Anatomy of an Illness as Perceived by the Patient (3 page)

Seldom had I known such elation. The ascorbic acid was working. So was laughter. The combination was cutting heavily into whatever poison was attacking the connective tissue. The fever was receding, and the pulse was no longer racing.

We stepped up the dosage. On the second day we went to 12.5 grams of ascorbic acid, on the third day, 15 grams, and so on until the end of the week, when we reached 25 grams. Meanwhile, the laughter routine was in full force. I was completely off drugs and sleeping pills. Sleep—blessed, natural sleep without pain—was becoming increasingly prolonged.

At the end of the eighth day I was able to move my thumbs without pain. By this time, the sedimentation rate was somewhere in the 80s and dropping fast. I couldn't be sure, but it seemed to me that the gravel-like nodules on my neck and the backs of my hands were beginning to shrink. There was no doubt in my mind that I was going to make it back all the way. I could function, and the feeling was indescribably beautiful.

I must not make it appear that all my infirmities disappeared overnight. For many months I couldn't get my arms up far enough to reach for a book on a high shelf. My fingers weren't agile enough to do what I wanted them to do on the organ keyboard. My neck had a limited turning radius. My knees were somewhat wobbly, and off and on, I have had to wear a metal brace.

Even so, I was sufficiently recovered to go back to my job at the
Saturday Review
full time again, and this was miracle enough for me.

Is the recovery a total one? Year by year the mobility has improved. I have become pain-free, except for one shoulder and my knees, although I have been able to discard the metal braces. I no longer feel a sharp twinge in my wrists when I hit a tennis ball or golf ball, as I did for such a long time. I can ride a horse flat out and hold a camera with a steady hand. And I have recaptured my ambition to play the Toccata and Fugue in D Minor, though I find the going slower and tougher than I had hoped. My neck has a full turning radius again, despite the statement of specialists as recently as 1971 that the condition was degenerative and that I would have to adjust to a quarter turn.

It was seven years after the onset of the illness before I had scientific confirmation about the dangers of using aspirin in the treatment of collagen diseases. In its May 8, 1971, issue,
Lancet
published a study by Drs. M. A. Sahud and R.J. Cohen showing that aspirin can be antagonistic to the retention of vitamin C in the body. The authors said that patients with rheumatoid arthritis should take vitamin C supplements, since it has often been noted that they have low levels of the vitamin in their blood. It was no surprise, then, that I had been able to absorb such massive amounts of ascorbic acid without kidney or other complications.

What conclusions do I draw from the entire experience?

The first is that the will to live is not a theoretical abstraction, but a physiologic reality with therapeutic characteristics. The second is that I was incredibly fortunate to have as my doctor a man who knew that his biggest job was to encourage to the fullest the patient's will to live and to mobilize all the natural resources of body and mind to combat disease. Dr. Hitzig was willing to set aside the large and often hazardous armamentarium of powerful drugs available to the modern physician when he became convinced that his patient might have something better to offer. He was also wise enough to know that the art of healing is still a frontier profession. And, though I can't be sure of this point, I have a hunch he believed that my own total involvement was a major factor in my recovery.

People have asked what I thought when I was told by the specialists that my disease was progressive and incurable.

The answer is simple. Since I didn't accept the verdict, I wasn't trapped in the cycle of fear, depression, and panic that frequently accompanies a supposedly incurable illness. I must not make it seem, however, that I was unmindful of the seriousness of the problem or that I was in a festive mood throughout. Being unable to move my body was all the evidence I needed that the specialists were dealing with real concerns. But deep down, I knew I had a good chance and relished the idea of bucking the odds.

Adam Smith, in his book,
Powers of the Mind
, says he discussed my recovery with some of his doctor friends, asking them to explain why the combination of laughter and ascorbic acid worked so well. The answer he got was that neither laughter nor ascorbic acid had anything to do with it and that I probably would have recovered if nothing had been done.

Maybe so, but that was not the opinion of the specialists at the time.

Two or three doctors, reflecting on the Adam Smith account, have commented that I was probably the beneficiary of a mammoth venture in self-administered placebos.

