SHOCK THERAPY AND ANALYSIS OF FEAR: THE ORIGINS OF MODERN TECHNIQUES

Thomas Cogan (1736-1816) defended his dissertation De Animi Pathematum vi et modo agendi in inducendis vel curandis morbis (On the

[83] Thomas Cogan (1736-1818) was 31 years old when he took his degree in Leiden. He started his career as a minister of the Anglican Church in England, but he became a Unitarian and had to leave his parish in 1762. He went to the Hague, where he served as a minister. When he intended to marry a banker's daughter, he was refused by her father, unless he trained for the medical profession. He got his medical degree at Leiden in 1765 and presented his dissertation in 1767. He defended his thesis under Gaub, saying that he had collected his material from different authors and different schools, but that he thanked his teachers (probably also B. S. Albinus) for their support. It is clear from this study that he wanted to be well informed on the physiology of the mental processes and that he was avoiding explanations in the field of moral theology. In his later work he tried to combine the medical and the moral insights into the problem. His essay Philosophical Treatise on the Passions was printed in 1800; in 1802 a second edition followed. Later, he turned fully to moral theology, See Dictionary of National Biography (London: Smith and Elder, 1887), vol. 11.

[84] Thomas Pemberton was born in 1750. He took his medical degree in Edinburgh and went to Leiden. His father, Eduard, was a friend of Boerhaave. See Innes Smith, English-speaking Students.

power of the emotions and their action in causing or curing disease) in 1767. His study is in complete agreement with Gaub's concepts on the disturbances of the mental processes by the pathemata, which he describes as perturbations of the mind by the classical emotions: hope, joy, love, shame, anger, fright, fear, and sadness.^[85] Cogan discusses each affect in a physiological and a psychological context. He also offers suggestions on how to induce some of these emotions in patients. Terror (fright) cannot be medically cured or provoked. But the effect of terror can be produced by inducing a state of shock.^[86] Such induced shock has been successful in curing symptoms of depression. It is possible to cure a fever by inflicting terror; even a mute may talk after a shock! A paralyzed patient may suddenly walk, and girls may suddenly start to menstruate. But shock treatment is not indicated for the already frightened patient. Imposed terror will further paralyze a fearful patient: he becomes pale and cold, with trembling lips, his hair rises, and he loses control over his bladder and bowels. His heartbeat accelerates, his pulse becomes rapid and uneven, and he feels pressure (anxietas ) on his chest.^[87] Fear, Cogan states, is the gateway to serious diseases: it agitates the irritability of the nervous system, the capillaries contract, and patients who are living in a continuous state of anxiety may suffer physically. According to mechanical principles, if the contracted capillaries were not supplying the delicate parts of the body with sufficient quantities of blood, irregular cell growth or tumors could result. Cogan cites Van Swieten's remarks on breast cancer in women who live under stress.^[88] Fear has other negatives in connection with disease. Frightened people are likely to contract contagious diseases earlier than those who are strong-minded (fortitudo animae ), as was described by Diemerbroeck's study on an epidemic of the bubonic plague.^[89] Cogan offers

[85] Spes. gaudium, amor, pudor, ira, terror, metus, moeror—this is the classical series from Galen onward. A systematic description with a classification of the passions was published by Christian Heinrich de Marees, De Animi Perturbationum in corpus potentia (Göt-tingen, 1775).

[86] Thomas Cogan, De Animi Pathematum vi et modo agendi in inducendis vel curandis morbis (Leiden, 1767), 28.

[87] Ibid., 30.

[88] G. van Swieten, Commentaria in Hermanni Boerhaave Aphorismos de cognoscendis et curandis morbis (Commentaries on Herman Boerhaave's Aphorisms on diagnosing and curing diseases) (Hildburghausen, 1754), 1:495. Van Swieten notes the danger of long-lasting depressions (affectus animi tristes et biliosi ). These can provoke tumors or change chronic illness into cancer. The case of the breast tumor was described ibid. 1:127.

[89] IJsbrand van Diemerbroeck (1609-1674) studied an epidemic of the bubonic plague at Nijmegen in 1636-1637, which he published in 1644 in Arnhem. The book was reprinted several times. The idea of fear as a provoking factor for infectious diseases was already known to the ancients.

a mechanical explanation to describe how fear-based skin eruptions complicate disease: fear causes the skin vessels to contract, limiting the expulsion of contagious material through perspiration, which aggravates skin eruptions. Since eighteenth-century doctors saw many patients with smallpox, Diemerbroeck's observations at the time of a bubonic plague epidemic received new interest and a new underlying theory was considered.

