Notes on Geroulanos and Meyers manuscript workshop: case studies and organismic integration

Yesterday I had the chance to participate in a pre-publication workshop on a book by Stefanos Geroulanos and Todd Meyers of NYU. The book concerns concepts of integration and individuality in early 20^th century medicine, with special attention to military medicine in World War I.

In this note, I’d like to talk about Chapter 2, on case studies. I’ll talk about the manuscript, but also about what thoughts the ms provoked in me. As a philosopher, I was drawn to this chapter for four reasons. 1) The wide variety of logical relations involving individuals. 2) The epistemological question of a “science of the individual.” 3) The mind / body relation in shell shock. 4) The methodological one; we don’t do very many case studies in philosophy, but I think we should.

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Let’s start with the logical relations. I see the following relations at work in the chapter.

1. The part / whole relation (participation).

1. The biological part / whole relation: cells are parts of organs, systems, and organisms.

1. The administrative part / whole relation: an individual soldier is a part of various units above him / her: the squad, the regiment, the division, etc.

2. The political individual / state relation (membership / possession): a soldier is a citizen or subject of a state possessing various legal rights and duties relative to military service (drafted, volunteered upon entry; discharged and eligible for benefits).
3. The sociological individual / collective relation (membership / display): a soldier displays the characteristics of his / her society (its form of bravery, of motivation, etc.)
4. The biological individual / species relation (membership / belonging): a soldier belongs to several stacked classes: an animal, a mammal, a human being, a man or woman.
5. The medical token / type relation (exemplification): a soldier’s condition fits (or doesn’t) a diagnostic category.

Let’s stay with that one for a minute. In the Aristotelian schema, below the lowest difference forming the species are individuals who differ not logically but materially. As I work with Deleuze, let’s see what he does here; I’m quoting a PhD thesis I recently examined by DJ Allen at University of Warwick:

According to Deleuze, the sensible determinations for which the movement of the Hegelian dialectic fails to account are precisely non-conceptual differences. Deleuze finds persuasive, in this connection, a number of cases of what, in the introduction to Difference and Repetition, he calls conceptual ‘blockage’ (DR, p. 20 ff./p. 11 ff.). A concept is ‘blocked’ when it encounters a difference that it cannot specify; and this is precisely what happens, according to Deleuze, when conceptual thought is confronted by ‘differences of nature’ between individuals of the same general type, in other words, distinct individuals that instantiate the same concept (DI, p. 44/p. 33)

I’ll come back to Deleuze in the fourth topic, case studies as philosophical method. For now, we can note that Deleuze (following Simondon) emphasizes individuation as a process of “actualization” coming out of a pre-individual “field” which is the intensive expression of a virtual Idea or multiplicity composed of differential elements, relations, and singularities (for a brief treatment of Deleuze’s metaphysics, see the Stanford Encyclopedia of Philosophy article here).

Hence for Deleuze individuation is not a logical relation of participation, membership, instantiation, belonging, or exemplification, as they are all about the relation of a substance to different properties (or subject to different predicates). That is, they are about products, whereas Deleuze is about the production process, about individuation as the resolution or integration of a differential field. You can “freeze” the individuating process and consider the properties of the substance at a synchronic time-slice if you wish, but you should be aware of your action of freezing.

In a way, Deleuze is after a singular concept, a way of seeing the genesis of the individual from an actualization of an Idea that would provide the sufficient reason for the individual’s path through the world. (This is related to the Leibnizian notion of the unique function, or to the 3^rd way of knowing for Spinoza.) This push to the singular concept is tied in with two Kantian notions. First, the reflective judgment in Critique of Judgment: not subsumption of a given under pre-existing concept but finding the concept for a given individual that eludes existing concepts. Second, Deleuzean individuals are like Kantian schematisms: they are ways of ordering spatial-temporal dynamisms adequate to a concept: this lion hunts this terrain, this hurricane takes this path — you can see the later Deleuzoguattarian notions of territory, refrain, haecceity.

We see the push to individual concepts at 123 of the Geroulanos and Meyers manuscript:

But for those who thought that “borderline cases” constituted genuine medical problems and signaled the failure of medical categories, thinking in cases demanded a very different logic: rather than physiological laws, they found in the proliferation of cases the reason of the case history. This problem became first of all one of categorization as the aggressive refinement of the categories of knowledge so that these could speak to particular patients—and not a refinement of the patient’s symptomatology so that it could fit into the existing categories.