Such a hypothesis bothers me not at all. Respectable names in the history of medicine, like Paracelsus, Holmes, and Osler, have suggested that the history of medication is far more the history of the placebo effect than of intrinsically valuable and relevant drugs. Such modalities as bleeding (in a single year, 1827, France imported 33 million leeches after its domestic supplies had been depleted); purging through emetics; physical contact with unicorn horns, bezoar stones, mandrakes, or powdered mummies—all such treatments were no doubt regarded by physicians at the time as specifics with empirical sanction. But today's medical science recognizes that whatever efficacy these treatments may have had—and the records indicate that the results were often surprisingly in line with expectations—was probably related to the power of the placebo.

Until comparatively recently, medical literature on the phenomenon of the placebo has been rather sparse. But the past two decades have seen a pronounced interest in the subject. Indeed, three medical researchers at the University of California, Los Angeles, have compiled an entire volume on a bibliography of the placebo. (J. Turner, R. Gallimore, C. Fox
Placebo: An Annotated Bibliography
. The Neuropsychiatric Institute, University of California, Los Angeles, 1974.) Among the medical researchers who have been prominently engaged in such studies are Arthur K. Shapiro, Stewart Wolf, Henry K. Beecher, and Louis Lasagna. (Their work is discussed in the next chapter.) In connection with my own experience, I was fascinated by a report citing a study by Dr. Thomas C. Chalmers, of the Mount Sinai Medical Center in New York, which compared two groups that were being used to test the theory that ascorbic acid is a cold preventative. “The group on placebo who thought they were on ascorbic acid,” says Dr. Chalmers, “had fewer colds than the group on ascorbic acid who thought they were on placebo.”

I was absolutely convinced, at the time I was deep in my illness, that intravenous doses of ascorbic acid could be beneficial—and they were. It is quite possible that this treatment—like everything else I did—was a demonstration of the placebo effect.

At this point, of course, we are opening a very wide door, perhaps even a Pandora's box. The vaunted “miracle cures” that abound in the literature of all the great religions all say something about the ability of the patient, properly motivated or stimulated, to participate actively in extraordinary reversals of disease and disability. It is all too easy, of course, to raise these possibilities and speculations to a monopoly status—in which case the entire edifice of modern medicine would be reduced to little more than the hut of an African witch doctor. But we can at least reflect on William Halse Rivers's statement, as quoted by Shapiro, that “the salient feature of the medicine of today is that these psychical factors are no longer allowed to play their part unwittingly, but are themselves becoming the subject of study, so that the present age is serving the growth of a rational system of psychotherapeutics.”

What we are talking about essentially, I suppose, is the chemistry of the will to live. In Bucharest in 1972, I visited the clinic of Ana Aslan, described to me as one of Romania's leading endocrinologists. She spoke of her belief that there is a direct connection between a robust will to live and the chemical balances in the brain. She is convinced that creativity—one aspect of the will to live—produces the vital brain impulses that stimulate the pituitary gland, triggering effects on the pineal gland and the whole of the endocrine system. Is it possible that placebos have a key role in this process? Shouldn't this entire area be worth serious and sustained attention?

If I had to guess, I would say that the principal contribution made by my doctor to the taming, and possibly the conquest, of my illness was that he encouraged me to believe I was a respected partner with him in the total undertaking. He fully engaged my subjective energies. He may not have been able to define or diagnose the process through which self-confidence (wild hunches securely believed) was somehow picked up by the body's immunologic mechanisms and translated into antimorbid effects, but he was acting, I believe, in the best tradition of medicine in recognizing that he had to reach out in my case beyond the usual verifiable modalities. In so doing, he was faithful to the first dictum in his medical education: above all, do not harm.

Something else I have learned. I have learned never to underestimate the capacity of the human mind and body to regenerate—even when the prospects seem most wretched. The life-force may be the least understood force on earth. William James said that human beings tend to live too far within self-imposed limits. It is possible that these limits will recede when we respect more fully the natural drive of the human mind and body toward perfectibility and regeneration. Protecting and cherishing that natural drive may well represent the finest exercise of human freedom.