In his psychological analysis of the anima pathemata Cogan discusses combinations of the emotions. He describes the effects of proneness to anger (iracundia ), which produces a grim visage, sleepless nights, and bad appetite, especially in combination with hatred and jealousy.^[90] While loneliness produces fear and sadness, a combination of fright, sadness, and anger may drive a person to suicide.^[91] Cogan also rejects humoral theories to explain the effects of the emotions upon the body and maintains that all responses are dependent on the system of nervous irritability and sensibility; the patient responds to diverse stimuli with diverse reactions.^[92] Here then was a model of psychology that depended exclusively on prescribed notions of mind and body viewed in relation.

But why has the highest Arbiter Rerum (God) created the emotions in such a way that they always produce the same phenomena in the human body? Why does anger act so differently from sadness and hope so differently from fear? Cogan also introduces the human element in differing human responses, but he considers the infliction of emotions not only a matter of physics but a consequence of the construction of the society as well.^[93] The living-together of people influences the mind. The body reacts on the conflicts in society by the passway of the mind. We

[90] Cogan, De Animi Pathematum vi, 35.

[91] Ibid. The idea of composed passions of the mind in different combinations is present in Descartes's and Hume's theories. Descartes analyzes the emotions in passiones primitivae with the opposite passion, for instance amor-odium, laetitia-tristitia, spes-metus. He refines the emotions further: hope gives safety, fear gives despair, indignation gives wrath. Cogan analyzes more as a physician! But he is an admirer of Descartes, judging by his motto: "Nihii affirmo, nihilque ab ullo credi velim, nisi quod ipsi evidens et invicta ratio persuadebit" ("I affirm nothing, and I would have no one believe anything unless convinced by clear and irrefutable reasoning") (Principia philosophiae [Amsterdam, 1644], pars 4, art. 207).

[92] Cogan, De Animi Pathematum vi, 36. He relies on Robert Whytt, Physiological Essays, … II. Observations on the sensibility and irritability of the parts of men (Edinburgh, 1755), 2-3.

[93] Cogan, De Animi Pathematum vi, 38-39.

can notice these changes in the trembling, frightened people who must appear in court, even when they are not guilty. But, Cogan asserts, the human body adjusts itself to the burden of the emotions imposed by society on the mind. It is the physicians' task to take better notice of the mental state of their patients, to find the right way to stimulate the emotion that favors the healing of the disease.^[94]

Thomas Pemberton's psychological analysis of metus is quite interesting. He states that fantasy, the product of disordered imagination, causes disease, whereas the expectation of an approaching calamity generates fear. He cites David Hume's remark on a man in prison who had just received a death warrant.^[95] Pemberton speaks of terror (fright), the sudden confrontation with an unexpected danger. There is also pavor, the children's fright, as described by John Locke—a consequence of a faulty education by maids and nurses who tell the children stories about ghosts and monsters. Timor is the kind of walled-in fear of which the patient is unaware. Pemberton pays particular attention to this form of fear, the tired and sick patient with lower-back pain, weak and slow pulse, and frequent urination. He describes cold and perspiring hands and feet, deep sighs, pale faces, visual disturbances, and inertia as signs of suppressed anxiety.^[96] One recognizes in this description the quintessential neurasthenia, described in 1880 by George Miller Beard, as the new disease of American civilization,^[97] just as hypochondria had been the disease of English civilization par excellence in Europe during the seventeenth and eighteenth centuries. Pemberton also discusses the fear of earthquakes, of volcanic eruptions, of confrontation with masked men, of burglars, of ghosts, of bed-curtains, of mice, of women, of loneliness, of poison, and of contagious diseases. And he also mentions the use of inflicting terror (fright) as a means of therapy.

Aside from the cases described by Pemberton, various textbooks offer grotesque studies using terror in the form of therapy. For instance, the

[94] Ibid. Various students use this point of opposite passions in their dissertations. They refer to Sanctorius, Ars de Statiea Medicina, the chapter on the emotions (sec. 7, aphorism 12). "Ira et spes auserunt timorem, et laetitia moestitiam" (Wrath and hope may chase fear, and joy sadness). For instance, Wilhelmus Ouwens, a Dutch student who got his doctor's degree in Leiden in 1737 on the subject De Horrore (On Shivering), 44, and Pemberton, De Metu, 59.

[95] Pemberton, De Metu, 17, citing David Hume, Of the Passions (n. 17 above), 190.

[96] Pemberton, De Metu, 35.

[97] George Miller Beard (1839-1883) published in 1880 A practical treatise on nervous exhaustion (neurasthenia); its symptoms, nature, sequences, treatment. The concept "neurasthenia" was first published in the Boston Medical and Surgical Journal 3 (29 April 1869): 217-220.