And perhaps the unique spatial-temporal dynamism aspect at 127:

Philippe Huneman reflects on “such a simple thing” as the clinical case in Philippe Pinel’s early-nineteenth-century psychiatry, a story (historiette) that:

reports how one has fallen ill, and with what illness, what has happened to that patient once he or she became ill, how the patient is being treated, and finally if the person recovers. ‘Case’ then designated at the same time an ontological category – a case is a unique spatial-temporal entity, unlike a class, a property, or a rule – more than a discursive category; the case history is different from a demonstration, from an inference or a taxonomy.

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Second, let’s discuss a “science of the individual.” Geroulanos and Meyers mention both Aristotle and Foucault here. The Aristotelian impossibility of a science of the individual due to the infinite variation of individuals (their uniqueness or singularity [discussed at 127 of the ms.]) and the Foucaultian possibility of a science of the individual, which is laid out in Birth of the Clinic and in Discipline and Punish (to which Geroulanos and Meyers refer in note 41 of Ch 2).

In Birth of the Clinic, Foucault ties this possibility of a science of the individual to the pushing of categorial language onto perceptual singularity in case studies, thereby revealing the ontological relations of disease, life, and death. Quoting Gary Gutting, Foucault’s Archeology of Scientific Reason (Cambridge UP, 1989):

But for anatomo-clinical experience, each case can be appreciated in its full individuality. “Only individual illnesses exist” (168). This is because the space of illness has now been entirely identified with the bodily space of the individual suffering from it. The entire reality and meaning of disease resides in its specific bodily sites. In this way, Foucault notes, contrary to the long-standing Aristotelian doctrine, a science of the individual is not only possible but necessary. Ironically, it is death, the destruction of the individual, that was the key unlocking this “forbidden, imminent secret: the knowledge of the individual” (170).

Here is Foucault from BC, 169-170:

It is no longer a question of correlating a perceptual sector and a semantic element, but of bending language back entirely towards that region in which the perceived, in its singularity, runs the risk of eluding the form of the word and of becoming finally imperceptible because incapable of being said. To discover, therefore, will no longer be to read an essential coherence beneath a state of disorder, but to push a little farther back the foamy line of language, to make it encroach upon that sandy region that is still open to the clarity of perception but is already no longer so to everyday speech—to introduce language into that penumbra where the gaze is bereft of words. …

Language and death have operated at every level of this experience, and in accordance with its whole density, only to offer at last to scientific perception what, for it, had remained for so long the visible invisible—the forbidden, imminent secret: the knowledge of the individual. (BC, 169-170)

In Discipline and Punish, on the other hand, the description is much less melodramatic, it is much more administrative than ontological. We approach a science of the individual due to advances in examination and recordkeeping: the construction of dossiers with indexing allowing compilation of statistics.

Thanks to the whole apparatus of writing that accompanied it, the examination opened up two correlative possibilities: firstly, the constitution of the individual as a describable, analysable object, not in order to reduce him to 'specific' features, as did the naturalists in relation to living beings, but in order to maintain him in his individual features, in his particular evolution, in his own aptitudes or abilities, under the gaze of a permanent corpus of knowledge and, secondly, the constitution of a comparative system that made possible the measurement of overall phenomena, the description of groups, the characterization of collective facts, the calculation of the gaps between individuals, their distribution in a given 'population'.

These small techniques of notation, of registration, of constituting 6les, of arranging facts in columns and tables that are so familiar to us now, were of decisive importance in the epistemological 'thaw' of the sciences of the individual. One is no doubt right to pose the Aristotelean problem: is a science of the individual possible and legitimate? A great problem needs great solutions perhaps. But there is the small historical problem of the emergence, towards the end of the eighteenth century, of what might generally be termed the 'clinical' sciences the problem of the entry of the individual (and no longer the species) into the field of knowledge; the problem of the entry of the individual description, of the cross-examination, of anamnesis, of the 'file' into the general functioning of scientific discourse.

