An exhibition at the National Library of Medicine National Institutes of Health • Bethesda, Maryland I i Emotions and Disease Emotions and Disease National Library7 of Medicine Bethesda, Maryland November 13, 1996 to May 1, 1997 Emotions and Disease An exhibition at the National Library of Medicine Exhibition Directors: Elizabeth Fee Esther M. Sternberg Visiting Curators: Anne Harrington Theodore M. Brown Friends of the National Library of Medicine Published in conjunction with the exhibition Emotions and Disease, organized by the History of Vledicine Division, National Library of Medicine This project was made possible by the generous support of the Charles A. Dana Foundation, the John D. and Catherine T MacArthur Foundation, the Fetzer Institute and the National Institute of Mental Health Copyright © 1997 Friends of the National Library of Medicine. All rights reserved Printed in the Lnited States of America Cover: (left) Walt her Ryff (d. 1548). Spiegel und Regiment der Gesundheyt, Frankfurt, 1555. Graphic: Photographic reproduction of woodcut illustration. (right) Rudolf Yirchow (1821-1902), Die Cellularpathologie in ihrer Begriindung auf PAysio/ogisrne und Pathologische Gewebelehre, Berlin, 1858. Contents Exhibition Directors' Statement page vi Emotions and Disease in Historical Perspective paee 1 Notes ac page 46 Checklist for Emotions and Disease page 52 Acknowledgments page 65 Exhibition Directors' Statement The exhibition Emotions and Disease was initially developed by the History of Medicine Division of the National Library of Medicine, in conjunction with the Third International Congress of the International Society for Neuroimmunomod- ulation which met at the National Institutes of Health in November 1996. The exhibition was intended to provide historical perspective and context for the scientific discus- sions and presentations at the Congress and to explain to the general public the meaning and relevance of scientific developments linking neurophysiology to the functioning of our immune systems. Using the historical approach, we believed we could make these sophisticated scientific devel- opments more accessible to a non-specialist audience. The historical approach could also be used to show the complex relationships between scientific theories, popular ideas, and their cultural context. One of the paradoxes we found was that the close relationship between health, disease, and the emotions seemed to be more readily accepted in popular culture than within the contemporary scientific community. Why, we asked, has the close relationship of emotions to disease been so central to the long history of medical practice, yet has been regarded with suspicion by some sectors of the modern bio- medical community? This exhibition evolved as a dialogue between scien- tists and historians pursuing answers to these questions. The dialogue has been fruitful, although difficult at times. The historians involved have had to learn some of the language and perspectives of the biomedical sciences, and the scien- tists have had to cope with the different language and per- spectives of the historians. Working on this exhibition, we found that the collaboration across disciplines, indeed across the great divide between contemporary science and the humanities, can be a rewarding adventure for all participants and well worth the occasional linguistic, philosophical, and political struggles involved. The results appeal to and engage a variety of audiences from students of science and history to professionals in these fields. vi We would like to thank Dr. Sheldon Cohen, himself a model of interdisciplinary work between the history of med- icine and contemporary science, for introducing us: Elizabeth Fee, a historian of medicine, and Esther Sternberg, a neuro- endocrinimmunologist. Together we developed the general outline of the exhibition and invited Anne Harrington and Theodore M. Brown to serve as visiting curators, responsible for the overall intellectual development of the exhibition and tor writing the panels, captions, and catalogue materials. Gretchen Hermes joined us for a summer as assistant curator. Key to the success of the exhibition were our panel of distin- guished consultants and the timely and generous support of the Charles A. Dana Foundation, the John D. and Catherine T. MacArthur Foundation, the Fetzer Institute, and the National Institute of Mental Health. Also essential were the invaluable contributions of Lou Storey as exhibition designer, Anne Whitaker as collections manager, and Patricia Tuohy as exhibition manager. The acknowledgments in this catalogue recognize the many individuals who contributed to this pro- ject and to whom we are grateful. The talented people involved in the creation of this exhibition have worked together to show how historical research and contemporary science, presented through cre- ative use of visual design and modern media, can be effective in bringing new forms of scientific understanding to the pub- lic. We believe that the history of science and medicine can help us understand and appreciate the frontiers of science while also demonstrating the ways in which our forebears have addressed, explored, and puzzled over the same issues that engage us today. By addressing past and current contro- versies in science and medicine, we hope to captivate public interest and help build awareness of the need for further his- torical and medical research. As in the case of Emotions and Disease, federal agencies and private foundations can work together to produce attractive and instructive educational materials on health and medicine for the public. We hope this project may serve as an inspiration and model for many other such efforts. Elizabeth Fee, Ph.D. Chief, History of Medicine Division National Library of Medicine Esther M. Sternberg, M.D. Chief, Section on Neuroendocrine Immunology and Behavior National Institute of Mental Health vn JCut from Walther Ryff |d I 548). Spiegel und Regiment der Gesundheyt, Frankfurt, 1555 ■r-.de scene in a traditional medical set' - ig, the physician is in close contact with the patient, taking the pulse and in easy : .•-'!■■<; -ange 72 Emotions and Disease in Historical Perspective Theodore M. Brown In the world today, science is about to validate long-held beliefs about the relationship between emotions and disease. A new field of research, exploring the connections between the neuroendocrine and immune systems, has already pro- duced exciting discoveries which promise to confirm, in the most modern scientific terms, the influence of emotions on the onset, course, and remission of disease. For centuries and long before the first glimmerings of modern science, physi- cians and non-physicians alike have acknowledged that the way people felt in their minds could influence the way they responded in their bodies. When prevailing medical theory denied the very possibility of such interactions, common experience and sometimes quite startling clinical encounters suggested otherwise. The relationship between emotions and disease has often been like a haunting melody that could not be forgotten, while it has sometimes surged into full chorus. It has been this way ever since the beginning of the Western scientific tradition. Although the specific terms of discussion have changed many times in the course of history and even though medicine has been transformed several times in the process, perceptive observers have regularly returned to the study of the interactions of body, mind and medicine. These interactions have continued to fascinate, even though they have never been completely understood. At times when the majority of physicians and scientists focused attention elsewhere, a minority refused to let the issues die. Now the issues are back again, front and center, in the convergent focus of the lay public, clinical medicine, and modern laboratory science. This exhibition highlights signifi- cant achievements and major turning points on a well-trav- eled historical road which is taking a turn yet again as it leads into the promising but indefinite future. Hippocrates, Hippokratous . . . latrike, Basel, This is a Renaissance edition of works by Hippocrates, with parallel text in Greek and Latin. The Balance of Passions This story begins, as did so many other components of our culture, in Greek and Roman antiquity where medicine first emerged as a secular activity independent of religion. There Hippocrates (ca. 460 B.C.-ca. 370 B.C.) and his followers com- bined naturalistic craft knowledge with ancient science and philosophy to produce the first systematic explanations of the behavior of the human body in health and illness. Distant ancestors of modern biomedical scientists began to explore the solid and fluid parts of the human organism for keys to unlock the hidden mechanisms of disease. They made the first attempts to understand emotions as mental phenomena which had surprising and complex connections to physiologi- cal order and pathological disorder. Early Western physicians recognized that emotions were of essential significance, however, their medical systems were actually weighted more heavily on the body side of the mind-body balance. The dominant theory of Hippocrates and his successors was that of the four "humors": black bile, yel- low bile, phlegm, and blood. When these humors were in bal- ance, health prevailed; when they were out of balance or viti- ated in some way, disease took over. The goal of an individ- ual's personal hygiene was to keep the humors in balance, and the goal of medical therapy was to restore humoral equi- librium by adjusting diet, exercise, and the management of the body's evacuations (e.g.: the blood, urine, feces, perspira- Johannes de Ketham (fl. 1455-1470), Fasciculus Medicinae, Vienna, 1495 Johannes de Ketham, a professor of medicine in Vienna, published Fasciculus Medicinae, which included illustrations on bloodletting and urine flasks snowing the "resemblance of the elements and the bodily consti- tutions.' This is an English translation of Latin text. 7 don, etc.). The bedside scene from Walther Ryff's Spiegel und Regiment and the diagram from Johannes de Ketham's Fasciculus Medicinae, although both from later periods, clearly illustrate these classical themes. Emphasizing the humors gave classical medicine what modern philosophers call a "reductionist" bias—the humors were used to explain more complex phenomena like emotional states in much simpler physical terms. For exam- ple, when a patient was melancholy, physicians assumed that his or her complicated feelings of sadness and depression resulted from the physical excess of black bile. Likewise, an excess of yellow bile was thought to make a person angry and impulsive. In the Hippocratic treatise The Sacred Disease, the author explains that "those maddened through bile are noisy, evil-doers and restless, always doing something inop- portune"2; this explanation assumes that emotions are the more complicated consequences of the simpler and prior humoral causes. Even in the unmistakably reductionist Hippocratic writings, however, certain emotional states appear as causal elements. In one case, a woman began to exhibit fears, depression, incoherent rambling speech, and the uttering of obscenities after suffering from a "grief with a reason for it"; and another "without speaking a word . . . would fumble, pluck, scratch, pick hairs, weep and then laugh, but. . . not speak," also "after a grief."3 In The Sacred Disease, epilepsy is said in certain circumstances to be "caused by fear of the mysterious."4 Emotional factors played only a minor role in the subsequent development of classical medical thought because authors after Hippocrates continued to rely primarily on humoral-reductionism and did not actively pursue emotional causal elements. These medical authorities worked hard to clarify and codify the humoral ideas embedded in Hippocrates's work. They also systematized a therapy based on "opposition," w hereby excess humors were depleted and "cold" medicines such as oil of roses countered "hot" dis- eases like fevers and vice versa. Some writers in late antiquity also added important anatomical features to their reductionist medical systems.5 But another dimension to medical thought became increasingly prominent in later antiquity. This was the orien- tation towards emotions as causes, which was strongly influ- enced by Galen (A.D. 131-201). Known for his prolific writ- ings and essential loyalty to humoralism, he was accepted in the medieval and Renaissance periods as coequal with or even superior to Hippocrates. Deeply respected for his diag- nostic skill, Galen was celebrated for his differential diag- noses, especially for those which distinguished between ill- nesses traceable to organic causes and those which seemed to mimic them but were actually traceable to emotional causes Justus Cortnummius (ca. 1624-1675), De Morbo Attonito Liber Unus, Leipzig, 1677 For much of the medieval and Renaissance periods, Galen and Hippocrates were regarded as coequal medical authorities, with Galen even assuming a superior position for certain medical teachers or com- mentators. In the seventeenth century, however, the more empirically oriented Hippocrates came to be regarded as superior to the more theoretical Galen. This distinction between the two men is depicted here on the title page by Hippocrates touching the rose- bush on the side of the flowers and Galen touching the side of the thorns. Galen, Opera ex Sexta Juntarum Editione, Venice, 1586 Galen is making a diagnosis of love-sickness. 