Anatomy of an Illness as Perceived by the Patient Read online

  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.

  The problem posed by many drugs is that they do these things apart from the purpose intended by the physician. There is always the need, therefore, for the doctor to balance off the particularized therapy against the generalized dangers. The more powerful the drug, the more precarious his balancing act.

  Complicating the doctor’s dilemma about drugs is the fact that many people tend to regard drugs as though they were automobiles. Each year has to have its new models, and the more powerful the better. Too many patients feel the doctor is lacking unless a prescription calls for a new antibiotic or other miracle drug that the patient has heard about from a friend or read about in the press.

  Because of the very real dangers associated with powerful new drugs, the prudent modern physician takes full advantage of his freedom of choice, specifying potent drugs when he feels they are absolutely necessary, but disregarding them, prescribing placebos or nothing at all, when they are not.

  A hypothetical illustration of how a placebo works is the case of a young businessman who visits his doctor and complains of severe headaches and abdominal pains. After listening carefully to the patient describe not only his pains but his problems, the physician decides that the businessman is suffering from a common disease of the twentieth century: stress. The fact that stress doesn’t come from germs or viruses doesn’t make its effects any the less serious. Apart from severe illness, it can lead to alcoholism, drug addiction, suicide, family breakdown, joblessness. In extreme form, stress can cause symptoms of conversion hysteria—a malaise described by Jean Charcot, Freud’s teacher. The patient’s worry and fears are converted into genuine physical symptoms that can be terribly painful or even crippling.

  In sympathetic questioning, the doctor learns that the businessman is worried about the ill health of his pregnant wife and about newly hired young people in his office who seem to him to be angling for his job. The doctor recognizes that his first need is to reassure the patient that nothing is fundamentally wrong with his health. But he is careful not to suggest in any way that the man’s pains are unreal or not to be taken seriously. Patients tend to think they have been accused of having imagined their symptoms, of malingering, if their complaint is diagnosed as being psychogenic in origin.

  The doctor knows that his patient, in accordance with convention, would probably be uncomfortable without a prescription. But the doctor also knows the limitations of medication. He is reluctant to prescribe tranquilizers because of what he believes would be adverse effects in this particular case. He knows that aspirin would relieve the headaches but would also complicate the gastro-intestinal problem, since even a single aspirin tablet can cause internal bleeding. He rules out digestive aids because he knows that the stomach pains are induced by emotional problems. So the doctor writes a prescription that, first of all, cannot possibly harm the patient and, secondly, might clear up his symptoms. The doctor tells the businessman that the particular prescription will do a great deal of good and that he will recover completely. Then he takes time to discuss with his patient possible ways of meeting the problems at home and at the office.

  A week later the businessman telephones the doctor to report that the prescription has worked wonders. The headaches have disappeared and the abdominal pains have lessened. He is less apprehensive about his wife’s condition following her visit to the obstetrician, and he seems to be getting along better at the office. How much longer should he take the medicine?

  The doctor says that the prescription will probably not have to be refilled but to be sure to telephone if the symptoms recur.

  The “wonder” pills, of course, were nothing more than placebos. They had no pharmacological properties. But they worked as well as they did for the businessman because they triggered his body’s own ability to right itself, given reasonable conditions of freedom from stress and his complete confidence that the doctor knew what he was doing.

  Studies show that up to 90 percent of patients who reach out for medical help are suffering from self-limiting disorders well within the range of the body’s own healing powers. The most valuable physician—to a patient and to society—knows how to distinguish effectively between the large number of patients who can get well without heroic intervention and the much smaller number who can’t. Such a physician loses no time in mobilizing all the scientific resources and facilities available, but he is careful not to slow up the natural recovery process of those who need his expert reassurance even more than they need his drugs. He may, for such people, prescribe a placebo—both because the patient feels more comfortable with a prescription in his hand and because the doctor knows that the placebo can actually serve a therapeutic purpose.

  The placebo, then, is not so much a pill as a process. The process begins with the patient’s confidence in the doctor and extends through to the full functioning of his own immunological and healing system. The process works not because of any magic in the tablet but because the human body is its own best apothecary and because the most successful prescriptions are those filled by the body itself.

  Berton Roueché, one of America’s most talented medical reporters, wrote an article for the New Yorker magazine in 1960 in which he said that the placebo derives its power from the “infinite capacity of the human mind for self-deception.” This interpretation is not held by placebo scholars. They believe that the placebo is powerful not because it “fools” the body but because it translates the will to live into a physical reality. And they have been able to document the fact that the placebo triggers specific biochemical changes in the body. The fact that a placebo will have no physiological effect if the patient knows it is a placebo only confirms something about the capacity of the human body to transform hope into tangible and essential biochemical change.

  The placebo is proof that there is no real separation between mind and body. Illness is always an interaction between both. It can begin in the mind and affect the body, or it can begin in the body and affect the mind, both of which are served by the same bloodstream. Attempts to treat most mental diseases as though they were completely free of physical causes and attempts to treat most bodily diseases as though the mind were in no way involved must be considered archaic in the light of new evidence about the way the human body functions.

  Placebos will not work under all circumstances. The chances of successful use are believed to be directly proportionate to the quality of a patient’s relationship with a doctor. The doctor’s attitude toward the patient; his ability to convince the patient that he is not being taken lightly; his success in gaining the full confidence of the patient—all these are vital factors not just in maximizing the usefulness of a placebo but in the treatment of illness in general. In the absence of a strong relationship between doctor and patient, the use of placebos may have li
ttle point or prospect. In this sense, the doctor himself is the most powerful placebo of all.