TWO

T
HE
M
YSTERIOUS
P
LACEBO

Over long centuries, doctors have been educated by their patients to observe the prescription ritual. Most people seem to feel their complaints are not taken seriously unless they are in possession of a little slip of paper with indecipherable but magic markings. To the patient, a prescription is a certificate of assured recovery. It is the doctor's IOU that promises good health. It is the psychological umbilical cord that provides a nourishing and continuing connection between physician and patient.

The doctor knows that it is the prescription slip itself, even more than what is written on it, that is often the vital ingredient for enabling a patient to get rid of whatever is ailing him. Drugs are not always necessary. Belief in recovery always is. And so the doctor may prescribe a placebo in cases where reassurance for the patient is far more useful than a famous-name pill three times a day.

This strange-sounding word, placebo, is pointing medical science straight in the direction of something akin to a revolution in the theory and practice of medicine. The study of the placebo is opening up vast areas of knowledge about the way the human body heals itself and about the mysterious ability of the brain to order biochemical changes that are essential for combating disease.

The word placebo comes from the Latin verb meaning “I shall please.” A placebo in the classical sense, then, is an imitation medicine—generally an innocuous milk-sugar tablet dressed up like an authentic pill—given more for the purpose of placating a patient than for meeting a clearly diagnosed organic need. The placebo's most frequent use in recent years, however, has been in the testing of new drugs. Effects achieved by the preparation being tested are measured against those that follow the administration of a “dummy drug” or placebo.

For a long time, placebos were in general disrepute with a large part of the medical profession. The term, for many doctors, had connotations of quack remedies or “pseudomedicaments.” There was also a feeling that placebos were largely a shortcut for some practitioners who were unable to take the time and trouble to get at the real source of a patient's malaise.

Today, however, the once lowly placebo is receiving serious attention from medical scholars. Medical investigators such as Dr. Arthur K. Shapiro, the late Dr. Henry K. Beecher, Dr. Stewart Wolf, and Dr. Louis Lasagna have found substantial evidence that the placebo not only can be made to look like a powerful medication but can actually act like a medication. They regard it not just as a physician's psychological prop in the treatment of certain patients but as an authentic therapeutic agent for altering body chemistry and for helping to mobilize the body's defenses in combating disorder or disease.

While the way the placebo works inside the body is still not completely understood, some placebo researchers theorize that it activates the cerebral cortex, which in turn switches on the endocrine system in general and the adrenal glands in particular. Whatever the precise pathways through the mind and body, enough evidence already exists to indicate that placebos can be as potent as—and sometimes more potent than—the active drugs they replace.

“Placebos,” Dr. Shapiro has written in the
American Journal of Psychotherapy
, “can have profound effects on organic illness, including incurable malignancies.” One wonders whether this fact may be the key to the puzzle of those cancer sufferers who, according to documented accounts, have recovered after taking Laetril, even though many of the nation's leading cancer research centers have been unable to find any medicinal value in this particular substance.

It is obviously absurd to say that doctors should never prescribe pharmacologically active drugs. There are times when medication is absolutely essential. But the good doctor is always mindful of its power. No greater popular fallacy exists about medicine than that a drug is like an arrow that can be shot at a particularized target. Its actual effect is more like a shower of porcupine quills. Any drug—or food, for that matter—goes through a process in which the human system breaks it down for use by the whole.

There is almost no drug, therefore, that does not have some side-effects. And the more vaunted the prescription—antibiotics, cortisone, tranquilizers, antihypertensive compounds, antiinflammatory agents, muscle relaxers—the greater the problem of adverse side effects. Drugs can alter or rearrange the balances in the bloodstream. They can cause the blood to clot faster or slower. They can reduce the level of oxygen in the blood. They can prod the endocrine system, increase the flow of hydrochloric acid to the stomach, slow down or speed up the passage of blood through the heart, impair the blood-making function of the body by depressing the bone marrow, reduce or increase blood pressure, or affect the sodium-potassium exchange, which has a vital part in the body's chemical balance.