3 . . . $' cewte to t/tc co/ic/ics/o/i- tAat s//c urns saffe/wui/ro/H o/tc oj t/oo t/u/tps.: e/t/te/^/rom- a /tte/a/tc/io/t/ CL/e&€fic/ent o/i k/acA o//e, or »twuk/& a/wut so/ttet/t/'/u? s/te oxm ufiusi//v2x^ to cotf/ess. Galen As quoted in Galen—On Mental Disorders, Stanley W. Jackson 1 1 Maimonides (1 135-1204), Tractatus Rabbi Moysi de Regimine Sanitatis ad Soldanum Regem, Augsburg, 1518 Gregor Reisch (d. 1525), Margarita Philosophica cum Additionibus Novis, Basel, 1517 Gregor Reisch included an often-reproduced woodcut profile of the head in his book Margarita Philosophica. The figure locates various faculties of the soul fcogitation. memory, etc.) in specific regions. Note that Imaginativa (imagination) is located directly over the eyes. instead. In one famous case he treated a young woman who seemed to exhibit the signs of physical illness but who, upon closer examination, revealed no organic pathology. After elim- inating any possible humoral explanation, Galen identified the real, emotional cause of her somatic symptoms: a hidden love interest.6 He used the sudden irregularity of her pulse as a crucial diagnostic clue. Galen likewise contributed an important new interest in the balance not only of the humors but of what he called the "non-naturals," among which he included the "passions or perturbations of the soul."7 According to the doctrine of the non-naturals—which was incorporated in medieval medical books alongside the humors—it was important for physicians to help patients keep their emotions in balance, for the sake of their bodies as well as their mental states. The influence of strong emotions on physical health and illness thus became a central tenet of medical belief which grew progressively stronger in the medieval period. As rabbi, philosopher and physician Moses Maimonides expressed the point in the twelfth century, "It is known . . . that passions of the psyche produce changes in the body that are great, evident and mani- fest to all. On this account... the movements of the psyche . . . should be kept in balance . . . and no other regimen should be given precedence."8 Ideas about the "balance of the passions" were popu- lar in the Renaissance and early modern periods. One famous work showing how influential these ideas would become is Robert Burton's The Anatomy of Melancholy which included the following observations about the possibly disastrous role of unchecked emotions: "the mind most effectually works upon the body, producing by his passions and perturbations miracu- lous alterations . . . cruel diseases and sometimes death itself."" Also in this period, speculation about the role of the "imagination" added other elements to the non-physical caus- es of disease. Some authors suggested that the imagination affected the body directly by its immaterial agency, others that it operated indirectly by first arousing the emotions which, in turn, "are greatly alterative with respect to the 4 ^■^^■JouMma&coe&^tAataatA**^ and a// tAeAeaAAj, ^oaUfo^cAc^sfMalatalll&ne*, and'tAat da, sAoa/dde relievedtftfofiaw^tfifojte^ tAat cause a/ior/etu. Moses Maimonides (1135-1204) The Regimen of Health Ambroise Par^ (15107-1590), The Workes, London, Speculation about the influence of the "imagination" was intense during the Renaissance period. It was widely believed that vivid ideas could lead to various bodily consequences, including diseases and monstrous births. Pare, a famous early surgeon, reported on two cases, one of a child born with the body of a calf, and another that occurred in 1517, of a child "born having the face of a frog," pro- duced by the power of the mothers imagination. The mother, advised by her neighbor to hold a live frog in her hand as a means to cure her fever, was still holding the frog that evening, when she and her husband conceived a child. William Falconer (1744-1824), A Dissertation on the Influence of the Passions Upon the Disorders of the Body, London, 1788 body."'" There was general agreement that emotionally- charged ideas could exert enormous effects, as in the case of the monstrous "frog baby" produced by vivid maternal imagi- nation, reported by Pare. Intellectuals and lay people alike were strongly committed to these ideas in the seventeenth and eighteenth centuries. While certain philosophical fashions within the medical community changed to reflect the Scientific Revolution going on around it, much medical practice remained traditional and fundamentally unaltered. Consider- ation of the role of the imagination and of strong emotions in the onset and course of illnesses continued into the nine- teenth century. Medical literature included extensive essays and specialized monographs on emotional states and their impact on somatic health and disease.11 One example is William Falconer's A Dissertation on the Influence of the Passions Upon the Disorders of the Body. Bobonne, Bobonne, tu me ferais un mon- stre comme ca, ne le regarde pas tant!, Honore D'umier (1808-1879) S^ The hu- tempting to '-ad his pregnant v ooae of V~< great apes at the ■"■a: \y. ioom' ■ at the ape in her ■ ■ . . • h ■- -r :■ deformed In many ways, however, the close of the eighteenth century marked a new era. As part of the Scientific Revolution, anatomical investigation once undertaken in antiquity had revived and became a hotly pursued field of study. Andreas Yesalius in sixteenth century Padua and Thomas Willis in seventeenth century Oxford were just two of the many bold explorers who cut into the body, probed its structure, and displayed their findings in beautifully illustrat- ed works. In the eighteenth century, physicians increasingly turned to anatomy as a foundation for pathology. As a result, disease processes were progressively "localized," that is, said to reside primarily in the disruptions or "lesions" of the solid AltyTOMlCOXVM ltiSTIJr'MZ'HJOFjrM DEUVJJTIO. QVADRAGESIMIPRIMI CAPITIS FIGVRARVM, eiufdcmq; charafterum Index. Illustration of dissecting instruments from Andreas Vesalius's De Humanl Corporis Fabrica. The De Fabrica, the first modern work of anatomy wasSally published in 1 543. This plate is from the 1568 Ven,ce edition. Andreas Vesalius Edouard Hamman (1819-1 What is particularly notable about this scene of Vesalius about to perform an autopsy is his gaze, directed away from the cadaver, and his hand resting on the left arm, almost as if taking a pulse. Like the Chartran portrayal of Laennec, this nineteenth century image strongly conveys the anatomical basis of the new medicine. Andreas Vesalius (1514-1564), De Humani Corporis Fabrica, Venice, 1 568 7 Thomas Willis (1621-1675), The Remaining Medical Works of Thomas Willis, London, 1679 An outstanding example of seventeenth-century anatomi- cal achievement was Thomas Willis's Cerebri Anatome (On the Anatomy of the Brain), first published in 1664. Shown here are Willis's engravings of the human brain (left page) and of the sheep brain (right page). parts of the body rather than in the imbalance of humors. Post mortem dissection became an increasingly common medical practice.12 At the turn of the nineteenth century, diagnostic breakthroughs swiftly succeeded the maturation of gross pathological anatomy. R.T.H. Laennec invented a primitive stethoscope (he called it a "cylinder") to help him hear inside his patient's body and thus imagine what the parts "looked" like because of the particular sounds they elicited. In the process of concentrating their attention on the anatomical abnormalities of the solid parts of the body during an illness and as a result of disease, Laennec and other physicians of his time gained precision in their diagnoses but began to lose the immediacy and intimacy of verbal contact with their patients.13 Clearly captured in Chartran's painting of Laennec performing a physical examination is the growing communica- tion gap between doctor and patient, each seemingly con- tained in his own separate world. This stands in sharp con- trast to the scene typically depicted at the medieval bedside. The further development of microscopic anatomy by Rudolf Virchow and others in the nineteenth century led to Laennec-style Stethoscope In 1819, Laennec first described his powerful new diagnostic invention, the. cylinder-like stethoscope. The physician placed one end of the instrument on the patient's chest and his ear to the other, so he could listen to the sounds of disrupted anatomy within. Courtesy Historical Collections, The National Museum of Health and Medicine, Armed Forces Institute of Pathology, Washington, D.C. Laennec, A I Hopital Necker, Ausculte Un Phtisique Theobald Chartran , 1849-1907) Rene Theophile Hyacinthe Laennec (1781-1826), De ('Auscultation Mediate, ou, Traite du Diagnostic des Maladies des Poumons et du Coeur (On Mediate Auscultation, or. Treatise on the Diagnosis of the Diseases of the Lungs and Heart), Paris, 1819 The stethoscope is illustrated here in a fold-out plate with parts of the lung shown at the right. H Rudolph Virchow (1821-1902) is regarded as perhaps the greatest medical scientist of the nineteenth century. He was a pioneer in the field of cellular pathology and pursued pathological anatomy at the tissue and cell level. Rudolf Virchow, Die Cellularpathologie in ihrer Begriindung auf Physiologische und Pathologische Gewebelehre, Berlin, 1858 In Virchow's most influential book, Die Cellularpathologie, he described and depicted the precise microscopic structure of Ceiis-including nerve cells-but seemed to leave no place in the body's operation for the influence of the emotions. greater knowledge of tissues and cells. This development, unfortunately, also fragmented the notion of organismie unity implicit in classical and early modern medical theory. Emotions became more and more separated from disease. By the mid-nineteenth century, however, a place was secured for emotions in connection with disease even as post- mortem anatomy and cellular pathology advanced. Already in the eighteenth century William Cullen had noted that patients with certain major disorders—"insanity," for exam- ple—did not always show the expected organic lesions upon postmortem dissection. He reasoned that, instead, such patients may have developed "a considerable and unusual excess in the excitement of the brain" and that this excite- ment could in turn have derived from "violent emotions or passions of the mind."15 Cullen and Robert Whytt were two William Cullen (1710-1790), First Lines of the Practice of Physic, Edinburgh, 1784 .../// is/ai/iy //tsta/ice$ oft/Mcuz&f^rsofis,, tAeir- l>rair?s AadAeesi e.xxmt//?(> (oAo/^etbeat to tAe/nsdom, "9foutA, A?ea/tA, otpo/\r\ . . William James The Varieties of Religious Experience, 1902 William James Notman (photographer) ?? Despite professional anxiety and disapproval, self- healing continued to spread in the twentieth century. John Kearsley Mitchell's Self Help for Nervous Women and Charles Fremont Winbigler's How to Heal and Help One's Self are just two examples of the literally hundreds of books, manuals, and magazines that were published in the early decades. Emile Coue's technique of "autosuggestion," according to which patients affirmed to their own image in a mirror that "Day by day, in every way, I am getting better and better," was just another, mildly hypnotic self-healing ritual which became a national fad in the early 1920s.31 The creation of Alcoholics Anonymous in the thirties as a network of self-help groups drew from these same sources.'2 By the 1940s the self-help movement took on an increasingly secular, more psychologi- cal and less religious tone.33 Dale Carnegie's How to Stop Worrying and Start Living, Norman Vincent Peale's The Power of Positive Thinking, and Thomas Harris's I'm OK—You're OK were later representatives of the genre, as was the "Laughter is the Best Medicine" feature in Reader's Digest. The emphasis on the positive role of upbeat emotions has been continued recently in Norman Cousins's many books and articles, even though Cousins rested his self-help advice more heavily on medical authority than did most of his predecessors.34 Focus on the salutary effect of optimism had another important consequence for medicine: it put long-standing popular enthusiasm for "cures," "remedies," devices, and so- called "patent medicines" in a new perspective. At the turn of this century, organized medicine fought a pitched battle with those purveyors of hope one historian has called the "Medical Messiahs"—and generally won, at least in the sense that in 1906 Congress endorsed the American Medical Association's campaign and passed the Pure Food and Drug Act, which banned false and fraudulent advertising and labelling practices.35 The AM A was even more effective in curbing the commercial drug market by creating its own regulatory mechanisms for product testing and surveillance and by putting pressure on newspapers and magazines to refuse lucrative advertising revenues.36 But astute physicians realized that well into the twentieth century, people contin- ued to purchase extraordinary quantities of worthless nos- trums—"Boyd's Batteries" and even "powdered unicorn's horn"—not merely because they were gullibly manipulated bv quacks and cheats but because people believed that at least a few of these products, in some sense, really "worked." Patients often felt better after following a commercially pur- veyed regimen or swallowing a mass manufactured tonic. In certain cases they actually did get better. "Mental medi- cine" of some sort, the physicians assumed, was operating behind the scenes. Many times before, physicians had confronted the phenomenon of misplaced public trust validated by apparent- ly successful cures. One of the more notable episodes 23 Norman Vincent Peale (1889-1994), The Power of Positive Thinking, New York, 1992, ©1952 Reproduced with permission of Random House Thomas A. Harris (1913- ), I'm OK—You're OK, New York, 1973, ©1967 By permission of Avon Books sav a sentence without snapping his ^ fingers. So the wife finally prevailed V upon him to see a psychiatrist. ^ While the psychiatrist interviewed^ him, the exasperating quirk asserted w itself. "Are vou happily married? Ever quarrel with your wife?" "Oh, (snap) never. She's the finest | woman a (snap) man could wish for. ^ We're deeply in (snap) love." || "Gut along with vuur boss?" f "Marvelously (snap), lie's pruba-lf; bly (snap) the most congenial (snap|J| boss in the city of New (snap) York."J| "Teli me," the psychiatrist contiririp Lied, "did you ever feel resentful oE;f|| your father or mother?" "No (snap), they were (snap) ideal parents, always (snap) loving anil under(snap)standing." ,.gj Desperate, the doctor uujuiretPlp point blank, "Then why this'compuk&j sion to snap vour fingers?" ;-;N|M "Oh (snap)," the patient iep«&js "perfectly (snap) simple. I do that tAj keep the (snap) elephants away." ^rjg ■•Bl, g0„d u*. ™«y-j)g£ the best medicine Mrs. Dexter Fellows, widow of the well-known circus press agent, tells about the time her husband was traveling with a Boupe in a Western city and a Bon escaped. A posse was hasdlv ibrmed to track the beast down', but before the search began the men stopped at a saloon where they all ordered drinks. All. that is, but Fellows. "Oh, tome on," he was urged, "have a drink with us." "Not me." Fellows said in a shaky voice. "Whiskey gives me loo much courage." In nit advertising business a great promotional idea can raise a man overnight into the high income brack- ets. And, if ivc ever heard an idea that was sensational, this is it. They were looking for a name for a new product in one of the conference rooms on Madison Avenue, when a copywriter suddenly sprang to his feet. "I've got it!" he cried "Let's call it Brand X and cash in on all die free publicity." - Jm* Siding Show, CBS I eUecmnVJ know then ithin 20c "You (snap) s beaming. "Damned (si what?" - Com A fellow I know who let Ids sports car get somewhat ahead of the spml limit was pulled over to the curb ' Igj a motorcycle cop who leaned onftej; door, tapped Ms cap back and ask* ; "So which way are they coming -tygj land or by sea?" . '■'} : business occasionally takes him to Maine reports that at die , "Laughter is the Best Medicine," Reader's Digest, April 1958 By the middle of the century, even such mainstream journals as Reader's Digest had absorbed the mes- sage that positive emotions were "good medicine." Courtesy Ghilta Sternberg. Used with permission from Readers Digest f* V mSsL REMEDIES Fevers Conrrfsaiari 2 Worms.WomreverWoimC 3 T(lttll«{ toht tryl«5 Sleepl- 4 Oiarrhda OICnildieMrAt 5 OysdHeryci.pn.jji.ousc 6 Cholera Morbus, vomiim; 7 COUgtlS ColdsBtmrnitu 8 Neuralgia Tooinacl* racea 9 HtaoaChei S.ckHpadatrit.V 10 Dyspepsia,indi^sinnwuk 25 20IWItaepilHJ CoUjI.Siosmnlit CKfli 25 II Ear Discharges. Ear 25 a Enlar ■" ' 25 24 General OeiiMy pn.5,1 25 2St1a*sea Vomiting, Sea Sickness 25 9 Heaoaches Sn»nn*«tcJ(iJiiji 25 2V Kidney Diseases 25 10 Dyspepsia.in^isi-Diiweiksiimitn 25 28 Nervous Prostration too u Suppressed Menses ami Scanty 25 23 Sort-Monti,.CiBter.FwerSires. 25 IZ leucorrheaarProtuse Menses 25 30 Urinary Weakness •trfct;* M 25 13 Lnuf.mmmmiwyfK 25 31 Painful Menses. 25 14 [czema Erysipelas, emotions 25 32 Disorders ti itfHean Mpt** 100 IS Rheumatism ana Rheumatic fams 25 33 Spasms and Convulsions 100 IG Malaria Cltilis fever andA;ue 25 34 SoreThroalUu.ns,-UkeratM Ttiical <5 17 Puts gr Hemorrhoids. 