Pl. 13. Cartoon by T. Rowlandson, "Delusion of Persecution" (1792).

well-known case of Herman Boerhaave's action in the orphanage of Haarlem is recorded. In this orphanage a girl fell into convulsions caused by a sudden fright. Gradually the other children developed fear symptoms and one after the other fell to the floor. Boerhaave called all the children into the common room of the orphanage. He had pots prepared with glowing coals. On these pots he put small iron hooks of different configurations. Then he said to the children: "I do not know of any medicine to cure you. But each child be it a boy or a girl, that falls into a convulsion, will be burned with a little hook in his arm." The children were terrified with this prospect and nobody fell down again. Indeed, when one can detach the mind from an idea and replace it by another feeling or by terror, convulsions can be cured.^[98]

Pemberton also mentions a case described by Tissot:

[98] Pemberton, De Metu, 54. This case history was quoted by many authors. It was first described by Boerhaave's nephew Abraham Kaau Boerhaave in his study Impetum faciens dictum Hippocrati per corpus consentiens philologice et physiologice illustratum (The so-oiled Hippocratic arousal, experienced in the body, explained by its philology and physiology) (Leiden, 1745), 355-406. See G. A. Lindeboom, "Boerhaave in het weeshuis," Nederlands Tijdschrift voor Geneeskunde 102, no. 1 (1958): 24.

A Swiss officer refused to be bled since he always fainted at the sight of blood. The commander solved the problem by giving the order: attention! accompanied by a role of the drums. This distraction allowed the officer to be bled without problems.^[99]

Two further examples which Pemberton describes come from Schenck von Grafenberg and may be considered "classic" studies of recovery with induced shock:

A depressed girl refused to obey the physician's orders. The doctor asked her father's permission for a drastic therapy. The doctor went out, undressed, rushed back naked into the room and jumped into the girl's bed. The startled girl jumped from her bed and her depression ended.^[100]

An unmarried woman was frightened by a mouse and became subject to a permanent fear of mice. The doctor forced her to put a dead mouse in her lap and again shock acted as a cure.^[101]

The lap was, of course, the crucial geographic spot. If the girl could keep it there—as she apparently did, although for what length of time is unknown and unrecounted—close to the uterus, for so long the acknowledged seat of female hysteria, then her dread of mice would be allayed. According to Pemberton, who found the story credible, it was successful. In both cases, the action of the physician held overtones of sexual aggression, which were salutary for the patients. The girl who refused to get up from her bed was probably a virgin. The woman who feared mice was generally fearful and timid. Shock was induced and both were able to reduce their anxieties. In another example of induced terror, Pemberton mentioned a lecture, given by William Cullen on whooping cough in children. Cullen discussed terror as a therapeutic agent, and he mentioned some habits used in folk medicine but not well documented. Children who were suffering long-lasting coughs were

[99] Mentioned by S. A. Tissot. See n. 46 above. I found the passage in the German edition Säimtliche zur Arztneykunst gehörige Schriften … übersetzt nach den neuesten Verbesserungen (Leipzig, 1761), 4:338.

[100] Pemberton, De Metu, 55. He cited Joannes Schenck yon Grafenberg (1530-1598), a famous physician from Freiburg. His book, which contains many case histories, was later edited by his son and reprinted many times. See ParathsÎwn sive observationum medicarum rarum, novarum, admirabilium, et monstrosarum volumen (Volume of rare, new, remarkable, and strange medical observations) (Frankfurt, 1609), 154: "singulari solertia medici a melancholia asserta" (A case of melancholy, cured by the extraordinary ingenuity of a physician). This book by Schenck was kept as a handbook for medical students in the university library at Leiden, having been acquired in 1618. The call number is 637A1.

[101] Pemberton, De Metu, 44.

locked into a working mill.^[102] The crepitaculum molare (the sound of the grinding millstone) would so frighten them that they would overcome their coughing reflex. According to Pemberton, Cullen was not supporting this drastic treatment, he just offered it as a neutral example of the therapeutic effect of terror. Cullen mentioned the mill in his textbook when he discussed the therapy of whooping cough, but he promoted the use of herbal medicines.

Cogan as well as Pemberton had discarded considerably the earlier mechanistic explanations of the interaction between mind and body in cases of anxiety. Both discuss the nervous system as the seat of the disturbances, and they accept the vascular changes only as secondary symptoms. They notice the variation of sensibility of the brain for the stimuli of fear, and, after careful analysis, they record a difference in anxiety-proneness. Pemberton acknowledges that anxiety may underlie other emotional symptoms, such as a general state of depression. But they both use the classic shock agent again, to expel a passion with the opposite emotion. Still, their observations witness a sharp analysis of emotions, and they come very near to modern trends in psychology and even more contemporary ones in psychiatry.^[103]