  A striking example of the doctor’s role in making a placebo work can be seen in an experiment in which patients with bleeding ulcers were divided into two groups. Members of the first group were informed by the doctor that a new drug had just been developed that would undoubtedly produce relief. The second group was told by nurses that a new experimental drug would be administered, but that very little was known about its effects. Seventy percent of the people in the first group received sufficient relief from their ulcers. Only 25 percent of the patients in the second group experienced similar benefit. Both groups had been given the identical “drug”—a placebo.

  How much scientific laboratory data has been accumulated on placebo efficacy? The medical literature in the past quarter-century contains an impressive number of cases:

  The late Dr. Henry K. Beecher, noted anesthesiologist at Harvard, considered the results of fifteen studies involving 1,082 patients. He discovered that across the broad spectrum of these tests, 35 percent of the patients consistently experienced “satisfactory relief” when placebos were used instead of regular medication for a wide range of medical problems, including severe postoperative wound pain, seasickness, headaches, coughs, and anxiety. Other biological processes and disorders affected by placebos, as reported by medical researchers, include rheumatoid and degenerative arthritis, blood-cell count, respiratory rates, vasomotor function, peptic ulcers, hay fever, hypertension, and spontaneous remission of warts.

  Dr. Stewart Wolf wrote that placebo effects are “neither imaginary nor necessarily suggestive in the usual sense of the word.” His comments were connected to the results of a test in which specialized blood cells called eosinophils accumulate beyond their normal numbers and circulate throughout the system. The test showed that placebos can change body chemistry. Wolf also reported a test by a colleague in which a placebo reduced the amount of fat and protein in the blood.

  When a patient suffering from Parkinson’s disease was given a placebo but was told he was receiving a drug, his tremors decreased markedly. After the effects of the placebo wore off, the same substance was put into his milk without his knowledge. The tremors reappeared.

  During a large study of mild mental depression, patients who had been treated with sophisticated stimulants were taken off the drugs and put on placebos. The patients showed exactly the same improvement as they had gained from the drugs. In a related study doctors gave placebos to 133 depressed patients who had not yet received a drug. One-quarter of them responded so well to placebos that they were excluded from further testing of actual drugs.

  When a group of patients were given a placebo in place of an antihistamine, 77.4 percent reported drowsiness, which is characteristic of antihistamine drugs.

  In a study of postoperative wound pain by Beecher and Lasagna, a group of patients who had just undergone surgery were alternately given morphine and placebos. Those who took morphine immediately after surgery registered a 52-percent relief factor; those who took the placebo first, 40 percent. The placebo was 77 percent as effective as morphine. Beecher and Lasagna also discovered that the more severe the pain, the more effective the placebo.

  Eighty-eight arthritic patients were given placebos instead of aspirin or cortisone. The number of patients who benefited from the placebos was approximately the same as the number benefiting from the conventional antiarthritic drugs. Some of the patients who had experienced no relief from the placebo tablets were given placebo injections. Sixty-four percent of those given injections reported relief and improvement. For the entire group, the benefits included not just pain relief but general improvement in eating, sleeping, elimination, and even reduction in swelling.

  A. Leslie reported that morphine addicts have been given placebos (saline injections) and have not suffered withdrawal symptoms until the injections were stopped.

  A group of medical students were invited to participate in an experiment they were told was for the purpose of testing the efficacy of a depressant and a stimulant. They were informed in detail of the effects, beneficial and adverse, that could be expected from these drugs. They were not told that both “stimulants” and “depressants” were actually placebos. More than half the students exhibited specific physiological reactions to the placebos. The pulse rate fell in 66 percent of the subjects. A decrease in arterial pressure was observed in 71 percent of the students. Adverse side effects included dizziness, abdominal stress, and watery eyes.

  Medical officials of the National Institute of Geriatrics in Bucharest, Romania, undertook a double-blind experiment to test a new drug designed to activate the endocrine system and thus enhance health and the prospects for increased longevity. A total of 150 Romanians sixty years of age, all of whom lived under approximately the same village conditions, were divided into three groups of 50 each. The first group received nothing. The second group received a placebo. The third was given regular treatment with the new drug. Year by year, all three groups were carefully observed with respect to mortality and morbidity. The statistics for the first group conformed with those for other Romanian villagers of similar age. The second group, on the placebo, showed a marked improvement in health and a measurably lower death rate than the first group. The third group, on the drug, showed about the same improvement over the placebo group as the placebo group showed over the first.

  If the placebo can do a great deal of good, it can also do a great deal of harm. The cerebral cortex stimulates negative biochemical changes just as it does positive changes. Beecher stressed as long ago as 1955, in the Journal of the American Medical Association, that placebos can have serious toxic effects and produce physiological damage. A case in point is a study of the drug mephenesin’s effect on anxiety. In some patients, it produces such adverse reactions as nausea, dizziness, and palpitation. When a placebo was substituted for mephenesin, it produced identical reactions in an identical percentage of doses. One of the patients, after taking the placebo, developed a skin rash that disappeared immediately after placebo administration was stopped. Another collapsed in anaphylatic shock when she took the drug. A third experienced abdominal pain and a build-up of fluid in her hips within ten minutes after taking the placebo—before she had even taken the drug.

  It would be reasonable to conclude from the foregoing that the placebo effect applies to all drugs in varying degrees. Indeed, many medical scholars have believed that the history of medicine is actually the history of the placebo effect. Sir William Osler underlined the point by observing that the human species is distinguished from the lower orders by its desire to take medicine. Considering the nature of nostrums taken over the centuries, it is possible that another distinguishing feature of the species is its ability to survive medication. At various times and in various places, prescriptions have called for animal dung, powdered mummies, sawdust, lizard’s blood, dried vipers, sperm from frogs, crab’s eyes, weed roots, sea sponges, “unicorn horns,” and lumpy substances extracted from the intestines of cud-chewing animals.

  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.”