25 K Chronic Congestions amitnstions 25 IB Ophthalmia or Sore Eyes. 25 77 Grip. La Grippe Grippe 25 m ■ 111 ■51 ^1 \NT1 BIIJOUS 1 ■ ■ilTTERSl ■?H||"iw"*'u"' 1 1 3 1 Unicorn's Horn Courtesy Elaine and Arthur Shapiro Warner's Safe Cure Almanac and Book of Handy Information 1895, Buffalo, New York (upper rightj from the National Library of Medicine, and a selection of "patent medicines" from the collection of Elaine and Arthur Shapiro Powdered Unicorn's Horn Courtesy Elaine and Arthur Shapiro Benjamin Douglas Perkins (1774-1810), The Family Remedy; or, Perkins's Patent Metallic Tractors, For the Relief of Topical Diseases of the Human Body; and of Horses, London, 1800 John Haygarth, Of the Imagination, as a Cause and as a Cure of Disorders of the Body; Exemplified by Fictitious Tractors, and Epidemical Convulsions, Bath, 1800 Four Batteries Perkins's Metallic Tractors may have been exposed as fraudulent, but the public has repeatedly resisted the cautions of the medical establishment and contin- ued over the years to "discover" the therapeutic power of similar kinds of objects. In this century, "Boyd's Batteries" and similar objects were worn around the neck to improve flagging energy and soothe various aches and pains. Courtesy Elaine and Arthur Shapiro involved a patented device called "Perkins's Metallic Tractors." These little pins were advertised as curative for "topical diseases" from gout to rheumatism. Many discerning people, including (Jeorge Washington, testified that the trac- tors worked. Dr. John Haygarth attempted to expose the fraud (he found that wooden pins worked as well as the allegedly metallic ones that were supposed to channel the body's "galvanic" electricity) in a tract entitled Of the Imagination, as a Cause and as a Cure of Disorders of the Body; Exemplified ay Fictitious Tractors, and Epidemical Convulsions. Haygarth's attempt to discredit a popular fad by highlighting the therapeutic role of aroused imagination was repeated by other medical authors, perhaps most impressively in the widely read Illustrations of the Influence of the Mind I'pon the Body In Health and Disease, Designed to Elucidate the Action of the Imagination, written by the respected British psychiatrist Daniel Hack Tuke. Tuke exhaustively documented the Perkins episode but concluded with a critique of the medical profession. Those physicians like Haygarth who debunked Perkins by pointing triumphantly to the role of the "imagina- tion" and then dropping the issue without seeming to care whether or not patients actually improved, displayed a behav- ior that struck Tuke "as astonishing as that the public should believe in, and allow themselves to be cured by, the metallic tractors."37 By 1900 a sizeable group of American physicians regularly invoked Tuke as a weighty authority as they battled against both public credulity and seeming professional indif- ference to "mental medicine." The issue was quite complicated and compromised for physicians. Many of them were aware that they too pre- scribed medications whose principal basis of action was the dn tAu^fu/tAt uducA use Auwe to umae ince&santA/y againsti^arances and o-uacAeru; amon^ tAe massd& amAfodie& of a//sort? amonay tA& cAas^es,, diaaria- sis, not aruqytngA, u? oar cAi^aj^afon ofoffeAe&. William Osier Aequanimitas, "Chauvinism in Medicine," 1904 26 patient's credulous belief. The term "placebo" was long used in medicine for a prescribed substance thought to be medical- ly inert but helpful for cajoling or controlling "neurotic" patients by giving them something in which to believe and by which they might be "cured." w The most experienced and sophisticated physicians knew that many medicines thought to be effective were really not, at least not on the basis of pharmacological principles. The regular profession was itself often guilty of "over-drugging." Thus William Osier, the beloved and influential turn-of-century professor of medicine at Johns Hopkins University, could slap down quacks and jab at his colleagues at the same time by saying, "In the fight which we have to wage incessantly against ignorance and quackery . . . diagnosis, not drugging, is our chief weapon of offense." Some went even further. Lewellvs F. Barker, Osier's successor as professor of medicine at Hopkins, suggested that whatever success modern physicians had with their pre- scribed medications depended largely on their ability to "awaken confidence and inspire the idea of authority by their scientific training and by their mode of inquiry and of exam- ining the patient."39 Even more provocatively, Harvard profes- sor of psychiatry C Macfie Campbell declared in a much noted 1924 lecture that physicians sometimes brought about the improvement of their patient "unwittingly, when the patient is already prepared for the display of power." "It is well to realize," he cautioned, that the patient "who comes from afar to a great medicine-man with these wonderful machines, which extract wisdom from the air, is already half- way on the road to recovery."4" Thus the groundwork was laid for the serious investi- gation of the role of hope, imagination and expectation in the operation of medications and procedures in scientific medi- cine. W.R. Houston defined the issue clearly in a 1937 address to the American College of Physicians when he said, "The great lesson ... of medical history is that the placebo has always been the norm of medical practice."41 Eugene F. DuBois, professor of medicine at Cornell University, 9/ous caruwt adrifo afresxy^ftton uHtAuAut t/w eAement oft/i& tdaceAo^. Afreiud^toff^^ tAwJkwurfttions. Scarries, ade&At, tA^a^^cfttd^ Eugene F. DuBois "The Use of Placebos in Therapy," Cornell Conferences on Therapy, 1946 27 expressed similar sentiments in 1^46. B\ this time drug companies were marketing code-named placebos for use in clinical practice. Soon afterwards, scientists conducted experi- ments on placebo effects. This coincided, not accidentally, with the period when the pharmaceutical industry was pro- ducing penicillin and other "wonder" drugs whose full power and range of action had not yet been tested and when psychosomatics had become a central concern of mainstream medicine.4-1 Rigorous studies, often measuring placebo effects in experimental drug trials, multiplied rapidly, more being published in the four years from 1954 to 1957 than in all prior Placebos were produced for clinical use in a range of different shapes and colors and physicians even discussed which colors and shapes worked best. Bottles were labeled with simple code names (Cebocap, Obecalp) so patients would not catch on to the fact that they were being given a placebo rather than a real drug. Milk sugar (or lactose) was the classic placebo that physicians sometimes used in their SSJSS. ^ °f mi'k SU9ar ^^ ™^Pr°dUCed for " ^"ck Courtesy Elaine and Arthur Shapiro 2« years combined. In 1955 one of the leading young investiga- tors, Louis Lasagna, was invited to write about placebos in Scientific American, a clear sign that the field had "arrived."43 Serious work on placebos continued over the next two decades. Investigators pursued many fruitful lines of research, but two of the most productive turned out to be the exploration of psychological mechanisms in experimental subjects identified as "placebo reactors"44 and the specifica- tion of the brain biochemistry which underlay placebo effects.45 In one of the most suggestive studies in this second line of research, published in The Lancet, Levine, Gordon, and Fields concluded that the activity of "endogenous opioids"(the body's own opium-like substances) accounts for "placebo analgesia." Although there are many unanswered questions, by the late 1970s it appeared as if both clinicians and basic scientists had accepted the placebo effect as a central phenomenon in medicine—indeed, as one of the body's arsenal of self-protective weapons—and thought it ultimately explicable in the most modern biochemical terms. S-r.iv2lZ£«— Jon D. Levine, Newton C. Gordon and Howard L. Fields, 'The Mechanism of Placebo Analgesia," The Lancet, September 23, 1978 ©1978 by The Lancet Ltd. By the ,950s, medical researchers began to use placebos in a «^^ and others dummy drugs that looked identical-ancI therurompaed ^^^^^^^ effect of its placebo. bo effect in its own right, but to sort out the real effec of f^6^.^^ ™B^e Antidepressant medications. Pharmaceutical companies produced these placebos in the 1960s for use in tesony a i* y Courtesy Elaine and Arthur Shapiro 29 Long Island Expressway 'he stress of everyday life often begins with the drive to work. Courtesy Peter Gridley/FPG Stress and Deprivation During the same few decades which saw great advances in the understanding of placebos, psychosomatic medicine also underwent significant changes, both in the research and clini- cal field and in the wider area of popular interest. The most important changes centered on the virtual abandonment of ideas about the role of unconscious emotions, early childhood experiences, and personality peculiarities—all derived from psychoanalysis. These ideas were replaced by a focus on manifest emotions, current life situations, and the socio- environmental circumstances in which disease occurred.46 Scientists often stated the newer formulations in terms of maladaptation and loss or, more commonly, "stress" and "deprivation." Researchers drew from physiological theory and experiment and extended their concepts to all diseases, not just the classic "psychosomatic seven" (which included peptic ulcer, asthma, hypertension and, depending on the psychosomatic texts, colitis, cardiac arrhythmia, neuroder- matitis, and hyperthyroidism). Yet at the same time that sci- entists broadened the range of emotion-disease connections, the once almost unquestioned presumption of psychogenic etiology for the "psychosomatic" diseases gave way to an increasingly somatic orientation. In the realm of therapy and disease management, individual psychotherapy was replaced by stress reduction, structured mobilization against feelings of loss and loneliness, and increased reliance on the therapeutic options of biomedicine. The decline in the medical popularity of psycho- analysis, evident in the late 1950s and continuing in the 1960s and 1970s, set many of these changes in motion.47 Leading researchers submitted analytically-based theories of peptic ulcer, asthma and ulcerative colitis to searching criticism and substantial revision. Therapeutic approaches relied more and more on new drugs and medical interventions and less and less on psychodynamic psychotherapy.4" In the most dramatic case, scientists have recently attributed the cause of peptic ulcer to a spiral bacterium, best managed clinically with antibiotics. This new movement even attacked conversion hysteria—one of the major contributions of Freud and a mainstay of psychosomatic theory. Several important critics started picking at the loose and unreflective consensus that had come to surround symbolically interpreted hysteria. One of the most influential critics, the respected neurologist Eliot Slater, in a widely noted paper published in 1965, called the diagnosis of conversion hysteria "a disguise for ignorance and a fertile source of clinical error."4'' This discrediting of psychoanalysis created a widen- ing gap in psychosomatic thought that was steadily filled by a variety of theoretical alternatives. These concepts rested on more directly observable and less arcane linkages between 31 emotions and the onset of disease. However much these the- oretical alternatives differed, they had in common a psychobi- ological orientation, in the sense that they were clearly based on notions of holistic body and mind response of the total human organism to various stimuli, threats and assaults from its environment. A common origin explained the similar ori- entation of these new theoretical approaches, for they all derived in some sense from the fundamental work of early twentieth-century Harvard physiologist Walter B. Cannon. Cannon's general program was to show how the biological organism automatically mobilized its physiological and bio- chemical resources by a built-in "wisdom of the body," to defend itself against real or threatened assault. As an example of defensive mobilization, he explained in Bodily Changes in Pain, Hunger, Fear and Rage, the organism responds to fear and rage as though preparing for fight or flight, by shutting down energy-storing functions and activating energy-releasing ones. In the 1940s, psychosomatic investigator Harold G. 32 Wolff and his associates at Cornell Medical School incorporat- ed many of Cannon's ideas.50 Wolff then moved from a model of organismic self-defense directly borrowed from Cannon to a generalized notion of "stress and disease," according to which disease was the "inept" version of a normally "apt pro- tective reaction pattern" that allowed the human organism to mobilize against stressful situations or events.51 Stress became a leading new idea in psychosomatic theory in the 1950s and Hans Solve emerged as its best known and most effective proponent. Selye was a Vienna- born, Prague-trained physician and biochemist who settled in Montreal in the 1930s and wrote the leading endocrinology textbook in 1947. In 1950 he published a 1,025-page mono- graph entitled The Physiology and Pathology of Exposure to Stress, in which he elaborated ideas he had been developing since 1936 on what he called the "General Adaptation Syndrome."52 Selves theory was that various "stressors" (cold, heat, solar radiation, burns, "nervous stimuli") produce a generalized, stereotyped response in the biological organism as it works to "perform certain adaptive functions and then to reestablish normalcy." As the organism automatically mobilizes its defense mechanisms, the hypothalamus (a nerve center at the base of the brain) is excited first. Later, after a chain of effects, the adrenal glands produce "corticoid" hormones. Corticoid hormones cause a characteristic set of somatic reac- tions including the development of gastrointestinal ulcers. Due largely to their synthetic scope, Selye's ideas swept the field and exerted an enormous influence. As F.L. Engel noted in 1956, "[Selye's theory of stress and the dis- eases of adaptation] has permeated medical thinking and influenced medical research in every land, probably more rapidly and more intensely than any other theory of disease ever proposed."53 The "stress syndrome" became even more popular and widely known in the sixties, partly because of its appeal as a replacement for older, increasingly discredited psychoanalytically-based psychosomatic theories and partly due to Selye's charisma and prodigious output. He published forty books and over 1,700 scientific papers in the course of his career.54 Selye was frequently quoted throughout medi- cine, nursing, and other health fields, and his fame spread to the wider culture, a reputation he deliberately cultivated by publishing such books for the general reader as The Ston: of the Adaptive Syndrome (1952), The Stress of Life (1956 and 1976), and Stress Without Distress (1974). Yet by the 1970s there was discord in the field of stress research as Selye conceived it. Growing confusion and controversy riddled theory and exper- iment. Some critics blamed Selye for having caused a great deal of it with his conceptual