To this simple question of fact, one must no doubt give an answer lacking in 'nobility': one should look into these procedures of writing and registration, one should look into the mechanisms of examination, into the formation of the mechanisms of discipline, and of a new type of power over bodies. Is this the birth of the sciences of man? It is probably to be found in these 'ignoble' archives, where the modern play of coercion over bodies, gestures and behaviour has its beginnings. (DP, 190-191)

So a suggestion for the case study chapter would be a brief treatment of the recordkeeping procedures in WWI medicine that allowed comparison of cases.

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Third is the mind/ body relation in shell shock. I’ve recently been following the introduction of the concept of “moral injury” into PTSD discussions.

The traditional etiology of PTSD has been physiological trauma from prolonged episodes of stress with involvement of both fear and anger. PTSD is thus usually seen as physiological overload resulting in flashbacks, low threat thresholds and hyper-arousal, etc.

“Moral injury” as a type of PTSD is based on psychological trauma: what happens to you due to how you experience what you have done to others. Moral injury involves a betrayal of moral framework resulting in symptoms of guilt, shame, loss of enthusiasm for life, and risk of self-harm via alcohol and suicide. I’ve come across two theories of moral injury.

First is the group focus or even culturalism of Jonathan Shay (author of Achilles in Vietnam and Odysseus in America) write of a “betrayal of ‘what’s right’ in a high-stakes situation by someone who holds power.” (Thus in Shay’s Homer analogy, it all starts with Agamemnon stealing Briseus from Achilles.) Shay writes of the need for cultural purification to aid those suffering from moral injury:

Our society lacks any real understanding of what's needed for purification after battle. We need rituals, we need liturgies, we need narratives, we need artworks. We all need to clean ourselves up after war. These people went on our behalf and in our name, and we need to purify as a community, not just as just say to this returning veteran you need purification.

Second, Litz et al, 2009 is individualized; it’s about the soldier as much as or more than about the commander: “perpetrating, failing to prevent, bearing witness to, or learning about acts that transgress deeply held moral beliefs and expectations.” (Clinical Psych Rev, 2009)

In moral injury you can see a sort of “retrospective agency” (an idea I mention here). Even when the practical agent is group with de-subjectified / borderline conscious agents such that many soldiers take moral responsibility even in a situation of distributed agency. There thus seems to be a move against “bad faith”: many cling to guilt, haunted by the feeling that they “could have done something.” Could we even talk about a “centripetal” subject that is irresponsible in taking upon itself this responsibility?

A further twist is PTSD in drone pilots (this implies there is a PTSD for each assemblage?) Gregoire Chamayou, A Theory of the Drone lays this out nicely: Drone pilots are physically far away and hence shielded from harm, but affectively close due to video images. (Note that there is a question of how much resolution the military allows in public vs what the operators see. Eyal Weizman, “Violence at the Threshold of Detectability,” e-flux, http://www.e-flux.com/journal/violence-at-the-threshold-of-detectability/.)

Peter Asaro (2013): “The labor of surveillance and bureaucratized killing.” Social Semiotics (free access here). Quotes from drone pilots

• “I mean, there are horror sides to working Predator. You see a lot of death. You know you see it all, as I said, I can tell you what kind of shoes you are wearing from a mile away, it is pretty clear about everything else that is happening….”
• “A lot of people look at me like, how can you have PTSD if you weren’t active in a war zone? Well, technically speaking every single day I was active in a war zone. I mean, I may not have been personally harmed but I was directly effecting people’s lives over there every single day.”
• “There is stress that comes with that, with having to fire, with seeing some of the death, with seeing what is going on, having anxiety, looking back at a certain situation or incident over and over and over, you know, bad dreams, loss of sleep. You know, it’s not like a videogame, I can’t switch it off. It’s always there. There was a lot of stress with that. They call it virtual stress.”

Also interesting is an interview with Ethan Hawke about Good Kill (2014)

• “It’s interesting, the kind of depression that unfolds,” he says of drone pilots, who are tasked with protecting troops and killing people, but, he says, experience little of the honor and bravery and physical adversity that tend to come with old fashioned warfare.
• “These drone pilots are doing the hard part from a human point of view, and they’re being robbed of the part where the integrity comes from, which is putting yourself in harm’s way.”

