Anatomy of an Illness as Perceived by the Patient (5 page)

Pondering this grim array of potions and procedures, which were as medically respectable in their day as any of the vaunted medicines in use today, Dr. Shapiro has commented that “one may wonder how physicians maintained their positions of honor and respect throughout history in the face of thousands of years of prescribing useless and often dangerous medications.”

The answer is that people were able to overcome these noxious prescriptions, along with the assorted malaises for which they had been prescribed, because their doctors had given them something far more valuable than the drugs: a robust belief that what they were getting was good for them. They had reached out to their doctors for help; they believed they were going to be helped—and they were.

Some people are more susceptible to placebo therapy than others. Why? It used to be assumed that there was some correlation between high suggestibility and low intelligence, and that people with low IQs were therefore apt to be better placebo subjects. This theory was exploded by Dr. H. Gold at the Cornell Conference on Therapy in 1946. The higher the intelligence, said Dr. Gold on the basis of his extended studies, the greater the potential benefit from the use of placebos.

Inevitably, the use of the placebo involved built-in contradictions. A good patient-doctor relationship is essential to the process, but what happens to that relationship when one of the partners conceals important information from the other? If the doctor tells the truth, he destroys the base on which the placebo rests. If he doesn't tell the truth, he jeopardizes a relationship built on trust.

This dilemma poses a question involving medical ethics: when is a physician justified in not being completely candid with the patient? In terminal cases, the doctor may think it unwise and even irresponsible to add desolation to pain: and so he skirts around the truth. What about drug addiction? Placebos are now being used by some doctors as a substitute for hard drugs in a systematic attempt to wean their patients away from addiction. In these cases, the patient exhibits the same solution as he does to heroin or cocaine. The body's raging desire for the drug is appeased—but it doesn't pay the physiological price of the addictive poisons. Should doctors withhold such treatment because they feel it is a breach of medical ethics not to inform the patient about the true nature of the treatment?

In an even more fundamental sense, it may be asked whether it is ethical—or, what is more important, wise—for the doctor to nourish the patient's mystical belief in medication. An increasing number of doctors believe they should not encourage their patients to expect prescriptions, for they know how easy it is to deepen the patient's psychological and physiological dependence on drugs—or even on placebos, for that matter. Such an approach carries with it the risk that the patient will go across the street to another doctor; but if enough doctors break with ritual in this respect, there is hope that the patient himself will regard the prescription slip in a new light. Dr. Richard C. Cabot once wrote that “the patient has learned to expect a medicine for every symptom. He was not born with that expectation.… It is we physicians who are responsible for perpetuating false ideas about disease and its cure.”

Another problem in medical ethics arises because many doctors believe not enough is known about the effects of the placebo on the delicate structure and functions of the body's nervous system. Should the benefits of the placebo be deferred until such time as more answers are obtained?

Certainly the medical profession is not without precedent in the use of modalities or drugs about which full knowledge is still absent. Electric shock is being used in the treatment of mental disease even though doctors don't know exactly what happens inside the brain when it is jolted by high voltage. The most widely used drug in the world is aspirin, yet why it reduces inflammation is a mystery.

True, not everything is known about the placebo. But enough is known to put its continued study high on the medical and human agenda. Knowing more about the gift of life is not merely a way of satisfying random curiosity. In the end, it is what education is all about.

The most prevalent—and, for all we know, most serious—health problem of our time is stress, which is defined by Hans Selye, dean of the stress concept, as the “rate of wear and tear in the human body.” This definition would thus embrace any demands, whether emotional or physical, beyond the ready capability of any given individual.

The war against microbes has been largely won, but the struggle for equanimity is being lost. It is not just the congestion outside us—a congestion of people and ideas and issues—but our inner congestion that is hurting us. Our experiences come at us in such profusion and from so many different directions that they are never really sorted out, much less absorbed. The result is clutter and confusion. We gorge the senses and starve the sensitivities.

“Your health is bound to be affected,” Boris Pasternak wrote in
Dr. Zhivago
, “if, day after day, you say the opposite of what you feel, if you grovel before what you dislike and rejoice at what brings you nothing but misfortune. Our nervous system isn't just a fiction; it's a part of our physical body, and our soul exists in space, and is inside us, like the teeth in our mouth. It can't be forever violated with impunity. I found it painful to listen to you, Innokentii, when you told us how you were re-educated and became mature in jail. It was like listening to a horse describing how it broke itself in.”

It is doubtful whether the placebo—or any drug, for that matter—would get very far without a patient's robust will to live. For the will to live is a window on the future. It opens the individual to such help as the outside world has to offer, and it connects that help to the body's own capability for fighting disease. It enables the human body to make the most of itself. The placebo has a role to play in transforming the will to live from a poetical conception to a physical reality and a governing force.

In the end, the greatest value of the placebo is what it can tell us about life. Like a celestial chaperon, the placebo leads us through the uncharted passageways of mind and gives us a greater sense of infinity than if we were to spend all our days with our eyes hypnotically glued to the giant telescope at Mt. Palomar. What we see ultimately is that the placebo isn't really necessary and that the mind can carry out its difficult and wondrous missions unprompted by little pills. The placebo is only a tangible object made essential in an age that feels uncomfortable with intangibles, an age that prefers to think that every inner effect must have an outer cause. Since it has size and shape and can be hand-held, the placebo satisfies the contemporary craving for visible mechanisms and visible answers. But the placebo dissolves on scrutiny, telling us that it cannot relieve us of the need to think deeply about ourselves.