inconsistencies and his shifting and sometimes contradictory formulations.55 One major alternative challenged the stress model during the height of its initial popularity. George Engel and his colleagues at the University of Rochester Medical Center 33 Hans Selye, The Physiology and Pathology of Exposure to Stress, Montreal, 1950 Reader's Digest, February 1957 Courtesy Ghilta Sternberg. Reproduced with permission from Readers Digest American Journal of Nursing, March 1965 Used with permission of Lippincott-Raven Publishers i «± A developed a theory they ultimately called "conservation-with- drawal." Like Solve, Engel and his associates focused on psy- chobiological threats to an individual's well-being. But instead of considering threats as "stressors" that elicited defensive and protective behaviors from the hyperaroused organism, the Rochester group conceptualized the most important of these behaviors in terms of "losses" and "deprivations" that caused the organism to become withdrawn, depressed and shut- down.56 The Rochester group was generally attuned to psy- choanalytic theory and remained committed to preserving a place for it even in post-Alexandrian psychosomatic medicine. They thus developed a complex scheme framed in terms of disrupted relationships between individuals, affects of "help- lessness" and "hopelessness," and a state of "conservation- withdrawal" in which physiological function was depressed to the point of creating a "final common pathway" to illness and death. The Rochester group's work grew at the juncture between clinical studies on such diseases as leukemia and ulcerative colitis57 and a naturalistic experiment on an infant, "Monica," who was fortuitously admitted to Rochester's Strong Memorial Hospital during the course of their work.58 Monica had been born with a blockage in her esophagus, which required that two surgical openings be made, one in her neck to drain anything she took by mouth and one in her m jf™^ Monitoring Monica's gastric (stomach) secretions, Engel and his associ- ates found that physiological activity increased sharply, not only in the presence of food, but in the course of Monica's interactions with other, trusted human beings. Joyful reunions following separation were asso- ciated with especially copious secretions. At the same time, when Monica emotionally disengaged and withdrew—for example, in the presence of a stranger—there was a pronounced shutdown of physio- logical activity. In a sense, the body "withdrew" also, as if trying to conserve resources, Courtesy Dr. George Engel U'j i»t. ilji/SV f 14 t GJ^AjLtyOit 'i-O v*'-*.. :U •r« DcBcripitkKi ■Xi Voli P" *.«a/l ",111 -¥•?•- 'f -T*J «Jfl ■nurkl ZH Kfl 1H ) f SJj Stl 0 tool \r\ ICur*u;{ri.,4 .-/£-■ "■■ ""•.......'• ''»" -*: O- £,',:.~,^ £«■' n 1 li nA ILL c itaH i«J ftt Hvl- l«,u 1.0 1 «t ''. ) »" 'i. ■> ?"•?,- J'?"' i.£ TS t,Si 'if 0 '■ttfl -*> 1:i, -*««/*.,. -, A./.. ■£..„_ li'-ln i '« 12 t -' "f (■i> 0 "|k =)0 t-U,/!-^-^-/ K- -< A,.l, eJ..^. ' llli 11 . p Silit 0 i.H6| i?i &.f-;,^r,. ..,„., JL 1] Lit 0 %1-lr *\ S^./.,. - —__ T""..-;;'$f fjt 1 UA/I- >''..• - ■<...'« " "/ ~~* fe..^ ^. 10 U I \ 34 stomach through which she could be fed. Monica did not do well and was admitted to the hospital at fifteen months in a dangerous condition. While she was being nursed back to health, Engel and his associates designed a study in which they measured her gastric secretion continuously and correlat- ed their observations with Monica's moods. They found that Monica's physiological activity increased when she was engaged with the members of the group, whether joyfully or angrily, and especially on reunion after separation. By con- trast, her gastric secretion ceased entirely, and even became unresponsive to histamine (which normally stimulates gastric secretion), when she withdrew physically and emotionally from a stranger who replaced the familiar members of the group. Monica's behavior made sense as a psychological and physiological shutdown that served to conserve her organis- mic resources. It also helped put into perspective the sepa- rately collected clinical data on patients who articulated feel- ings of "giving up" or being "given up" shortly before the onset or exacerbation of a variety of somatic diseases.59 By the 1970s the psychosomatic field thus had a pair of new concepts, one emphasizing stress-induced hyper- arousal and the other deprivation-caused hypoarousal. A major achievement of the next decade was the merger of this pair of ideas into one model of socio-environmental challenge and response and the connection of that model with other streams of work focused on "life change events" (divorce, bereavement, and job loss) and "social stressors" (high inten- sity living and work situations and major social dislocations from normal support networks).60 The seventies were also notable for the application of progressively more sophisticated biostatistical techniques and more rigorous epidemiological study designs.61 Striking landmarks were Sidney Cobb and Robert M. Rose's study of "Hypertension, Peptic Ulcer, and Diabetes in Air Traffic Controllers," the 1973 conference in New York City on "Stressful Life Events," John Cassel's Wade Hampton Erost Lecture of 1976 at the American Public Health Association on "The Contribution of the Social Environment to Host Resistance," and David Jenkins's report in the New England Journal of Medicine the same year of sub- stantial evidence confirming the significance of the "Type A" behavior pattern as a risk factor for coronary artery disease.62 Although there were critics of some of this new work in psy- chosomatic medicine, the strong consensus in the 1970s— both within the psychosomatic field and more broadly in sci- ence and medicine—was that studies on the relationship between social support, life stress, and disease onset were sig- nificant and very promising for the future.63 It was well estab- lished in the popular imagination that the stress of modern life, work-related tension and anxiety, and devastating tragedy accompanied by the loss of community could lead to very severe health consequences. Also notable in the seventies was the translation of Dismissal (or) Pink Slip Howard Taft Lorenz The shock to the system caused by loss and broken trust is starkly captured in this WPA painting by Lorenz. Courtesy National Museum of American Art, Smithsonian Institution, transfer from Museum of Modern Art B. Kent Houston and C.R. Snyder, editors, Type A Behavior Pattern: Research, Theory, and Intervention, New York, 1988 Reproduced with permission from John Wiley and Sons, Inc. 35 dt/c cAief cuuAtj/tmaru cause of. . . ftAcf t/ery /af id increase of neroousness is mode/ri eioi/ization, udticA as distinc/uisAed y/a/n tAe ancient Au tAesefioe cAaractcristics.' stean//)ou>c/\ tAe feriodteaAftrcss, tAe te/ey/afeA, tAe sciences, and tAe ineutu/ act/oily ofiaomen. George M. Beard American Nervousness, Its Causes and Consequences, 1881 Rocitalion Center. Looking South. Sara logo Spa. N. Y. Saratoga Spa, N.Y., ca. 1950s A vacation "in the country," away from the routines of life, remains a tried-and-true remedy for "stress." Courtesy Ghilta Sternberg new theoretical insights into practical intervention strategies, sometimes actively promoted by the researchers themselves. Thus, Meyer Friedman and Ray Rosenman, the physicians who initially defined the Type A concept, published a popu- lar book which included practical chapters on how to "re- engineer" one's daily life and develop "drills" to replace old and harmful habits.64 Similarly, Harvard's Herbert Benson pro- moted a simple, "noncultic" technique to elicit the "relax- ation response" as a counter to the stress-induced "emer- gency response." He showed that physicians could teach the relaxation response to patients as either a preventive or thera- peutic strategy.65 Several other investigators introduced "biofeedback" techniques (in which various physiological variables such as heart rate and muscle tension were dis- played to the patient) as practical clinical methods for manag- ing hypertension and a variety of other conditions.66 In work settings, employers introduced timeouts for stress-reducing exercise sessions and even redesigned the production process itself. Of course, the time-honored "vacation in the country" or "stay at the spa" remained popular outlets for people's accumulated tension. But in a period sensitive to the impor- tance of loss as well as overload, health practitioners intro- duced newer interventions to affiliate isolated and vulnerable people with one another through support groups, to provide them with beloved objects of affection, and to encourage shared group solidarity of great symbolic and emotional sig- nificance. If stress and deprivation could cause disease, relax- ation and reconnection may be able to cure it or, at least miti- gate its effects. 36 Dilbert, Scott Adams, September 15, 1996 Scott Adams, creator of the popular comic strip Dilbert, has updated the idea of "office stress" for the economically insecure 1990s. © 1996 United Feature Syndicate, Inc. Volvo Assembly Line, Sweden • >■ ton a cinnifiranr pffnrt to imorove the environment of its factories and alter the assembly In 1987 the Volvo Truck Corporation initiated a s.gnifican^effort tci improvetn'? restructuring the way car and employees decreased and morale increased. Courtesy Volvo Truck Corporation, Powertrain Division, Skovde. Sweden 37 .. '--•? :**a j* 5> j| lis * BR^. . m* F *» r c 5 kdfl 8u3km Positron emission tomography or PET scanning—one of several new imaging techniques—tracks the course of high energy, very short- lived radioactive compounds through the brain. In this way, a "map" is created of the brain's changing blood flow and chemistry as a person thinks and feels. Courtesy GE Medical Systems Frontiers of the Mind Two of the most compelling features of the last twenty years have been dramatic achievements in the laboratory and strik- ing advances in biomedical technology. Together, they have literally extended the frontiers of the mind by embodying emotions in the biology of the brain more successfully than ever before and by creating the possibility of identifying the intricate interconnections between brain-based emotions and the functioning of the neuroendocrine and immune systems. Spectacular developments in laboratory science and visualiza- tion technology have been essential components of the explo- sive development of neuroscience, a field which has quickly become one of the most respected, exciting and actively pur- sued in medicine.67 Within the neurosciences an area various- ly called "psychoneuroimmunology" and "neuroimmunomod- ulation"'* has recently emerged which seems on the verge of tracing the pathways between emotions and disease whose connections had long been glimpsed in clinical contexts by physicians ranging from Galen to Freud and from Maimonides to Alexander. The modern grounding of emotional expression in the biology of the brain began with the work of the American neuroanatomist James Papez. In 1937, Papez argued from anatomical and clinical evidence that an "ensemble of struc- tures" in the lower, subcortical areas of the brain constituted the "anatomic basis" and "harmonious mechanism" for the elaboration and expression of emotions. Rejecting the possi- bility that emotion is "a magic product," Papez insisted that it is "a physiologic process which depends on an anatomic mechanism."69 Papez's ideas were effectively promoted by Paul MacLean, a physician and neurophysiologist. In 1949, MacLean proposed a hypothesized "visceral brain" as an anatomical and functional system intermediate between the "intellectual" cortex and the "discharging" hypothalamus. This system was "largely concerned with visceral and emo- tional functions."70 In the 1950s, MacLean generalized his ideas into a theory of the "limbic system," an integrated set of subcortical structures in the brain including the hippocam- pus and amygdala whose precise role in emotional expression and modulation he explored through the electrical and chemi- cal stimulation of specific anatomical regions and structures.71 Other investigators added human clinical evidence and the results of surgery on the brains of laboratory animals, which also pointed to the role of the limbic system in the expression of emotions. Interest in the limbic system remained strong through recent times, although in the last several years neuro- scientists have raised questions about the looseness of some of the earlier theoretical assumptions and anatomical con- structs. They are still interested in the neural substrates of 39 An overactive amygdala. emotion within the brain but have shifted their attention to the hemispheres of the cerebral cortex and to the interactions between cortical and subcortical regions. In the 1970s, neuro- scientists began to concentrate on the right cortical hemi- sphere as the most interesting locus of emotional control.73 Roger Sperry's award of the Nobel Prize in 1981 for his work on "cerebral laterality" (the differences between the "left" and the "right" brain and their behavioral significance) rein- forced this trend, but respected neuroscientist RAY. Doty indicated in a 1989 review article that "any idea of emotion in an intact mammal being played out purely via subcortical circuitry is an unsustainable abstraction. On the other hand, the evidence is unequivocal that subcortical structures are essential for the expression of the more 'primitive' emotions, and can support such expression in the absence of the neo- cortex."4 Current work is verifying the integrative function- ing of cortical and subcortical areas (especially the amygdala) in the organism's response to primitive emotional experiences such as fear.75 Powerful new imaging techniques have supported and made possible the recent emphasis on the anatomical substrates of emotion.76 The most impressive techniques arc computer assisted tomography (CAT scans), magnetic reso- nance imaging (MRI), positron emission tomography (PET REGIONAL BRAIN ACTIVITY DURING TRANSIENT HAPPINESS INCREASED ACTIVITY Left Anterior Cingulate. Medial Prefrontal Cortex DECREASED ACTIVITY Bilateral Temporo-parietal Right Prefrontal Cortex Using PET scans, scientists are in the first stages of relating different emotional states—pleasure, sorrow—to different patterns of brain activity. Courtesy Mark S. George, Medical University of South Carolina, Charleston PET scans of people who have been asked to look at. listen to, speak or think about a word. Different parts of the brain become active, depending on how the word signal is received. Courtesy Marcus E Raichle, Washington University, St. Louis, Missouri 40 scans), single-photon emission computed tomography (SPECT), and functional magnetic resonance imaging (fMRI). The breakthrough technology was computer assisted tomography, developed in the 1960s and 1970s, for which Allan Cormack and Godfrey Hounsfield received the Nobel Prize in 1979. The basic principle was the computer synthesis of a three-dimensional image from a series of two-dimension- al "slices" taken at multiple angles (tomography) of some sig- nal aimed at or emanating from the patient and detected outside his or her body. This principle was applied first to CAT scans where the measured property was an x-ray attenu- ation coefficient. The same principle was then applied to MRI imaging and PET scans, where the measured