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CHAPTER 1
The Whole on the Verge of Collapse: Physiology's Test
On or around June 1, 1905, Sigmund Freud published Three Essays on the Theory of Sexuality, which announced his concept of the drive: "The drive is ... one of the concepts on the frontier delimiting the psychic from the physical. What differentiates drives from one another and endows them with specific qualities is their relation to their somatic sources and their aims. The source of a drive is an excitatory process in an organ, and the immediate aim of the drive lies in the annulment of this organic stimulus." Around the same date, perhaps that very evening, the thirty-six-year-old English physiologist Ernest Starling was dining at Caius College, Cambridge. Ever since he and his brother-in-law William Bayliss had carried out experiments on the chemical control of the body a year earlier, Starling had become a star scientist. The experiments resulted in the invention of "secretin," which forced the revision of Ivan Pavlov's famous theory on the nervous control of the gut, favoring chemical control instead. Yet Starling remained unconvinced by existing names for the internal secretions that enabled the body's chemical governance, and, the anecdote goes, his fellow diner W. T. Vesey proposed a Greek-language alternative.
Three weeks later, in the first of four Croonian Lectures to the Royal College of Physicians, Starling adopted Vesey's idea. "The Chemical Correlation of the Functions of the Body" was due, he said, to hormones: "These chemical messengers, ... or 'hormones' (from [TEXT NOT REPRODUCIBLE IN ASCII], I excite or arouse), as we might call them, have to be carried from the organ where they are produced to the organ which they affect by means of the blood stream and the continually recurring physiological needs of the organism must determine their repeated production and circulation through the body." The coincidence is astonishing. There was Freud, publishing his first words on the drives that underpin mental activity, noting the drive's independence from consciousness, its "representation" of somatic processes, its organic and integrative origins, its residence on the border of soma and psyche, and its purpose in rebalancing energy. At that same moment, here was Starling, seeking a term to represent what Freud called a "continuously flowing, endosomatic" force, capable of "correlating" chemical functions, and opting for an active verb denoting "to excite or arouse," as he says, but also to rush someone, to overwhelm, to attack. Harkening to a tradition dating to Claude Bernard, who in the 1860s had first argued that what conditioned physiological activity was the body's organized internal environment, Freud defined drive in terms of a continuous internal response to an internal excitation or disequilibrium, a regulatory operation seeking "the removal of this organic stimulus." Starling, even better aware of his discipline's tradition, and committed in heart and mind to the development of a systematic, scientific physiology, practiced much the same nominalism, dreaming up the body as a proto-unity calibrated and held in check by a fluid system responsive to bodily needs and regulation.
Over the past century, Freud and Starling have been read in very different intellectual estates, where drives and hormones do very different work. But while any serious reader of Freud would chafe at too close a comparison between drives and hormones, there ought to be little doubt that Freud and Starling imagined fundamentally isomorphic processes, or that they produced mirroring concepts to represent what to them seemed like bodywide, unconscious activities that were responsible for internal regulation as well as for the subject's behavior. Starling aimed at biological laws of messaging and organization, relying on animal experimentation to craft a model of the human body. Freud proposed a metapsychology that could bring his theory of the normal maturation of human behavior into conformity with his pathological cases and his hermeneutic and therapeutic practices. Each of them attempted a theory of the individual, insisting on the subject's individuality while granting agency not to each subject but to internal forces almost entirely outside the individual's control.
The tradition that followed Starling's discovery remains to this day a pillar of medical and biological thought, but much remains to be learned about integrationist physiology, about its epistemological transformation during World War I into a full-fledged theory of the body, behavior, pathology, and society, and about its conceptual reconstruction of humanity for a new century. In the chapters that follow, we find purposes that were common to Freud and Starling intermingling in the work, the promises, and the failures of neurologists, endocrinologists, and surgeons. We explore their stories, which gave new meaning to integration and disintegration, and developed a new ontology of the soldier, the patient, and the human subject in general.
Drawing Together the Whole
The identification of hormones in 1905 marked a definitive advance in human physiology and testified to a moment when the broader interpretation of the human body began to shift. Over the subsequent three decades, medical thinkers in the English-, French-, and German-speaking worlds rethought the body in terms of the integration of its different parts, organs, and systems. "Instead of taking an organ, such as the liver, and talking about all the different things that it does," Bayliss wrote, "we intend to discuss the processes in which it plays its part with the other organs." It was a curious kind of integration, motivated and articulated above all by the danger that an integrated, self-regulated body often faced: that certain events leading to even minor disequilibrium could cause systemic collapse. What in the restricted domain of physiology began to be called regulatory physiology, what gradually came to involve the bodily and conceptual duets of integration and radical crisis, we describe as integrationism.