Contemporary military medicine discusses two types of stress in drone pilots: operational and combat stress. Operational stress: long hours, shift work, transition back and forth from combat to home life. Combat stress: seeing the images of injury and death – moral injury. Most personnel report operational stress as contributing to burnout and cynicism, though combat stress can play a role in individual cases.

See: “Facets of Occupational Burnout Among U.S. Air Force Active Duty and National Guard/Reserve MQ-1 Predator and MQ-9 Reaper Operators, 2011.” Joseph A. Ouma, Wayne L. Chappelle, Amber Salinas. Accessed via: http://www.thenation.com/wp-content/uploads/2015/05/a548103.pdf

So one question I had for Geroulanos and Meyers was to any analogues to moral injury in the shell shock literature of WWI. Relevant here would be the differences among physical and perceptual distance and intensity of battlefield engagements, from bayonet attacks to artillery work. How one faced and dealt out death on the battlefield might be associated with different forms of physiological and psychological trauma.

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Fourth, in a departure from the Geroulanos and Meyers ms I’d like to say a few things about case studies as a method for philosophical work. We don’t do too many of them, as opposed to our standard methods: 1) textual interpretation; 2) thought experiments; and, now, 3) “experimental philosophy” studies. But I think we should start using them, for Deleuzean reasons.

From an interview with University of Minnesota Press about Political Affect (2009).

I think case studies are an important and under-used tool in philosophy, as opposed to thought experiments. As generations of philosophy students know, one of the most famous of all philosophical concepts, Descartes’s cogito (“I think, therefore I am”), is arrived at via the thought experiment of the evil genius, who can fool you about the real reference of all your ideas. But he can’t fool you that you’re thinking while you’re being fooled. (You can be mistaken that you’re sitting at your computer, but you can’t be mistaken that you think you’re sitting at your computer.)

Contemporary philosophy has lots and lots of thought experiments: not just the brain-in-a-vat, which updates Descartes, but also zombies, teleportation, Twin Earth, Swampman, a whole bestiary and cartography of strange beings and places! But it has very few case studies. Why is that? 

I think it’s because much of contemporary philosophy is still basically “essentialist.” That is, thought experiments aim at identifying the necessary and sufficient conditions for an essential distinction. With a thought experiment you try to find the core unshakeable idea that provides the criterion for membership of a thing in a category. What properties does this thing share with other things, but only those other things, in this category? Thought experiments want to end with a particular type of “eureka,” the classifying eureka: Aha, this fits here, and that fits there! 

But with case studies we’re not after essential distinctions at the borders of categories. Instead, we’re trying to explore concrete situations and the “problems” they express. Here is where my reliance on the thought of French philosopher Gilles Deleuze comes in. Deleuze did not think in terms of essences that would slot things into categories, but thought that events are the points of intersection of “multiplicities.” That’s a technical term for Deleuze which roughly speaking means a field in which several processes meet to produce events, much as a crystal or a lightning bolt or a hurricane forms out of a field of multiple processes. In dealing with analogous multiplicities in our social fields we see that (1) any one move changes the conditions for future moves and that (2) no one solution exhausts the potentials for future creatively different solutions. 

Now to express the sense of this irreducible complexity, Deleuze thought multiplicities formed “problematic” fields, and these Deleuzean problems, the problems of life, cannot be "solved" once and for all; they can only be dealt with. My friend James Williams uses this example of a problem: “should we raise the interest rate?” You can see how any one move here will change the condition for future moves and that no one move will ever exhaust the problem: we’ll still have to think what we should do with the interest rate, always – or at least until the economic system changes so drastically that other pressures produce other problems. A problem might cease to be a problem, but the world will always be problematic.

So using case studies we come to realize that concrete situations are “problematic” in this sense. The more we explore the Schiavo case, the Columbine case, the Katrina case, the more we realize that concrete situations are “crystallizations” of a problematic field, and that a change here or there, if it occurs at a critical point, might make all the difference in the world. 

The real issue at stake is that thought experiments looking at essences have a basically static image of the world. Things have properties, and our job is to find the essential distinctions that enable us to group them with other things with the same core set of properties. But Deleuze thinks we need to look to the processes that produce things with properties. And those processes have “singularities” or turning points. 

So what we’re doing with a case study is seeing what processes have come together to form this concrete situation and in so doing we find their singularities, those places where if things had been different, the process and hence the situation which is the product of those processes, would also have been different.