property was natural magnetization density in the first case and the concentration of an intravenously injected radioisotope in the second.77 The newer fMRI is based on the tomographic construction of images formed by the signal differences between MRIs taken of the brain in functionally activated and non-activated states.78 CAT scans and MRI images are now widely used in clinical settings to determine anomalies in cerebral anatomy. SPECT, PET and fMRI are valuable tools, at this point employed primarily in research settings to determine physiological and biochemical variations in brain activity, including anatomically-localized alterations in metabolism and neurochemical functioning which are visualized as they occur.79 Many of the achievements in the neurosciences have come at the intersection of this new imaging technology with recent breakthroughs in neurochemistry.80 As one of neuro- chemistry's leaders, Solomon Snyder, has said, "The glue that has brought together findings from so many different disci- plines into a coherent concept of brain function is chemistry. Indeed the revolution is more precisely characterized as a rev- olution in 'molecular neuroscience.'"81 Twenty years ago, Snyder was among those neuro- chemists who succeeded in identifying opium-like molecules in the brain (variously called "enkephalins," "endorphins," or sometimes just "endogenous opioids") that helped regulate the sensation of pain. Endogenous opioids are a type of "neu- rotransmitter," a long-studied class of biochemical substances that convey messages from nerve fiber endings to other bio- logical receptors, whether nerve, muscle or gland. Neuro- chemists were able to identify specific opiate "receptor sites" where the endogenous opioids normally attach but at which they are sometimes displaced by exogenous competitors such as morphine. Using photographic techniques that take pic- tures of samples incorporating radioactive materials and high power microscopy, scientists found large concentrations of these receptor sites in areas of the brain (in the limbic sys- tem) specifically associated with pain perception and other forms of emotional regulation.82 More recently and with the help of PET scan and fMRI technology, neuroscientists have Functional magnetic resonance imaging, or fMRI, is another new technology that can detect the living brain at work. This is a computer-enhanced fMRI scan of a person who has been asked to look at faces. The image shows increased blood flow in the part of the visual cortex that recognizes faces. Courtesy VP Clark, K. Keil, J. Ma. Maisog, S. Courtney, LG. Ungerleider, and J.V Haxby, National Institute of Mental Health 41 Optical imaging camera Courtesy Photometries The optical imaging camera allows scientists to peer even more deeply into the brain, making pictures of nerve cells working togeth- er in ensembles. A bright light shone onto the brain reflects back changes in nerve cell activity (measured through changing colors related to water content, cell size, and amount of oxygen in the blood). These are then turned into colorful images. Courtesy Ehud Kaplan and Richard Everson, Mount Sinai School of Medicine, New York Computerized imaging microscopes combined with molecular biolo- gy techniques for staining tissue show activated genes in the hypo- thalamus at the site they are expressed (in situ hybridization). Courtesy Miles A. Herkenham, National Institute of Mental Health New technologies, like computerized photomicrographic imaging, are bringing even the microscopic world of cells and genes more fully into the light of day. Courtesy Leica Inc . Deerfield. Illinois The scanning electron microscope allows scientists to see lymphoqtes red blood cells, macrophages and monocytes. -"-"■ ■'■"•■ ~1"'. rhaefer. National Cancer Institute been able to confirm the dense distribution of opiate recep- tors in the structures of the limbic system and especially in the amygdala. Neuroscientists thus seem to be closing in on both the biochemical mechanisms and the anatomical architecture of emotional expression in specific structures of the brain. In perhaps the most exciting development of all, a new field has emerged which is starting to combine the latest in the neurosciences w ith the latest in immunology to provide the scientific basis for understanding relationships between emotions and disease once explored only in clinical settings. Not yet possessing a generally agreed upon name, this new field has been able to demonstrate previously unsuspected but now verifiably direct connections between the immune system and the neuroendocrine system. The field developed in two waves. The first wave, rising in the late seventies and early eighties, was generally called "psychoneuroim- munology" (PNI). Its roots could in some sense be traced back to the pioneering studies of the Russian immunologist S. Metal'nikov at the Pasteur Institute in Paris in the 1920s and 1930s and to the considerable work in the Soviet Union from the 1920s through the 1950s on psychologically condi- tioned immunobiological effects. The field really began to take shape around 1980 under the combined leadership of the Americans George Solomon, Novera Herbert Spector and Robert Ader, the Swiss Hugo Besedovsky, and the Russian Elena A. Korneva.83 Although each of these leaders came from a different discipline and contributed different specific exper- tise (Ader, for example, was an experimental psychologist, Solomon was a psychiatrist and Besedovsky was an endocri- nologist), they all agreed on the need to break down the barri- ers that until then had artificially separated immunology as a field from endocrinology and the neurosciences. As Ader and his colleagues put the point in 1987, "In our view, the attempt to understand immunity as an adaptive process that is independent of and can be studied in isolation from other integrated adaptive processes is, in its extreme form, a restric- tive and restricting paradigm."84 Beginning in the late 1980s, the second wave was marked by the recruitment of molecular neuroscientists. This phase does not yet have a fixed name, although "neuroim- munomodulation" (NIM) is widely accepted, while some leaders prefer simply "neuro-immune interactions." Some of the scientists recruited to the field during this phase were wary of PNI and remained skeptical until they were persuad- ed by "harder" evidence that the immune and neuroen- docrine systems are in fact in close and bi-directional commu- nication and, indeed, "talk" to each other all the time. A short list of discoveries early in the second wave includes the fol- lowing: demonstration of direct microanatomical contacts between the nervous and the immune systems; discovery that anatomical lesions in or the electrical stimulation of parts of Different parts of your brain share information and organize plans for action through a code system that involves both chemistry and electricity. Chemicals called neurotransmitters are emptied from tiny sacs into the space between nerve cells. These chemicals cross that space and bind to receptors on other nerve cells. The binding process triggers an electrical stimulus in the receiving cells, that starts the whole process of chemical release all over again. 43 Activation of T Cells When a foreign toxin or bacteria, called an antigen, enters the body, immune system cells race to the site of invasion. These cells are called lymphocytes (T and B cells) and macrophages. Receptors on the surfaces of these cells rec- ognize and bind to the invader. The binding process triggers the production of chemical signals called interleukins. Interleukins allow immune cells to mature, communicate with each other, and to make antibodies and other substances that remove the invader. The Immune System and the Nervous System Neuroendocrine and Autonomic Pathways Bone Marrow Immunotransmlttere (feedback, regulation and modulation) 6 sCcO, TCell Kd Macrophage ______°o C LymphoWneso°0+ ^o%> Monokines 0 BCell At the same time that interleukins (sometimes called lymphokines and monokines) allow immune cells to sig- nal one another, they also allow immune cells to signal the brain—and vice versa. the brain influence antibody production in the spleen and lymph nodes; identification of receptor sites for neuroen- docrine hormones and neurotransmitters on cells of the immune system. The "clincher" was the repeated proof in several different animal models that interruptions of these communications on a genetic, surgical, or pharmacological basis, lead to increased susceptibility to inflammatory dis- eases like arthritis. The converse is now also being shown, that too much responsiveness of these systems leads to enhanced susceptibility to infection. Now it is certain that particular molecules of the immune system (cytokines or interleukins) signal areas of the brain directly as well as exert influences on peripheral parts of the nervous system such as the vagus nerve. This rigorously demonstrated "cross-talk" between the immune and neuroendocrine systems has won over neuroscientists and gained converts among the immunologists themselves. Even more important, it provides the scientific basis for understanding—at long last—how emotions can in fact influence the onset, course, and remis- sion of disease. Two very different signs of enthusiasm and "arrival" already mark the 1990s: the inclusion of an entry on "Neuroendocrine Regulation of Immunity" in the 1992 Encyclopedia of Immunology and the featuring of psychoneuro- immunolgy as a central theme in Bill Moyers's 1993 best sell- 44 er, Healing and the Mind.^ The first indicated the acceptance of the new field within the mainstream of previously resistant immunology and the second demonstrated popular fascina- tion with the emerging inter-discipline. Moyers and many of his readers seized upon the new field as seeming to validate long-suspected but frequently denied connections between emotions and disease. A spate of high-level international sci- entific conferences marked by unusual energy and bold proclamations have added to the sense of excitement. The proceedings of one of these was published in 1994 as volume three of the "Hans Selye Symposia on Neuroendocrinology and Stress." The editors of the Selye volume capture the cur- rent mood: The interaction of the nervous, endocrine and immune systems is only now being considered seriously. This field represents a novel, multidisciplinary approach in Biological Sciences. Even the name of the field has not been settled as yet and there are debates going on with regards to the proper term.....Modern science is equipped with powerful research tools which make it feasible to advance quickly in this complex multidisciplinary field, with the aim of understanding the whole organism, rather than trying to analyze restricted areas. The developments are spectacular, indeed, and the new insights gained. . . have already advanced our understanding of certain human diseases, such as autoim- mune disease, inflammatory diseases, nervous and endocrine abnormalities and the influence of behavioral factors and of aging on the immune response and disease. We sincerely hope this volume will contribute to the understanding and acceptance of this brave new area of scientific enquiry. It may be that this "brave new area" will finally validate long held beliefs about emotions and disease that we in the West have been grappling with for at least two millennia. 45 Notes 1. Sec. for example, Vivian Mutton, "Humoralism," in YY.F. Bynum and Roy Porter, eds., Companion Encyclopedia of the History of Medicine, Vol. I (London: Roiitledge, 1993), pp. 281-291 and Lawrence I. Conrad, et. al., The Western Medical Tradition (Cambridge: Cambridge University Press, 1995). 2. W.H.S. Jones, E.T. Withington and Paul Potter, eds. ex trans., Hippocrates, Works, 6 vols. (London: Loeb Classical Library/Heinemann, 1923-88), Vol. II, p 177. 3. Hippocrates, op. tit., Vol. I, p. 283. 4. Hippocrates, op. tit., Vol. II, p. 167. 5. See. for example, Heinrich von Staden, Herophilus: The Art of Medicine in Early Alexandria (Cambridge: Cambridge University Press, 1989). 6. Stanley Jackson, "Galen—On Mental Disorders," Journal of the History of the Behavioral Sciences, 5 (1969): 366. 7. L.J. Rather, "The 'Six Things Non-Natural,'" Clio Medica, 3 (1968): 337-347; Saul Jarcho, "Galen's Six Non-Naturals," Bulletin of the History of Medicine, 44 (1970): 372-377. 8. Ariel Bar-Scla, Hebbel E. Hoff and Elias Farus, "Moses Maimonides' Two Treatises on the Regimen of Health," Transactions of the America n Philosophical Society, ns, 54 (1964), Part 4: 25. 9. Robert Burton, The Anatomy of Melancholy (1621), ed. A.R. Shilleto (London: George Bell and Sons, 1893), vol. I, p. 288. 10. L.J. Rather, "Thomas Fienus' (1567-1631) Dialectical Investigation of the Imagination as Cause and Cure of Bodily Disease," Bulletin of the History of Medicine, 41 (1967): 356. 11. Erwin H. Ackerknecht, "The History of Psychosomatic Medicine," Psychological Medicine, 12 (1982): 17-24. 12. Russell C. Maulitz, Morbid Appearances: The Anatomy of Pathology in the Early Nineteenth Century (Cambridge: Cambridge University Press, 1987), 13. Joel Stanley Reiser, Medicine and the Reign of Technology (Cambridge: Cambridge University Press, 1978). 14. Leland J. Rather, Mind and Body in Eighteenth Century Medicine (Berkeley: University of California Press, 1965). 15. William Cullen, First Lines of the Practice of Physic (Edinburgh: C. Elliot & T. Cadell, 1 784). Vol. 4, p. 149. 16. Sander L. Gilman et. al., Hysteria Beyond Freud (Berkeley: University of California Press, 1993) and Mark S. Micale, Approaching Hysteria (Princeton: Princeton University Press, 1995). 17. Francois M. Mai and Harold Merskey, "Briquet's Treatise on Hysteria," Archives of General Psychiatry, 37 (1980): 1401-1405; Mai and Merskey, "Briquet's Concept of Hysteria: An Historical Perspective," Canadian Journal of Psychiatry, 26 (1981): 57-63. 46 18. Christopher G. Goct/, Michel Bonduelle, Toby Gelfand, Charcot: Constructing Neurology (Oxford: Oxford University Press, 1995). 19. Quoted ibid., p. 197. 20. Kenneth Levin, Freud s Early Psychology of the Neuroses (Pittsburgh: University of Pittsburgh Press, 1978), p. 46. 21. Martin Stone, "Shellshock and the Psychologists," in W.F. Bynum, Roy Porter and Michael Shepherd, eds.. The Anatomy of Madness (London: Tavistock, 1985), Vol. II, pp. 242-271 and Elaine Showalter, The Female Malady: Women, Madness and English Culture, 1830-1980 (New York: Penguin Books, 1985), pp. 167-194. 22. Harold I. Kaplan and Helen S. Kaplan, "An Historical Survey of Psychosomatic Medicine," Journal of 'Nervous and Mental Diseases, 124 (1956): 546-568 and John C. Burnham, J elliffe: American Psychoanalyst and Physician (Chicago: University of Chicago Press, 1983). 25. Martin Grotjahn, "Georg Groddeck and His Teaching About Man's Innate Meed for Svmbolization," Psychoanalytic Review, 52 (1945): 9-24. 24. Theodore M. Brown, "Alan Gregg and the Rockefeller Foundation's Support of Franz Alexander's Psychosomatic Research," Bulletin of the History of Medicine, 61 (1987): 155-182. 25. Benjamin V. White, Stanley Cobb: A Builder of the Modern Neurosciences (Boston: Francis A. Countway Library of Medicine, 1984). pp. 212, 245-246. 26. Gerald M. Grob, From Asylum to Community: Mental Health Policy in Modern America (Princeton: Princeton University Press, 1991), p. 17 and Nathan G. Hale, The Rise and Crisis of Psychoanalysis in the United States (Mew York: Oxford University Press, 1995), pp. 187-202, 282. 