At University College London, Starling, Bayliss, and their students dissected dogs, cats, and guinea pigs to study stomachs, hearts, and adrenal glands and to explain how secretions controlled bodywide systems. Meanwhile, at Harvard Medical School, Walter Bradford Cannon and his collaborators had begun using newly invented X-rays to determine the mechanisms of swallowing and of the stomach. Their work gradually led to a novel perspective on the influence of emotions, hunger, and pain on these functions. By taking advantage of new technologies and experimental protocols, British and American physiologists tested and reworked their epistemic universe, and in so doing they developed a theoretical and experimental corpus to match the French and German physiological work that until then had been canonical — the schools begun by Claude Bernard in Paris and Johannes Müller in Berlin. This influential body of work contributed to the creation of entire laboratory objects and new theoretical fields, from the physiology of emotion to the toxicity of chemical substances normally coursing through the body. As it disentangled the chemical, nervous, and emotional threads of interdependence that held the body together, the new physiology also generated an ever-mutating collection of demands for theoretical revisions and practical and laboratory problems.
With the explosion of World War I, these newly emerging promises and problems were abruptly seized and given new direction by the urgent need for a therapeutic conceptual arsenal to deal with the physical and social consequences of wartime violence. As the war dragged on, physiologists, neurologists, psychologists, and clinicians came face-to-face with diseases, injuries, and whole-body responses to violence for which traditional models of the organism could not account. High rates of mortality and permanent disability resulting from bodily reactions to apparently minor, nonlethal wounds were disruptive to both regimes of care and medical theories of bodily functioning.
Wartime researchers' objective was no longer to describe pathological phenomena on paper; it was to intercede in the war's disordering momentum on the body, reverse that momentum, alter its sequelae, and devise acts of repair in the face of seemingly impossible crisis. The processes of collapse, exhaustion, disequilibrium, and shock exceeded physiologists' knowledge just as they strained the human body to its limits. There was no consistent, systematic precedent for conceptualizing them because they tore at both the whole body and its discrete systems. Only because of recent advances did they consider this whole body available to them. Put another way, the earlier lurch toward general biological laws had careened into an immense multitude of "cases" that could not be covered by those laws and that demanded a staging of their differentials. The mechanistic understanding of the human body's composition that had underpinned research and experimentation encountered functional, or whole-body, conditions that could not be attributed to lesions or localizable derangements of the young, male, human machine, and that at times seemed to pit organs or organ systems against each other.
By 1914, physiologists had only partly formed a new paradigm. They could identify the failure of traditional approaches, and they were obliged to work in new directions with a very different sense of urgency. By shattering and disfiguring the body, the war placed demands on medical thought that the laboratory had not. New physiological advances offered ciphers of a different understanding of this body, which had been revealed to be easily torn asunder. Violence — extensively studied in more recent years in cultural-historical perspectives focused on the injured soldiers' suffering — is for us a central object because of the interdisciplinary elaboration of new scientific theories that sought and failed to understand the conduits of a body reacting to its tutelage. We are concerned with the engagements that caused scientists and clinicians to animate their existing systems of knowledge in order to arrest and contravene the brutal emerging norm of bodily breakdown and to move toward a new terrain of biological understanding.
This sought-after terrain mapped quite well onto the work of neurological, psychiatric, and ethnographic researchers — especially in the ways that this work changed direction during and after World War I. None of these fields was subsumed by physiology, although they were not distant from physiological concerns either. Neurology and physiology had been closely tied, especially since Charles Sherrington's 1906 The Integrative Action of the Nervous System, but wartime concerns radicalized integrationist priorities with an eye to both nervous and physiological concerns.
In the specific instance of aphasia, patients with brain injury brought neurologists to the conclusion that most past research on the subject was all but useless: scientists had sought the precise location of functions in the brain, but now it appeared that the brain and mind were fundamentally dynamic, indivisible, and nonlocalizable constructions that responded elaborately to intrusions. The brain and mind would have to be rethought as neurologic and symbolic totalities. Among a number of innovative neurophysiologists from Germany to the United States, including Albrecht Bethe in Frankfurt, Alexander Luria in Moscow, and Karl Lashley at Chicago — particularly innovative were Henry Head in London and Kurt Goldstein in Frankfurt, the latter partly through his collaboration with the gestalt psychologist Adhémar Gelb. Head and Goldstein approached brain injury and aphasia by studying individual cases carefully and by considering not so much the injury as the disturbance of a symbolic universe or the destruction of wellordered, integrated behavior; they demonstrated a capacity for intellectual abstraction that correlated with freedom from and within one's environment. The Soviet psychologist Alexander Luria similarly dedicated a book in 1932 to the psychological understanding of neurophysiological "disorganization and organization," focusing on aphasia and other disorders as pathologies demonstrating strong neuropsychological integration, and emphasizing that his purpose was to offer "an objective and materialistic description of the mechanisms lying at the basis of thedisorganization of human behavior and an experimental approach to the laws of its regulation."