The placebo, then, is an emissary between the will to live and the body. But the emissary is expendable. If we can liberate ourselves from tangibles, we can connect hope and the will to live directly to the ability of the body to meet great threats and challenges. The mind can carry out its ultimate functions and powers over the body without the illusion of material intervention. “The mind,” said John Milton, “is its own place, and in itself can make a heaven of hell, and a hell of heaven.”

Science is concocting exotic terms like biofeedback to describe the control by the mind over the autonomic nervous system. But labels are unimportant; what is important is the knowledge that human beings are not locked into fixed limitations. The quest for perfectibility is not a presumption or a blasphemy but the highest manifestation of a great design.

Some years ago, I had an opportunity to observe African witch-doctor medicine at first hand in the Gabon jungle country. At the dinner table of the Schweitzer Hospital at Lambarene, I had ventured the remark that the local people were lucky to have access to the Schweitzer clinic instead of having to depend on witch-doctor supernaturalism. Dr. Schweitzer asked me how much I knew about witch doctors. I was trapped by my ignorance—and we both knew it. The next day
le grand docteur
took me to a nearby jungle clearing, where he introduced me to
un de mes collègues
, an elderly witch doctor. After a respectful exchange of greetings, Dr. Schweitzer suggested that his American friend be allowed to observe African medicine.

For the next two hours, we stood off to one side and watched the witch doctor at work. With some patients, the witch doctor merely put herbs in a brown paper bag and instructed the ill person in their use. With other patients, he gave no herbs but filled the air with incantations. A third category of patients he merely spoke to in a subdued voice and pointed to Dr. Schweitzer.

On our way back to the clinic, Dr. Schweitzer explained what had happened. The people who had assorted complaints that the witch doctor was able to diagnose readily were given special herbs to make into brews. Dr. Schweitzer guessed that most of those patients would improve very rapidly since they had only functional, rather than organic, disturbances. Therefore, the “medications” were not really a major factor. The second group had psychogenic ailments that were being treated with African psychotherapy. The third group had more substantial physical problems, such as massive hernias or extrauterine pregnancies or dislocated shoulders or tumorous conditions. Many of these problems required surgery, and the witch doctor was redirecting the patients to Dr. Schweitzer himself.

“Some of my steadiest customers are referred to me by witch doctors,” Dr. Schweitzer said with only the slightest trace of a smile. “Don't expect me to be too critical of them.”

When I asked Dr. Schweitzer how he accounted for the fact that anyone could possibly expect to become well after having been treated by a witch doctor, he said that I was asking him to divulge a secret that doctors have carried around inside them ever since Hippocrates.

“But I'll tell you anyway,” he said, his face still illuminated by that half-smile. “The witch doctor succeeds for the same reason all the rest of us succeed. Each patient carries his own doctor inside him. They come to us not knowing that truth. We are at our best when we give the doctor who resides within each patient a chance to go to work.”

The placebo is the doctor who resides within.

THREE

C
REATIVITY AND
L
ONGEVITY

What started me thinking about creativity and longevity, and the connection between the two, were examples of two men who were very much alike in vital respects: Pablo Casals and Albert Schweitzer.

Both were octogenarians when I met them for the first time. Both were fully creative—almost explosively so. Both were committed to personal undertakings that were of value to other human beings. What I learned from these two men had a profound effect on my life—especially during the period of my illness. I learned that a highly developed purpose and the will to live are among the prime raw materials of human existence. I became convinced that these materials may well represent the most potent force within human reach.

First, some observations about Pablo Casals.

I met him for the first time at his home in Puerto Rico just a few weeks before his ninetieth birthday. I was fascinated by his daily routine. About 8
A.M.
his lovely young wife Marta would help him to start the day. His various infirmities made it difficult for him to dress himself. Judging from his difficulty in walking and from the way he held his arms, I guessed he was suffering from rheumatoid arthritis. His emphysema was evident in his labored breathing. He came into the living room on Marta's arm. He was badly stooped. His head was pitched forward and he walked with a shuffle. His hands were swollen and his fingers were clenched.

Even before going to the breakfast table, Don Pablo went to the piano—which, I learned, was a daily ritual. He arranged himself with some difficulty on the piano bench, then with discernible effort raised his swollen and clenched fingers above the keyboard.

I was not prepared for the miracle that was about to happen. The fingers slowly unlocked and reached toward the keys like the buds of a plant toward the sunlight. His back straightened. He seemed to breathe more freely. Now his fingers settled on the keys. Then came the opening bars of Bach's
Wobltemperierte Klavier
, played with great sensitivity and control. I had forgotten that Don Pablo had achieved proficiency on several musical instruments before he took up the cello. He hummed as he played, then said that Bach spoke to him here—and he placed his hand over his heart.

Then he plunged into a Brahms concerto and his fingers, now agile and powerful, raced across the keyboard with dazzling speed. His entire body seemed fused with the music; it was no longer stiff and shrunken but supple and graceful and completely freed of its arthritic coils.

Having finished the piece, he stood up by himself, far straighter and taller than when he had come into the room. He walked to the breakfast table with no trace of a shuffle, ate heartily, talked animatedly, finished the meal, then went for a walk on the beach.

After an hour or so, he came back to the house and worked on his correspondence until lunch. Then he napped. When he rose, the stoop and the shuffle and the clenched hands were back again. On this particular day, a camera and recording crew from public television were scheduled to arrive in mid-afternoon. Anticipating the visit, Don Pablo said he wished some way could be found to call it off; he didn't feel up to the exertion of the filming, with its innumerable and inexplicable retakes and the extreme heat of the bright lights.

Marta, having been through these reluctances before, reassured Don Pablo, saying she was certain he would be stimulated by the meeting. She reminded him that he liked the young people who did the last filming and that they would probably be back again. In particular, she called his attention to the lovely young lady who directed the recording.