27. Gail Thain Parker, Mind Cure in AV&r England (Hanover NH: University Press of Mew England, 1973) and Robert C. Fuller, Alternative Medicine and American Religious Life (Mew York: Oxford University Press, 1989). 28. William James, The Varieties of Religious Experience (Mew York: Longmans, Green, and Co., 1902), p. 94. 2^). Ibid., p. 122. 30. Quoted in Rennie B. Schoepflin, Lives on Trial: Christian Science Healers in the Progressive Era (University of Wisconsin Doctoral Dissertation: Madison, 1995), p. 210. 31. Donald Meyer, The Positive Thinkers (Mew York: Pantheon Books, 1980), p. 168. 32. Ernest Kurtz, Not-God: A History of Alcoholics Anonymous (Center City, MM: Hazelden, 1979). 33. Meyer, op. at., pp. 177-194, 259-289. 34. See, for example, Norman Cousins, Anatomy of an Illness (New York: WAV. Morton, 1979) and Head First: The Biology of Hope (New York: E.P Dutton, 1989). 47 35. James Harvey Young, The Toadstool Millionaires: A Social History of Patent Medicines in America Before Federal Regulation (Princeton: Princeton University Press, 1961) and The Medical Messiahs: A Social History of Health Quackery in Twentieth-Century America (Princeton: Princeton University Press, 1967). 36. Paul Starr, The Social Transformation of American Medicine (New York: Basic Books, 1982), pp. 127-134. 37. Daniel Hack Tuke, Illustrations of the Influence of the Mind Upon the Body in Health and Disease, Second American Edition (Philadelphia: Henry C. Lea's Son & Co., 1884), p. 439. 38. O.H. Perry Pepper, "A Note on the Placebo," American Journal of Pharmacy, 117 (1945): 409-412 and Arthur K. Shapiro, "The Placebo Effect in the History of Medical Treatment," American Journal of Psychiatry, 116 (1959): 298-304. 39. Lewellys F. Barker, "Psychotherapeutics," Transactions of the Association of American Physicians, 23 (1908): 478. 40. C. Macfie Campbell, "Psychiatry and the Practice of Medicine," Boston Medical and Surgical Journal, 190(1924): 1058. 41. W.R. Houston, "The Doctor Himself as a Therapeutic Agent," Annals of Internal Medicine, 11 (1938): 1418. 42. See, for example, Thomas Findley, "The Placebo and the Physician," Medical Clinics of North America, 37 (1953): 1821-1826 and Louis Lasagna, et. al., "A Study of the Placebo Response," American Journal of Medicine, 16 (1954): 770-779. 43. Louis Lasagna, "Placebos," Scientific American, 193 (August, 1955): 68-71. 44. Henry Byerly, "Explaining and Exploiting Placebo Effects," Perspectives in Biology and Medicine, 19 (1976): 423^436. 45. Priscilla Grevert and Avram Goldstein, "Placebo Analgesia, Naloxone, and the Role of Endogenous Opioids," in Leonard White, Bernard Tursky, and Gary E. Schwartz, eds., Placebo: Theory, Research, and Mechanisms (New York: Guilford Press, 1985), pp. 332-350. 46. Chase P. Kimball, "Conceptual Developments in Psychosomatic Medicine: 1939-1969," Annals of Internal Medicine, 73 (1970): 307-316; Z.J. Lipowski, "Psychosomatic Medicine in a Changing Society: Some Current Trends in Theory and Research," Comprehensive Psychiatry, 14 (1973): 203-215; Z.J. Lipowski, "Psychosomatic Medicine in the Seventies: An Overview," American Journal of Psychiatry, 134 (1977): 233-244 47. Nathan G. Hale, The Rise and Crisis of Psychoanalysis in the United States (Mew York: Oxford University Press, 1995), p. 322. 48. Ibid., pp. 312; 323-324; 326-327; 449, n. 43; 451-453, n. 3-8; 13-16. See also Robert Aronowitz and Howard M. Spiro, "The Rise and Fall of the Psychosomatic Hypothesis in Ulcerative Colitis," Journal of Clinical Gastroenterology, 10 (1988): 298-305. 48 49. Eliot Slater, "Diagnosis of 'Hysteria,'" British Medical Journal, 1 (1965): 1399. 50. Bela Mittelmann and Harold G. Wolff, "Emotions and Gastroduodenal Function," Psychosomatic Medicine, 4 (1942): 5-61 and Harold G. Wolff, "Protective Reaction Patterns and Disease," Annals of Internal Medicine, 27 (1947): 944-969. 51. Harold G. Wolff. Stress and Disease (Springfield IL: Charles C. Thomas, 1953). 52. Montreal: Acta, Inc., Medical Publishers, 1950. See also Hans Selye, "The Evolution of the Stress Concept," American Scientist, 61 (1973): 692-699. 53. Quoted in John W Mason, "A Historical View of the Stress Field," Part I, Journal of Human Stress, 1 (March, 1975): 10. 54. S. Szabo, "The Creative and Productive Life of Hans Selve: A Review of His Major Scientific Discoveries," Experientia, 41 (1985): 564-567 and Y. Tache, "A Tribute to the Pioneering Contributions of Hans Selye: An Appraisal Through His Books," Experientia, 41 (1985): 567-568. 55. John W. Mason, "A Historical View of the Stress Field," Part II, Journal of Human Stress 1 (June, 1975): 22-36. 56. Arthur H. Schmale, "Relationship of Separation and Depression to Disease," Psychosomatic Medicine, ns., 20 (1958): 259-277; George L. Engel, "A Life Setting Conducive to Illness," Annals of Internal Medicine, 69 (1968): 293-300; George L. Engel and Arthur H. Schmale, "Conservation-Withdrawal: A Primary Regulatory Process for Organismic Homeostasis," in Physiology, Emotion & Psychosomatic Illness, Ciba Foundation Symposium 8, ns (Amsterdam: Elsevier-Excerpta Medica, 1972), pp. 57-85. 57. William A. Greene, Jr., "Psychological Factors and Reticuloendothelial Disease," Psychosomatic Medicine, 16 (1954): 220-230 and George L. Engel, "Biologic and Psychologic Features of the Ulcerative Colitis Patient," Gastroenterology, 40 (1961): 313-317. 58. George L. Engel, Franz Reichsman, and Harry L. Segal, "A Study of an Infant With a Gastric Fistula," Psychosomatic Medicine, 18 (1956): 374_398 and George L. Engel and Franz Reichsman, "Spontaneous and Experimentally Induced Depressions in an Infant With a Gastric Fistula," Journal of the American Psychoanalytic Association, 4 (1956): 428-452. 59. A.H. Schmale, "Giving Up as a Final Common Pathway to Changes in Health," in Z. J. Lipowski, ed., Psychosocial Aspects of Physical Illness (Basel: Karger, 1972), pp. 20^10. 60. George L. Engel, "The Need for a New Medical Model: A Challenge for Biomedicine," Science, 196 (1977): 129-135 and George L. Engel, "The Clinical Application of the Biopsychosocial Model," American Journal of Psychiatry, 137 (1980): 535-543. 61. Z.J. Lipowski, "Psychosomatic Medicine: An Overview," Modern Trends in Psychosomatic Medicine, 3 (1976): 1-20. 49 62. Cobb and Rose, JAMA. 224 (1973): 489-192; Barbara Snell Dohrenwend and Bruce P. Dohrenwend, eds., Stressful Life Events: Their Nature and Effects (New York: John Wiley & Sons. 1974); John Cassel, "The Contribution of the Social Environment to Host Resistance," American Journal of Epidemiology, 104(1976): 107-123; C. David Jenkins, "Recent Evidence Supporting Psychologic and Social Risk Factors for Coronary Disease," New England Journal of Medicine, 294 (1976): 1033-1038. 63. Evelyn L. Goldberg and George W. Comstock, "Life Events and Subsequent Illness," American Journal of Epidemiology, 104 (1976): 146-158; Sidney Cobb, "Social Support as a Moderator of Life Stress," Psychosomatic Medicine, 38 (1976): 300-314; Judith G. Rabkin and Elmer L. Struening, "Life Events, Stress, and Illness," Science, 194 (1976): 1013-1020. 64. Meyer Friedman and Ray Rosenman, Type A Behavior and Your Heart (Mew York: Alfred A. Knopf, 1974), Chapts. 16 & 17. 65. Herbert Benson, The Relaxation Response (New York: Morrow, 1975). 66. See, for example, Lee Birk, ed., Biofeedback: Behavioral Medicine (New York: Grune and Stratton, 1973). 67. Francis O. Schmitt, "The Neurosciences Research Program: A Brief History," in Fred Samson and George Adelman, eds., The Neurosciences: Paths of Discovery II (Boston: Birkhauser, 1992), p. 15, points out that the Society for Neuroscience, which was founded in 1970 with an initial membership of 200, had grown to 13,500 members by 1989. 68. George Adelman, ed., Encyclopedia of Neuroscience (Boston: Birkhauser, 1987), pp. 798-799 and 1001-1004. 69. James W. Papez, "A Proposed Mechanism of Emotion," Archives of Neurology and Psychiatry, 38 (1937): 725-743, esp. 743. 70. Paul D. MacLean, "Psychosomatic Disease and the A'isceral Brain,'" Psychosomatic Medicine, 11 (1949): 338-353, esp. 351. 71. Paul D. MacLean and Jose M.R. Delgado, "Electrical and Chemical Stimulation of Frontotemporal Portion of Limbic System in the Waking Animal," Electroencephalography and Clinical Neurophysiology, 5 (1953): 91-100 and Paul D. MacLean, "Chemical and Electrical Stimulation of Hippocampus in Unrestrained Animals," Archives of Neurology and Psychiatry, 78 (1957): 113-142. 72. Antonio R. Damasio and GAY. Van Hoesen, "Emotional Disturbances Associated with Focal Lesions of the Limbic Frontal Lobe," in Kenneth Heilman and Paul Sat/., eds., Neuropsychology of Human Emotion (New York: Guilford Press, 1983), pp. 85-110. 73. Morman Geschwind, "Specializations of the Human Brain," Scientific American, 241 (September, 1979): 192. 74. R.W. Doty, in Guido Gainotti and Carlo Caltargirone, eds., Emotions and the Dual Brain (Berlin: Springer-Verlag, 1989), pp. 56-82. 75. Joseph E. LeDoux, "Emotion, Memory and the Brain," Scientific American, 270 (June, 1994): 50-57. 76. See, for example, John C. Mazziotta and Michael E. Phelps, 50 "Metabolic Evidence of Laterali/cd Cerebral Function Demonstrated by Positron Emission Tomography in Patients With Neuropsychiatric Disorders and Normal Individuals," in D. Frank Benson and Eran Zaidel, eds.. The Dual Brain (New York: Guilford Press, 1985), pp. 181-192 and Frank B. Wood et. al., "Cerebral Laterality in Functional Ncuroimaging," in Frederick L. Kitterle, ed., Cerebral Laterality: Theory and Research (Hillsdale NJ: Lawrence Erlbaum Associates, 1991), pp. 105-115. 77. Nancy C. Andreasen, ed.. Brain Imaging: Applications in Psychiatry (Washington: American Psychiatric Press, 1989). 78. Jeffrey R. Binder and Stephen M. Rao, "Human Brain Mapping with Functional Magnetic Resonance Imaging," in Andrew Kertesz, ed., Localization and Neuroimaging in Neuropsychology (San Diego: Academic Press, 1994). pp. 185-212 and John A. Sanders and William W Orrison, "Functional Magnetic Resonance Imaging," in William W. Orrison, et. al.. Functional Brain Imaging (St. Louis: Mosby, 1995), pp. 239-326. 79. Marcus E. Raichle, "Visualizing the Mind," Scientific American, 270 (April, 1994): 58-64. SO. For a lively account of neurochemistry in the 1970s, see Charles E Levinthal, Messengers of Paradise: Opiates and the Brain (New York: Anchor/Doubleday, 1988), esp. pp. 70-109. 81. Solomon H. Snyder, "Drugs, Neurotransmitters, and the Brain," in Pietro Corsi, ed.. The Enchanted Loom: Chapters in the History of Neuroscience (Mew York: Oxford University Press, 1991), p. 299. 82. Solomon H. Snyder, "Opiate Receptors and Internal Opiates," Scientific American, 236 (March, 1977): 44-56; cf. Leslie L. hersen, "The Chemistry of the Brain," Scientific American, 241 (September, 1979): 146-148. 83. For a brief historical overview, see Ruth Lloyd, Explorations in Psychoneuroimmunology (Orlando, FL: Grune & Stratton, 1987), Chapt. 1. For a collection of the critical papers that helped shape the discipline, see Steven Locke et. al., eds., Foundations of Psychoneuroimmunology (New York: Aldine, 1985). The seminal book that contained major review articles by the leading figures and that most dramatically launched the field was Robert Ader, ed., Psychoneuroimmunology (New York: Academic Press, 1981). 84. Robert Ader, Nicholas Cohen, David L. Felten, "Editorial: Brain, Behavior, and Immunity," Brain, Behavior, and Immunity, 1 (1987): 5. 85. Bryan M. Gebhardt and J. Edwin Blalock, "Neuroendocrine Regulation of Immunity," in Ivan M. Roitt and Peter J. Delves, eds., Encyclopedia of Immunology (London: Academic Press, 1992), pp. 1145-1149. 86. Bill Moyers, Healing and the Mind (New York: Doubleday, 1993) pp. 213-237. 87. Edited by Istvan Berczi and Judith Szelenyi, Hans Selye Symposia on Neuroendocrinology and Stress (New York: Plenum Press, 1994). 88. Ibid., p. vii. 51 Checklist for Emotions and Disea. ST Galen. Opera ex Sexta Juntarum Editione, Venice, 1586 Johann Engel (1463-1512). Astrolabium Planum in Tabulis Ascendens, Augsburg, 1488 Robert Burton (1577-1640J, The Anatomy of Melancholy, Oxford, 1632 In the list that follows, classmarks (call numbers) have been provided only for items from the collections of the National Library of Medicine. All measurements, when available, are given in centimeters unless otherwise noted. The Balance of Passions Walther Ryff (d. 1548), Spiegel und Regiment der Ccsiindlieyt, Frankfurt, 1555. Graphic: Photographic reproduction of wood- cut illustration, (illustrated page viii) A Long Tradition Johannes de Ketham (fl. 1455-1470), Fasciculus Medicinae, Vienna, 1495. Book: 31 (h) x 43 (open width) WZ240 K43f 1495. (illustrated page 2) Description of the Humoral system. Graphic: Photographic reproduction of illustration with English translation of the original Latin text. Based on an original illustration in Fasciculus Medicinae. (illustrated page 2) Hippocrates (ca. 460 B.C.-ca. 370 B.C.), Hippokratous . . . latrike, Basel, 1543. Book: 15 (h) x 21 (open width). WZ240 H667 1543. (illustrated page 2) Galen (131-201), Opera ex Sexta Juntarum Editione, Venice, 1586. Book: 36.5 (h) x 48.5 (open width). WZ 240 G153L 1586 v. 1. (illustrated page 52) Galen (131-201), Opera ex Sexta Juntarum Editione, Venice, 1586. Graphic: Photographic reproduction of illustration of a lovesick maiden taken from title page illustration, (illustrated page 3) Johann Engel (1463-1512), Astrolabium Planum in Tabulis Ascendens, Augsburg, 1488, copy 1. Book: 25.5 (h) x 37.5 (open width). WZ230 A585a 1488 c.l. (illustrated page 52) Gregor Reisch (d. 1525), Margarita Philosophica cum Additionibus Novis, Basel, 1517. Book: 21.5 (h) x 36 (open width). WZ240 R375m 1517. (illustrated page 4) Gregor Reisch (d. 1525), Margarita Philosophica cum Additionibus Novis, Basel, 1517. Graphic: Photographic repro- duction of illustration of profile of head, (image unavailable for catalogue) 52 Moses Maimonides (1135-1204), Tractatus Rabbi Moysi de Regimine Sanitatis ad Soldanum Regem, Augsburg, 1518. Book: 20 (h) x 28 (open width). WZ240 M91 ltL 1518. (illustrated page 4) Justus Cortnummius (ca. 1624-1675 m.), De Morbo Attonito Liber Units, Leipzig, 1677. Book: 21 (h) x 33 (open width). WZ250 C8298dm 1677. (illustrated page 3) Ambroise Pare (1510P-1590), The Workcs, London, 1649. Book: 33 (h) x 45.5 (open width). WZ250 fP227E 1649. (illustrated page 5) Honore Daumier (1808-1879), Bobonne, Bobonne, tu meferais un monstre comme ca, ne le regardepas tantl, 1860s. Lithograph: 33 (h) x 25 (w). (illustrated page 6) Robert Burton (1577-1640), The Anatomy of Alelancholy, Oxford: Printed for Henrv Cripps, 1632. Book: 29 (h) x 37.5 (open width). WZ250 B9745a 1632. (illustrated page 52) William Falconer (1744-1824), .4 Dissertation on the Influence of the Passions Upon the Disorders of the Body, London, 1788. Book: 20.5 (h) x 27 (open width). WZ260 F179d 1788. (illustrated page 6) Bloodletting lancet, 19th century. Lancet: 1/2" (h) x 1" x (w) T (1). Courtesy Historical Collections, The National Museum of Health and Medicine, Armed Forces Institute of Pathology, Washington, D.C. (illustrated page 53) Scarificator, 19th century. Scarificator: 2" (h) x 1" (w) x 2" (1). Courtesy Historical Collections, The National Museum of Health and Medicine, Armed Forces Institute of Pathology, Washington, D.C. (illustrated page 53) Artificial leech, 1879. Leech: 5" (h) x 1" (dia). Courtesy Historical Collections, The National Museum of Health and Medicine, Armed Forces Institute of Pathology, Washington, D.C. (illustrated page 53) Johannes de Ketham (fl. 1455-1470), Fasciculus Medicinae, Vienna, 1495. Graphic: Photographic reproduction of illustra- tion of bloodletting sites, (illustrated page 53) These mechanical bloodletting devices were used by physicians in the nineteenth century, an indication of the long persistence of humoral practice in medicine, even after the partial eclipse of humoral theory in the seventeenth century. Courtesy Historical Collections, The National Museum of Health and Medicine, Armed Forces Institute of Pathology, Washington, D.C. Johannes de Ketham (fl. 1455-1470), Fasciculus Medicinae, Vienna, 1495. 