols in the described process previously:

a) Symbols of reference:
    ·Sign of the Hospital, sign of the ward of Urgencies, of Admissions, of Operating room, etc...
    ·Warning Traffic signal of the hospital, rest of traffic signals
    ·The bus-stop
    ·Signs of the room of being of relatives, of the bathrooms etc...
    ·Uniforms of the personnel
    ·Signs of prohibition (to smoke etc...)
    ·Number of history of the patient
    ·Number of room, bed...
    All of them have an eminently indicative function.

b) Symbols of condensation:
    ·The Hospital in itself same, since we will treat later, has a significance for the collectivity that exceeds it of: building to treat patients. The Hospital condenses the profane  in opposition to the social structure that is the sacred..
    ·Separating Curtains in the stalls of Urgencies Mean beyond the physical separation between the patients, his isolation between his self and with regard to the others.
    ·The authorization for the intervention (written consent). In any institution the relations of power are symbolic relations, in this case it is a question of a ritual which significance is that of equality of power of the parts.
    ·Uniforms of the personnel, apart from their referential significance for the users, they serve to differ among different graduations of power.
    ·Uniform of the patients, of equal form and as we will see later, it symbolizes the absence of power and their (passive) patients' condition. For the neophytes there constitutes a symbol of solidarity and belonging the communitas.
    ·The Whole simbolysm associated with the numbers: Number of history, number of room, number of bed in Urgencies etc... They symbolize the new identity, this is, the ill.
    ·Gown of the relatives, it symbolizes the condition of healthy.
    ·Gifts, they symbolize the acceptance of the new status of the neophyte.

Analysis of the ritual

    The history of surgery is as old as man. In civilizations like Egyptian or pre-Columbian find evidence of interventions including skull. For Laín Entralgo "Cranial trepanation executed from the Palaeolithic in the most diverse places on the planet was undertaken with two different purposes, sometimes combined with each other: the surgical and magic."
    This ritual takes place today in a hospital setting, which is in line with the model defined Total Institution by Goffman.²
    The surgical intervention, immersed inside the analyzed process of hospitalization, answers to the characteristics of ritual as social formalized act -stylized, repetitive, stereotyped- forming a symbolic complex that depends on the social context where it is realized. The symbols present in it  already have been launched in the previous paragraph.
    The above mentioned ritual constitutes a rite of passage, because it supposes a transition between two conditions: sick and healthy. A.v.Gennep being based on E.Durkheim's ideas treats the rites of transition as opposition of the sacred and the profane. V.Turner³ extends the study of the rites of passage transfering this opposition to the concepts of social structure and communitas.
    This way so the dynamism of the rite of transition serves to explain and to differentiate two permanent conditions of the social structure. In the analyzed case it might think that the surgical intervention constitutes a rite of passage (transition among pathological/no-pathological, clean/infect, etc.) constituting this one the liminal phase of another rite of passage of major importance (transition sick/healthy). It is the first phase of a rite of major step of which it forms a part (the hospitalization).
    We will distinguish, applying the concepts proposed for Gennep and extended by Turner, three phases in the rite of transition:
    1. The preliminal phase is characterized by a separation of the status that is going to give up.
    It is necessary to stress a beginning of the process, to separate it from the order existing in the social structure. In this case the separation happens by an institution with the characteristics defined as Total Institution.² The above mentioned type of institutions are characterized for: the same space and authority, in this case doctor; every phase is realized in company of other companions; explicit procedures and hierarchy; official aims.
    In this process the identity of the subject is removed, his clothes are removed, it separates him -physically and symbolically- from the rest of the society. It is produced a crushing of the identity of the subject that is going to be re-socialized. It cross from being a healthy subject to the sick one.
    In the surgical act the phase preliminal fits with the preparation of the patient to go to the operating room. One withdraws his sick's uniform from him and he is placed by one of surgical patient. One submits him to new and specific procedures, his personal objects -his false denture- are removed.
    2. The liminal phase or marginalization one, it is from the point of view of the ritual the most interesting. The real transition takes place between both conditions not being the subject in any of them. He is, therefore, in an ambiguous condition (when does anyone stop being sick?, when does anyone stop suffering appendicitis?). It is a symbolic death of the person.
    In the previous phase we had exposed how the identity of subject is removed. There is assigned to him a number of clinical history, a number of stall is assigned to him in the casualty department, a number of room is assigned to him , in the operating room he is not considered to be a person but it is "the appendicitis", "the broken-hip"... Once inside the institution he is kept in isolation from the rest of the society, already he is not ruled by the rules of the rest of the people.
    His neophyte's condition forces him to assume a passive role opposite to the rest of persons of the institution. There are applied to him all kinds of restrictions and duties: His rights as a patient are only a small part of all those that he was possessing before entering the Hospital. Only he meets in situation of equality with the rest of patients, which dress in the same way as he.They form a communitas, they are treated as the same form without doing social distinctions.
    Certainly, the persons interact bearing the structures in mind where they are and, though they cannot change them, they are capable of using them manipulating in their particular interest. This way, though the access to the room of resuscitation is restricted to the sanitary personnel, the relatives of the patients appear to see how they are these. The patients use different strategies the procedure to skip or to use them in their interest already be negotiating with the authority (beginning for the lowest and more attainable degrees) or with the persons of their around.
    In spite of this marginal situation the process does not stop without having social recognition. The relatives and neighbor come to visit and support him on his patient's condition.
    The emphasis in the authority of the elders about speaks Turner (1973), is in this case the emphasis in the authority of the experience, those patients who have a major experience in the process of hospitalization have major quantity of resources and strategies to support their own reality.
    In the surgical intervention the liminal phase begins with the access to the anteroom of the operating room - together with his clinical History - where a cap is placed in his head and other elements (electrodes, night-shirt, etc ..) are put on him. Then continues with the surgical act. In this phase an extreme ambiguity takes place: he is/is not even a person.
    3. The posliminal phase is characterized by an incorporation to his new status, in this case the status of being healthy. The subject rejoins to the society, the restrictions get up and the process accompanies of symbols that make his new visible condition.
    In the surgical intervention the postliminal phase is the one in which the patient acquires a status of being operated on. As soon as it finishes the awakening of the patient he returns to his Hospitalization ward -the community wherefrom he was coming- and there one thinks with symbols that they reinforce his new status: flowers, magazines, chocolates, visits of his relatives...
    We will end up by affirming that this analyzed ritual fulfills an of integration function, since it grants sense to the discontinuity between health and disease, separating the patients of the rest of the society by means of a total institution. So this form, the opposition sacred/profane moves to the dichotomies sick/healthy and structure/anti-structure. Juan has been re-socialized, this ritual has served to internalize and readjust him to the different conditions for which he has passed and to update his cultural values. The society needs elements of identity that objects to others to reaffirm its values, Juan and his relatives like that recognize the healthy value in opposition to that of sick and this rite of passage grants meanings to this transition stressing the previous status and the later one.
    Finally, I would like to indicate another ritual (there are many others) happened during this rite of passage: The signature of the written authorization for the surgical intervention. It is a question of an over-messure of the reality with an integration function. The relation doctor-patient in the hospital is totally asymmetric, so that by means of this ritual the positions of both come to a symbolic equality. Though legally it could have other considerations, it does not stop being a ritual of reversal.

References

1. Laín Entralgo P. Historia de la Medicina. Barcelona, Salvat, 1978: 5.
2. Goffman E. Internados, ensayos sobre la situación social de los enfermos mentales. Buenos Aires, Amorrortu, 1987: 13-129.
3. Turner V. El proceso ritual. Madrid, Taurus, 1988.

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