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Physiology — a field rarely hailed as inspired, and later eclipsed by the progressive subdivision of the organism in genetics and molecular biology — needs to be understood as a star player in these developments. As the threat of bodily collapse, breakdown, or disintegration became more widely shared and prevalent across disciplines, it obliged a reconceptualization of the body, most of which involved studying the ways in which integration occurred through the intertwining of the body's agencies, organs, and systems. Through its newfound disposition toward corporeal integration, physiology emerged around World War I as an umbrella for this research, stretching the connective tissue between sciences like neurology, endocrinology, and surgery. Together, scientists from these disciplines could look at the wounded differently and could derive from the profusion of cases and the differences among them explanations hinging on the interlacing of the body.
Severely tested and profoundly transformed by the war, the hormonal self that was brought forth in physiology created an array of research objects, from emotions to bodily shock and from histamine poisoning to brain injury and the symbolic self of integrative neurophysiology. This hormonal self of 1905-1914, radicalized by its research promise and viewed as a major contributor to the experience of harm due to injury, interacted with other, similar selves, from the aphasic to the traumatic to the anaphylactic, in what had become by then new sciences of the individual. Together these sciences delineated the bodily and psychic systems that at once guaranteed completeness and health, and also staged disease, violence, and suffering, while becoming far more attentive to the patient-specific qualities of dissolution.
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In the development of a new epistemology — in the rethinking of how the body works, lives, breaks down, recuperates, fails to recuperate, harms itself, and perishes — we find the play of experiment, therapeutics, and philosophy. We find the development of a "style of thought," one that gradually coalesced into this consistent epistemology. We find experimental innovations and novel technological possibilities responding to demands placed on bodies in the theater of conflict. The continuallyrevised regimes of experimentation, care for the injured, technology, and therapeutics offered repeated openings for concept building and theoretical revision.
Here we focus on the process of how, across different disciplines, new concepts were worked out — concepts that affected human beings at that most fundamental level where the sciences of embodiment interact viscerally with physical care and its failure. Our task is to trace the refinement of such concepts in formation and reformulation, as lenses were retrained and meanings were tested, mobilized, advanced, dispensed with, overwritten, or conflated with seemingly similar problems, only to present dead ends or new domains of inquiry. Our scientist-actors recognized the fullness of pathology's effect on human functioning, whether in the laboratory, in the field hospital, or in the society that would reabsorb the affected men.
Among the concepts that endured repeated revision were ones concerning disease and pathology, disarrangement and disintegration, health and recovery, and norms. Perhaps the main concept that this generation of thinkers restyled from the 1910s to the 1930s was that of the individual, and before we look at the way physiology and other disciplines conceived wholeness and integration, it serves to anticipate some of the questions concerning individuality that will arise throughout this project. The individual was suddenly freed up for clinicians and researchers as a problem, and not only in simple terms of the subjective clinical attention given to the single patient. As each individual seemed to suffer somewhat differently, the need for categorizations could no longer obviate differences in suffering and in the complex corporeal impressions of injury. Such a rethinking of the pathological organism and of the value of therapeutics imposed itself as the question of how individual organisms reacting to particular aggressions obviated, or at least displaced, the question of how laws and physiological meaning could be generated. Highlighting this is essential: this was a particular kind of individuality, one premised on a need to treat each human being regardless of gender, race, age, or social status as singular while, perhaps surprisingly, actively depriving that human being of agency, voice, and subjectivity. As we shall see, agency came to apply to the individual as a totality of internal systems and not to the individual as subject. One might give several reasons why, in a war famous for the literature of the soldier, physicians did not listen to the soldier-patient's voice. For more than a century the thrust of the patient narrative had been at odds with the interpretation of symptoms, and because of administrative conventions there was no place for the soldier's story within the clinical ledger. It was a question of value: the patient-narrator speaks askance to the priorities of physiology, whereas the body simply speaks. The diagnostician, rightly or not, looks for signs and symptoms along the lines of physiology's priorities above and beneath what the patient reports. In other words, there was no convention for recording because there was little apparent value in recording: only for a body that stuttered in confusion did the voice help clarify. Because bodily testaments to injury and emotional disequilibrium far superseded spoken narratives, soldier-patients were not the adjudicators of their own will and conditions in the way that memoirists and novelists have come to be regarded. Instead they were cases.
(Continues…)
Excerpted from "The Human Body in the Age of Catastrophe"
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