53 Joseph Woodward used this microscope in his pioneer- ing work as a microscopist. The mirror reflected the light from a window through the microscope and onto a photoplate, thereby allowing Woodward—or other scientists—to photographically capture certain features of cells. Courtesy Historical Collections, The National Museum of Health and Medicine, Armed Forces Institute of Pathology. Washington, D.C. The Challenge of Anatomy Andreas Vesalius (1514-1564), De Humani Corporis Fabrica, Venice. 1568. Book: M.S (h) x 45 (open width). VVZ240 f\575d 1568. (illustrated page 7) Andreas Vesalius (1514-1564), De Humani Corporis Fabrica, Venice, 1568. Graphic: Photographic reproduction of illustra- tion of autopsy/dissection tools, (illustrated page 7) Thomas Willis (1621-1675), The Remaining Medical Works of Thomas Willis, London, 1679. Book: 34 (h) x 46.5 (open width). WZ250 fW35phE 1679a. (illustrated page 8) Rudolf Virchow (1821-1902), Die Cellularpathologie in ihrer Begriindung auf Physiologische und Pathologische Ccwcbclclirc, Berlin, 1858. Book: 11 (h) x 29.5 (open width). QSA V813c 1858. (illustrated page 9) Rudolph L.K. Virchow. Photograph: 16.5 (h) x 11 (w). (illus- trated page 9) Rene Theophile Hyacinthe Laennec (1781-1826), De I Auscultation Mediate, on, Traite du Diagnostic des Maladies des Poumons et du CoeurfOn Mediate Auscultation, or, 1'reatise on the Diagnosis of the Diseases of the Lungs and Heart), Paris, 1819. Book: 21 (h) x 26 (open width with illustration). WF L158de. (illustrated page 8) Postcard of Laennec, A THopital Necker, Auscu/te Un Phtisique, original painting by Theobald Chartran (1849-1907). Postcard: 15.7 (h) x 12 (w). (illustrated page 8) This autopsy kit from ca. 1845 shows instruments more refined than those of the sixteenth century, although their basic design is not much altered. Courtesy Historical Collections. The National Museum of Medical History, Armed Forces Institute of Pathology, Washington, D.C. Laennec-style stethoscope. Stethoscope: 10" (1) x 1.5" (dia). Courtesy Historical Collections, The National Museum of Health and Medicine, Armed Forces Institute of Pathology, Washington, D.C. (illustrated page 8) Microscope, 1864. 11" (h) x 16" (1) x 9.5" (d). Courtesy Historical Collections, National Museum of Health and Medicine, Armed Forces Institute of Pathology, Washington, D.C. (illustrated page 54) Alexandar Levy, Woodward Working in the Laboratory, ca. 1952. Graphic: Photographic reproduction of illustration, (image unavailable for catalogue) Autopsy/dissection kit, ca. 1845. 1" (h) x 3" (w) x 7" (1) closed. Courtesy Historical Collections, National Museum of Health and Medicine, Armed Forces Institute of Pathology, Washington, D.C. (illustrated page 54) 54 Edouard Hamman (1819-1888), Andreas Vesalius, ca. 1848. Lithograph: 31.2 (h) 40.2 (w). (illustrated page 7) Lucia Rosetti, The Uuivcrsin of Padua, An Outline of Its History, Trieste, 1983. Courtesy Esther Sternberg, (image unavailable for catalogue) The Compromise William Cullen (1710-1790), First Lines of the Practice of Physic, Edinburgh, 1784. WZ260 (»67f 1784. (illustrated page 10) Roberty Whvtt (1714-1766), Observations on the Nature, Causes and Cure of Those Disorders Which Have Been Commonly Called Nervous, Hypochondriac, or Hysteric, Edinburgh, 1765. Book: 20.5 (h) x ZS (open width), (illustrated page 55) Austin Flint (1812-1886), .4 Treatise on the Principles and Practice of Medicine, Philadelphia, 1868. WB F623t 1868. (illus trated page 11) Psychosomatic Medicine: The "Puzzling Leap" Andre Brouillet, Cue Lecon Clinique a la Salpetriere, 1887. Graphic: Photographic reproduction of painting. B4519. (illus trated page 12) Camera, ca. 1900. Camera: 16" (h) x 16" (w) x 42" (1). Courtesy Historical Collections, The National Museum of Health and Medicine, Armed Forces Institute of Pathology, Washington, D.C. (illustrated page 14) Desire-Magloire Bourneville (b. 1840) and Paul Regnard, Iconographie Photographique de la Salpetriere, Paris, 1877-1880. Graphics: Two Photographic reproductions of two patients with hysteria, (illustrated page 14) Honore Daumier (1808-1879), Le malade imaginaire, 1860s. Lithograph. Courtesy Penny Herscovitch. (illustrated page 13) Josef Breuer (1842-1925) and Sigmund Freud (1856-1939), Studies on Hysteria, New York, 1957. WM173 B846s 1957. (illustrated page 15) Berggasse 19, Sigmund Freud's Home and Office, Vienna 1938, The Photographs of Edmund Engelman, Chicago, 1976. CC2656. (image unavailable for catalogue) Robert Whytt (1714-1766), Observations on the Nature, Causes, and Cure of Those Disorders Which Have Been Commonly Called Nervous, Hypochondriac, or Hysteric, Edinburgh, 1765 55 Sidney Chafet/., Portrait of Sigmund Freud, 1964. Etching: 69 (h) x 56 (w). (illustrated page 15) H. Flanders Dunbar (1902-1959), Emotions and Bodily Changes: A Survey of Literature on Psych omatic Interrelationships, 1910-1933, New York, 1935. Book: 24.5 (h) x 35.5 (open width). WM90 D898e 1935 (illustrated page 18) Psychosomatic Aledicine, September-October 1959. Wl P582. (illustrated page 18) Smith Ely Jelliffe (1866-1959), "Psvchopathology and Organic Disease," Sketches in Psychosomatic Medicine, New York, 1939. Wl NE211 no.65 1939. (image unavailable for cata- logue) Georg Groddeck (1866-1934), The Book of the It, New York, 1928. Book: 23 (h) x 32.5 (open width). Wl NE211 v. 49. (illustrated page 17) Franz Alexander (1891-1964), Psychosomatic Medicine, New York, 1950. Book: 22 (h) x 31.5 (open width). WM90 A375p 1950. (image unavailable for catalogue) Franz Alexander (1891-1964), Psychosomatic Medicine, New York, 1950. Graphic: Photographic reproduction of schematic representation of specificity in the etiology of the peptic ulcer, (illustrated page 19) Helen Lundeberg (1908- ), Double Portrait of the Artist in Time, 1935. Graphic: Photographic reproduction of oil painting. Courtesy National Museum of American Art, Smithsonian Institution, Washington, D.C. (illustrated page 56) Roy Grinker (1900-1993 ) and John P. Spiegel, War Neuroses in North Africa: The Tunisian Campaign (January-Ala)', 1943). Prepared and distributed for the Air Surgeon, Army Air Forces by the Josiah Macy, Jr. Foundation, New York, September 1943. Book: 23 (h) x 15 (w). WM184 G867w 1943. (illustrated page 18) Roy Grinker (1900-1993 ) and John P. Spiegel, Men Under Stress, Philadelphia, 1945. Book: 33 (h) x 23 (w). WM184 G867m 1945. (illustrated page 18) Thomas W. Salmon (1876-1927), The Care and Treatment of Mental Diseases and War Neuroses ("Shell Shock") in the British Army, War Work Committee of the National Committee for Mental Hygiene, New York, 1917. Book: 24.5 (h) x 46.5 (open width with illustration). US 629 S172c 1917. (illustrated page 16) Double Portrait of the Artist in Time Helen Lundeberg Psychosomatic medicine traced the diseases suffered as an adult back to the developmental dramas and trau- mas of early childhood. Courtesy National Museum of American Art. Smithsonian Institution. Washington, D.C. 56 Frank Loesser (1910-1969), "Adelaide's Lament," Guys and Dolls, 1950. © 1950, 1978 Frank Music Corporation. Sheet music and lyrics. Donated by Lou Storey, (image unavailable for catalogue) Self-Healing, Patents, and Placebos, Pharmaceutical Era, February 1889. Graphic: Photographic reproduction of illustration of pharmacy designed and built by C.H. Bangs, (illustrated page 21) Pharmacy Bottle. Bottle: 26" (h) x 6" (dia). Courtesy Elaine and Arthur Shapiro, (illustrated page 57) Benjamin Rush (1746-1813), .4;/ Inquiry into the Effects of Ardent Spirits upon the Human Body and Mind, with an Account of the Means of Preventing, and of the Remedies for Curing Them, New York, 1811. Book: 17 (h) x 21.5 (open width). WZ270 R952i 1811. (illustrated page 21) Pharmacy Bottle. Courtesy Elaine and Arthur Shapiro. Albert Vernon, Correspondence Course of Instruction in the Science of Psychratism or Prowess of the Human Mind, Rochester, New York, The Vernon Academy of Mental Sciences and The Vernon Sanatorium, 1900. Book: 17.5 (h) x 53.5 (open width). BF V539c 1900. (illustrated page 57) Julia Anderson Root, Healing Power ofAIind: A Treatise on Mind-Cure, with Original Views on the Subject and Complete Instructions for Practice and Self-Treatment, Peoria, Illinois, 1886. Book: 20.5 (h) x 32.5 (w). WM R806h 1886. (illustrated page 22) Xotman, William James, Graphic: Photographic reproduction of a photograph. B15230. (illustrated page 22) Mirror with gilt frame (with Emile Coue quote), ca. 1920. Courtesy Elizabeth Fee. (image not available for catalogue) Charles Fremont Winbigler (1857-1925), How to Heal and Help Ones Self or a New Outlook on Life, Los Angeles, 1916. Book: 20 (h) x 14 (w). QT180 W758h 1916. (illustrated page 57) John Kearsley Mitchell (1859-1917), Self Help for Nervous Women: Familiar Talks on Economy in Nervous Expenditure, Philadelphia, 1909. Book: 20 (h) x 14 (w).WM M675s 1909. (illustrated page 57) "Laughter is the Best Medicine," Readers Digest, April 1958. Magazine: 7" (h) x 10" (w). Courtesy Ghilta Sternberg, (illustrat- ed page 23) Albert Vernon, Correspondence Course of Instruction in the Science of Psychratism or Prowess of the Human Mind, Rochester, New York, The Vernon Academy of Mental Sciences and The Vernon Sanatorium, 1900 Charles Fremont Winbigler (1857-1925), How to Heal and Help One's Self or a New Outlook on Life, Los Angeles, 1916 John Kearsley Mitchell (1859-1917), Self Help for Nervous Women: Familiar Talks on Economy in Nervous Expenditure, Philadelphia, 1909 57 Dale Carnegie (1888-1955), How to Stop Worrying and Start Living New York, 1985, © 1944. Book: 6" (h) \ 4" (w■). (image unavailable for catalogue) Thomas A. Harris (1915- ), /'/// Okay—You're OK, New York, 1973, ©1967. Book: 7" (h) x 4" (w). (illustrated page 23) Norman Vincent Peale (1889-1994), The Power of Positive Thinking, New York, 1992, ©1952. Book: 7" (h) x 4" (w). (illustrated page 23) Perkins's Metallic Tractors, late 18th century. Tractors: 5" (1) \ 1/2" (w). Courtesy Historical Collections, The National Museum of Health and Medicine, Armed Forces Institute of Pathology, Washington, D.C. (illustrated page 25) John Haygarth, Of the Imagination as a Cause and as a Cure of Disorders of the Body; Exemplified by Fictitious 'Tractors, and Epidemical Convulsions, Bath, 1800. Book: 21.5 (h) x 27.5 (w). WZ260 H4210 1800. (illustrated page 25) Benjamin Douglas Perkins (1774-1810), The Family Remedy; or, Perkins s Patent Metallic 'Tractors, For the Relief of'Topical Disease of the Human Body; And of Horses, 1800. Pamphlet: 22.5 (h) x 14.5 (w■). WBC P448c 1801. (illustrated page 25) Unicorn horn. Horn: 73" (h) x 4" (dia). Courtesy Elaine and Arthur Shapiro, (illustrated page 24) Kickapoo Oil: Relief from Aches and Pains. Courtesy Elaine and Arthur Shapiro, (illustrated page 24) Nerve ex Bone Liniment. Courtesy Elaine and Arthur Shapiro. (illustrated page 24) Dr. Pierce's Favorite Prescription. Courtesy Elaine and Arthur Shapiro, (illustrated page 24) Hood's Sarsaparilla, Gentian and Bitter Orange Compound. Courtesy Elaine and Arthur Shapiro, (illustrated page 24) Bliss Native Balsam. Courtesy Elaine and Arthur Shapiro, (illus- trated page 24) Swamp Root. Courtesy Elaine and Arthur Shapiro, (illustrated page 24) Milks Emulsion Natures Remedy. Courtesy Elaine and Arthur Shapiro, (illustrated page 24) Erso Anti-Bilious Bitters. Courtesy Elaine and Arthur Shapiro. (illustrated page 24) 58 Pastor Koenig's Nervine for Nervous Aliments. Courtesy Elaine and Arthur Shapiro, (illustrated page 24) Goldine Tonic and Nervine. Courtesy Elaine and Arthur Shapiro. (illustrated page 24) Ads Compound Syrup Hypophosphites Clear. Courtesy Elaine and Arthur Shapiro, (illustrated page 24) Dr. Pierce's Golden Medical Discovery. Courtesy Elaine and Arthur Shapiro, (image unavailable for catalogue) Powered unicorn horn. Courtesy Elaine and Arthur Shapiro. (illustrated page 24) Four Batteries. Batteries: 1" (dia) to 1" (dia). Courtesy Elaine and Arthur Shapiro, (illustrated page 23) Humphreys' Remedies sign. Sign: 16" (h) x 12" (w). Courtesy Elaine and Arthur Shapiro, (illustrated page 24) Warner's Safe Cure Almanac and Book of Handy Information 1895. Buffalo, New York. Book: 22 (h) x 15.5 (w). W6 P3 no. 7475. (illustrated page 24) Portrait of William Osier. Graphic: Photographic reproduction of painting. 20142. (illustrated page 26) Milk Sugar. Bottle: 5" (h) x 2" (dia). Courtesy Elaine and Arthur Shapiro, (illustrated page 28) Antilirium Placebo. Bottle: 4" (h) x 2" (dia). Courtesy Elaine and Arthur Shapiro, (illustrated page 28) Cebocap No. 1. Bottle 2" (h) x 1" (dia). Courtesy Elaine and Arthur Shapiro, (illustrated page 28) Cebocap No. 2. Bottle 2" (h) x 1" (dia). Courtesy Elaine and Arthur Shapiro, (illustrated page 28) Cebocap No. 3. Bottle 2" (h) x 1" (dia). Courtesy Elaine and Arthur Shapiro, (illustrated page 28) Nardil Placebo. Courtesy Elaine and Arthur Shapiro, (illustrated page 29) Placebo for Elavil HC1. Courtesy Elaine and Arthur Shapiro. (illustrated page 29) Placebo for Stelazine. Courtesy Elaine and Arthur Shapiro, (illus- trated page 29) 59 Placebo for Valium. Courtesy Elaine and Arthur Shapiro, (illus- trated page 29) Jon D. Levine, Newton C. Gordon, Howard L. Fields, "The Mechanism of Placebo Analgesia," The Lancet, September 23, 1978. Book: 28 (h) x 58 (open width). Wl LA453. (illustrated page 29) "Pain Pathways." Graphic: Photographic reproduction of illus- tration. Courtesy Alfred Mansour, Mental Health Research Institute, University of Michigan, (image unavailable for catalogue) Stress and Deprivation Peter Gridley, Long Island Expressway. Graphic: Photographic reproduction of photograph, (illustrated page 30) Chris Todd, "Noise Pollution." Audio recording. Walter Bradford Cannon. Graphic: Photographic reproduction of photograph. B30295. (illustrated page 32) Walter Bradford Cannon (1871-1945), Bodily Changes in Pain. Hunger, Fear and Rage: An Account of Ret cut Researches into the Functions of Emotional Excitement, New York, 1915. BF511 C266b 1915. (illustrated page 32) Walter Bradford Cannon (1871-1945), The Wisdom of the Body, New York, 1939. QT104 C226W 1939. (image not available' for catalogue) Hans Selye (1907-1982), The Physiology and Pathology of Exposure to Stress, Montreal, 1950. Book: 24.8 (h) x 39.5 (open width). QZ140 S469p 1950. (illustrated page 33) American Journal of Nursing, March 1965. Wl AM495. (illus- trated page 34) Readers Digest, February 1957. Magazine: 19 (h) x 27 (open width). Courtesy Ghilta Sternberg, (illustrated page 33) Howard Taft Lorenz, Dismissal (or) Pink Slip, 1940. Graphic- Photographic reproduction of oil painting. Courtesy National Museum of American Art, Smithsonian Institution, transfer from Museum of Modern Art. (illustrated page 35) Excerpts from Moniea Study, 1950s. Video. Courtesy Dr. George Engel. 60 Moniea, 1950s. Graphic: Photographic reproduction of six original photographs of Moniea. Courtesy Dr. George Engel. (illustrated page 54) 2/26/54 Applegate, Histamine laboratory "How sheets." Graphic: Photographic reproduction of original laboratory notes. Courtesy Dr. George Engel. (illustrated page 34) B. Kent Houston and C.R. Snyder, editors, Type A Behavior Pattern: Research, Theory, and Intervention, New York, 1988. Book: 24 (h) x 36 (w). WG300 T991 1988. (illustrated page 55) Robert Dantzer, The Psychomatic Delusion, New York, 1993. 1993 A261. (image unavailable for catalogue) Defuse Stress, Health Dynamics Poster Program. ©1988 Clement Communications, Inc. Poster: 56 (h) x 43.2 (w). A25395 (image unavailable for catalogue) Kai T Erickson, Everything in Its Path, New York, 1976. Donated by Lou Storey, (image unavailable for catalogue) Barry-J. Marshall, Richard W. MeCallum, Richard L. Guerrant, editors, Helicobacter Pylori in Peptic Ulceration and Gastritis, Boston, 1991. WI310 H475 1991. (image unavailable for catalogue) Scott Adams, Dilbert, September 15, 1996. Graphic: Photographic reproduction of cartoon. © 1996 United Feature Syndicate, Inc. (illustrated page 37) Volvo Assembly Line, Sweden, ca. 1987. Graphic: Two photo- graphic reproductions of the assembly line. Courtesy Volvo Truck Corporation, Powertrain Division, Skbvde, Sweden, (illustrat- ed page 37) Saratoga Spa, N.Y., ca. 1950s. Postcard: 3" (h) x 5". Courtesy Ghilta Sternberg, (illustrated page 36) Betty White with Thomas J. Watson, Betty Whites Pet-Love: How Pets Take Care of Us, New York, 1983. Book: 21.5 (h) x 30 (open width). DD8254. (illustrated page 61) Cindy Ruskin, photographs by Matt Herron, The Quilt: Stories from the NAMES Project, New York, 1988. Courtesy Nola Heffner. (image unavailable for catalogue) Betty White with Thomas J. Watson, Betty White's Pet-Love: How Pets Take Care of Us, New York, 1983 Some hospitals, hospices and nursing homes have dis- covered that patients feel calmer and less depressed in the presence of a loving, furry friend—some may even become more stable physiologically or recover more quickly from their illness as a result of their involvement in "pet therapy." Photograph credits (I to r): Courtesy of People-Pet Partnership Program; Flossie Stowell; Courtesy of People-Pet Partnership Program; Courtesy of People-Pet Partnership Program. Used by permission of William Morrow & Co., Inc. 61 Frontiers of the Mind How Emotions Matter Positron Emission Tomography (PET scanner). Graphic- Photographic reproduction. Courtesy GE Medical Systems, (illus- trated page 38) Emotions and Disease: The Delicate Balance, 1996. Video. Produced bv the National Library of Medicine with Multimedia Software Inc. for the exhibition Emotions and Disease. Tiger in the wild (including close-up). Graphic: Photographic reproduction from Emotions and Disease video. Courtesy National Geographic Television, (image unavailable for cata- logue) Fear-response system. Graphic: Photographic reproduction of Emotions and Disease video illustration. Illustrated by Bob 1 low ard Computer Graphics, (image unavailable for cata- logue) Neurotransmitters. Graphic: Photographic reproduction from Emotions and Disease video. Illustrated by Bob Howard Computer Graphics, (illustrated page 43) Optical imaging camera. Camera: 14.4 (h) x 13.21 (w) x 21.9 (d). Courtesy Photometries, Ltd. (illustrated page 42) Image created by optical imaging camera. Graphic- Photographic reproduction of imaging camera output. Courtesy Ehud Kaplan and Richard Everson, Mount Sinai School of Medicine, New York, (illustrated page 42) PET scans of brain activity during transient sadness and hap- piness. Graphic: Photographic reproductions of PET scans. Courtesy Mark S. George, Medical University of South Carolina, Charleston, (illustrated page 40) PET scans of brain activity of people who have been asked to look at, listen to, think about or speak a word. Graphic- Photographic reproduction of PET scans. Courtesy Marcus E. Raichle, Washington University, St. Louis, Missouri, (illustrated page 40) Functional magnetic resonance image (fMRI) of brain activity of a person looking at faces. Graphic: Photographic reproduc- tion of fMRI. Courtesy VP Clark, K. Keil, J. Ma. Maisog, S. Courtney, L.G. Ungerleider, and J.V Haxby, National Institute of Mental Health, (illustrated page 41) 62 Activation of T-cells. Graphic: Photographic reproduction of illustration, (illustrated page 44) Molecular structure of interleukin-1. Graphic: Photographic reproduction of illustration. Courtesy: Angela Gronenborn, National Institute of Diabetes and Digestive and Kidney Diseases. Illustrated by Bob Howard Computer Graphics, (image unavailable for catalogue) The Immune System and the Nervous System. Graphic- Photographic reproduction of illustration, (illustrated page 44) Physician examining a sick child. Graphic: Photographic reproduction. Courtesy National Institute of Allergy and Infectious Diseases, ((image not available for catalogue) Computerized photomierographic microscope. Graphic- Photographic reproduction. Courtesy Leica Inc., Deerfield, Illinois. (illustrated page 42) /// situ hybridization. Graphic: Photographic reproduction of imaging microscope output. Courtesy Miles A. Herkenham, National Institute of Mental Health, (illustrated page 42) Normal circulating human blood. Graphic: Photographic reproduction of scanning electron microscope output. Courtesy Bruce Wetzel and Harry Schaeffer, National Cancer Institute, (illus- trated page 42) Researcher and DNA sequencing gel. Graphic: Photographic reproduction. Courtesy National Institute of Allergy and Infectious Disease, ((image not available for catalogue) A Dynamic Balance Overactive hypothalamus. Graphic: Photographic reproduc- tion of Emotions and Disease video illustration. Illustrated by Bob Howard Computer Graphics, (image not available for catalogue) An overactive amygdala. Graphic: Photographic reproduction of Emotions and Disease video illustration. Illustrated by Bob Howard Computer Graphics, (illustrated page 40) Interruption of the brain/immune system communication. Graphic: Photographic reproduction of Emotions and Disease video illustration. Illustrated by Bob Howard Computer Graphics, (image not available for catalogue) 63 Immune system stuck in the on position. Graphic: Photographic reproduction of Emotions and Disease video illus- tration. Illustrated by Bob Howard Computer Graphics. (image not available for catalogue) Imbalance in the chemical transmission between neurons. Photographic reproduction of Emotions and Disease video illus- tration. Illustrated by Bob Howard Computer Graphics. (image not available for catalogue) 64 Acknowledgments This project was made possible by the generous support of the Charles A. Dana Foundation, the John D. and Catherine T. MacArthur Foundation, the Fetzer Institute, and the National Institute of Mental Health. Project Staff Esther M. Sternberg, M.D. National Institute of Mental Health Exhibition Director Elizabeth Fee, Ph.D. National Library of Medicine Exhibition Director Anne Harrington, Ph.D. Harvard University, Cambridge MA Visiting Curator, Exhibition Script Writer Theodore M. Brown, Ph.D. University of Rochester, Rochester NY Visiting Curator, Exhibition Catalogue Essay Author Gretchen Hermes, Washington DC Assistant Curator Patricia Tuohy, Washington DC Exhibition Manager; Managing Editor, Catalogue Anne Whitaker National Library of Medicine Collections Manager Edwina Smith, Washington DC Exhibition Coordinator Mary Parke Johnson National Library of Medicine Conservator Margaret Kaiser Elizabeth Tunis National Library of Medicine Proofreaders Roxanne Beatty National Library of Medicine Invitation Coordinator 65 William Leonard National Library of Medicine A udiovisual Coordinator Joe Fitzgerald National Library' of Medicine Chief of Graphics Troy Hill National Library of Medicine Graphic Designer Design and Production Lou Storey, Red Bank NJ Exhibition Designer Multimedia Software, Inc., Frederick MD Emotions and Disease:. 1 Delicate Balance Video Producer Exhibits Unlimited, Inc., Alexandria VA Exhibition and Graphic Fabricator Technical Artistry, New York NY Lighting Designer Donors and Lenders to the Exhibition George L. Engel Elizabeth Fee Mary Garofalo Nola Heffner Penny Herscovitch Historical Collections, The National Museum of Health and Medicine, Armed Forces Institute of Pathology, Washington DC Photometries Ltd, Tucson AZ Elaine and Arthur Shapiro Esther Sternberg Ghitta Sternberg Lou Storey 66 Exhibition Photographs and Graphics Scott Adams Y.P. Clark, K. Keil, J. Ma. Masog, S. Courtney, E.G. Ungerleider, and J.V. Haxby, National Institute of Mental Health George L. Engel GE Medical Systems, Milwaukee Wl Mark S. George, Medical University of South Carolina, Charleston Peter Gridley/FPG Angela Gronenborn, National Institute of Diabetes and Digestive and Kidney Diseases Miles A. Herkenham, National Institute of Mental Health Ehud Kaplan and Richard Everson, Mount Sinai School of Medicine Leica, Inc., Deerfield IL Alfred Mansour, University of Michigan, Ann Arbor National Cancer Institute National Institute of Allergy and Infectious Diseases National Geographic Television National Museum of American Art, Smithsonian Institution Marcus E. Raichle, Washington University School of Medicine, St. Louis United Media, New York NY Volvo Lastvagnar, Skovde, Sweden Bruce Wetzel and Harry Schaefer, National Cancer Institute Let There Be Light video excerpts Production Brian Matthews National Library of Medicine Editor Open captions and laser disk provided by Audiovisual Program Development Branch, Lister Hill National Center for Biomedical Communications, NLM 67 Monica Story video excerpts Video and Images Courtesy Dr. George L. Engel Monica Archives Committee, University of Rochester, Rochester NY Production Tim Shea Department of Psychiatry University of Rochester Medical School 1 'isual Consultant Brian Matthews National Library of Medicine Editor Open captions and laser disk provided by Audiovisual Program Development Branch, Lister Hill National ('enter for Biomedical Communications, NLM Emotions and Disease: A Del irate Balance video Video and Images The Arthritis Foundation Y.P. Clark, K. Keil, J. Ma. Maisog, S. Courtney, E.G. Ungerleider, and J.V. Haxby, National Institute of Mental Health "Digital Anatomist" team at University of Washington including: Dr. Cornelius Rosse, Dr. John Bolles, Dr. John W. Sundsten, Dr. James Brinkley, Draig Eno, Jeffery Prothero, Roger Williams Historical Collections, The National Museum of Health and Medicine, Armed Forces Institute of Pathology, Washington DC History of Medicine Division, National Library of Medicine Mark S. George, Medical University of South Carolina, Charleston Miles A. Herkenham, National Institute of Mental Health Ehud Kaplan and Richard Everson, Mount Sinai School of Medicine National Institute of Allergy and Infectious Diseases National Institute of Mental Health National Institute of Mental Health/DART National Institute of Diabetes and Digestive and Kidney Diseases National Cancer Institute National Geographic Television "Luncheon of the Boating Party" Reproduced courtesy of The Phillips Collection, Washington DC 68 Production Esther M. Sternberg, M.D. National Institute of Mental Health Executive Producer, Script Writer Marc Montefusco Multimedia Software, Inc. Producer Bob Howard Computer Graphics Art Direction, Animation, Digital Video Editing and Special Effects Paul Rose Charizmah, Inc. Composer, Original Score Special Advisors Michelle Trudeau National Public Radio, Irvine CA James Louie, M.D. Division of Rheumatology, Harbor-UCLA Medical Center Dr. C. Liana Bolis World Health Organization Dr. Rex Cowdry National Institute of Mental Health Dr. Scott Durum National Cancer Institute Dr. Suzanne Felten University of Rochester Dr. Jonathan Fritz National Institute of Mental Health Dr. Angela Gronenborn National Institute of Diabetes and Digestive and Kidney Diseases Dr. Pierre Henkart National Cancer Institute Dr. Steven Hyman National Institute of Mental Health 69 Dr. Ehud Kaplan Mount Sinai School of Medicine Dr. Joseph LeDoux New York University Dr. Ludise Malkova National Institute of Mental Health Dr. Bruce McEwen Rockefeller University Dr. Mortimer Mishkin National Institute of Mental Health Dr. Jon Newsom Eibrary of (ingress Dr. Stanley Pillemer National Institute of Arthritis and Musculoskeletal and Skin Diseases Dr. Marcus E. Raichle Washington University School of Medicine Dr. Harry Z. Rand National Museum of American Art Consulting Panel C. Liana Bolis, M.D. Division of Mental Health World Health Organization Ary Goldberger, M.D. Beth Israel Hospital Harvard Medical School, Boston MA Lynn G. Gordon, Ph.D. Fetzer Institute, Kalamazoo MI Vyacheslav Ivanov, Ph.D. University of California, Los Angeles, CA Institute of World Culture, Moscow University Ehud Kaplan, Ph.D. Mount Sinai School of Medicine, New York NY Joseph LeDoux, Ph.D. New York University, New York NY 70 William R. Lovallo, Ph.D. Mind-Body Network, Chicago IE MacArthur Foundation, Chicago IE Bruce McEwen, Ph.D. Rockefeller University, New York NY Society for Neuroscience, Washington DC Declan Murphy, Ph.D. DMR Management Group, Falls Church VA Jon Newsom, Ph.D. Library' of Congress, Washington DC Marcus E. Raichle, M.D. Washington University School of Medicine, St. Louis MO Ham Z. Rand, Ph.D. National Museum of American Art, Washington DC Douglas Smith, Ph.D. Boston Museum of Science, Boston MA Fred Steiner, Ph.D. Composer, Santa Fe \M 71 Special Thanks Donald A.B. Lindberg, M.D., Director, National Library of Medicine Jules As her, National Institute of Mental Health Maggie Bartlett, National Cancer Institute Rick Becker, Department of Psychiatry, University of Rochester Medical School Lois Ann Colaianni, Associate Director for Library Operations, National Library of Medicine Rex W. Cow dry, Acting Deputy Director, National Institute of Mental Health Isabel Davidoff, National Institute of Mental Health/DART Kathleen Gardner Cravedi, Special Expert, Office of Public Information, National Library of Medicine Daniel Garrett, National Institute of Diabetes and Digestive and Kidney Diseases Ah in Harris, Deputy Chief, Office of Administration, National Library of Medicine Steven E. Hyman, Director, National Institute of Mental Health Joy Jackson, NTH Video Unit Karlton Jackson, Staff Photographer, National Library of Medicine Donna Kerrigan, National Cancer Institute Karen Leighty, National Institute of Allergy and Infectious Diseases Robert Mehnert, Chief, Office of Public Information, National Library of Medicine Pamela Meredith, Head, Public Services Division, National Library of Medicine Elizabeth G. Rosso, Assistant Administrative Officer, National Library of Medicine Kent A. Smith, Ph.D., Deputy Director, National Library of Medicine Patricia Williams, Administrative Officer, National Library of Medicine Theodore E. Youwer, Chief, Office of Administration, National Library of Medicine Additional Thanks Al Abrams, Bethesda MD, print broker Litho Impressions, VA, brochure printer Frame of Mine, Washington DC, framing Jeff Watts, Staff Photographer, Infinite Color, Arlington VA, catalogue photography Chroma Graphics, Inc., Largo MD, catalogue printer 72