Anatomy of an Illness as Perceived by the Patient Read online

  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

  CREATIVITY AND LONGEVITY

  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 di
fficulty 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.

  Don Pablo brightened. “Yes, of course,” he said, “it will be good to see them again.”

  As before, he stretched his arms in front of him and extended his fingers. Then the spine straightened and he stood up and went to his cello. He began to play. His fingers, hands, and arms were in sublime coordination as they responded to the demands of his brain for the controlled beauty of movement and tone. Any cellist thirty years his junior would have been proud to have such extraordinary physical command.

  Twice in one day I had seen the miracle. A man almost ninety, beset with the infirmities of old age, was able to cast off his afflictions, at least temporarily, because he knew he had something of overriding importance to do. There was no mystery about the way it worked, for it happened every day. Creativity for Pablo Casals was the source of his own cortisone. It is doubtful whether any antiinflammatory medication he would have taken would have been as powerful or as safe as the substances produced by the interaction of his mind and body.

  The process is not strange. If he had been caught up in an emotional storm, the effects would have been manifested in an increased flow of hydrochloric acid to the stomach, in an upsurge of adrenal activity, in the production of corticoids, in the increase of blood pressure, and a faster heart beat.

  But he was caught up in something else. He was caught up in his own creativity, in his own desire to accomplish a specific purpose, and the effect was both genuine and observable. And the effects on his body chemistry were no less pronounced—albeit in a positive way—than they would have been if he had been through an emotional wringer.

  Don Pablo, though delicately built, almost frail, was a giant among men in spirit and creative stature. He was buoyantly sympathetic in manner, managing to involve himself very quickly in the concerns or problems of his friends or visitors. His responses were unhurried, genuine, full. He showed me some of his original Bach manuscripts, and he remarked that Bach meant more to him than any other composer.

  This was only one of several things he had in common with Schweitzer, I remarked.

  “My good friend Albert Schweitzer shares with me the belief that Bach is the greatest of all composers,” Don Pablo said, “but we like Bach for entirely different reasons. Schweitzer sees Bach in complex architectural terms; he acclaims him as a master who reigns supreme over the great and diverse realm of music. I see Bach as a great romantic. His music stirs me, helps me to feel fully alive. When I wake up each morning I can hardly wait to play Bach. What a wonderful way to start the day.”

  If Bach was his favorite composer, what was his favorite composition?

  “The piece that means the most to me was written not by Bach but by Brahms,” he said. “Here, let me show it to you. I have the original manuscript.”

  He took down from the wall, where it had been framed behind glass, one of the most valuable music manuscripts in the world now in private hands—Brahms’s B-flat Quartet.

  “Interesting, how I happened to acquire it,” he said. “Many years ago I knew a man who was head of the Friends of Music in Vienna. His name was Wilhelm Kuchs. One night in Vienna—this was before the war—he invited several of his friends for dinner, myself included. He had what I believe may have been the finest private collection of original music manuscripts in the world. He also owned an impressive collection of fine musical instruments—violins by Stradivarius and Guarneri among them. He was wealthy, very wealthy, but he was a simple man and a very accessible one.

  “Then the war came. He was in his eighties. He had no intention of spending the rest of his old age under Nazism. He moved to Switzerland. He was then more than ninety. I was eager to pay my respects. Just seeing him again, this wonderful old friend who had done so much for music, was to me a very moving experience. I think we both wept on each other’s shoulder. Then I told him how concerned I had been over this collection of manuscripts. I had been terribly apprehensive that he might not have been able to keep his collection from falling into Nazi hands.

  “My friend told me there was nothing to worry about; he had managed to save the entire collection. Then he went and got some items from the collection—some chamber music by Schubert and Mozart to begin with. Then he placed on the table before me the original manuscript of the Brahms B-flat Quartet. I could hardly believe my eyes. I stood transfixed. I suppose every musician feels that there is one piece that speaks to him alone, one which he feels seems to involve every molecule of his being. This was the way I had felt about the B-flat Quartet ever since I played it for the first time. And always I felt it was mine.

  “Mr. Kuchs could see that when I held the B-flat Quartet manuscript in my hands it was a very special and powerful emotional experience.

  “‘It is your quartet in every way,’ Mr. Kuchs said. ‘It would make me happy if you would let me give it to you.’ And he did.

  “I couldn’t thank him adequately then, but I did write him a long letter telling him of the great pride and joy his gift had brought to my life. When Mr. Kuchs replied, he told me many things about the history of the B-flat Quartet I had not known before. One fact in particular stood out. It is that Brahms began to write the quartet just nine months before I was born. It took him nine months to complete it. We both came into the world on exactly the same day, the same month, the same year.”

  As Don Pablo spoke, he seemed to relive the experience. His features, unmarred by any hard lines, were so expressive that his words seemed merely to confirm the image. Indeed, his face had the dramatic power of a full Ibsen cast.

  I asked Don Pablo whether any other indi
vidual compositions had special meaning for him.

  “Many pieces,” he said, “but none that I felt owned me and expressed me as much as the B-flat Quartet. Yet, when I get up in the morning, I can think only of Bach. I have the feeling that the world is being reborn. Nature always seems more in evidence to me in the morning.

  “There is one other piece I must tell you about. This one, too, has special meaning. I think it is the piece I would like most to hear again during my last moments on earth. How lovely and moving it is, the second movement of Mozart’s Clarinet Quintet.”

  Don Pablo played it. His fingers were thin and the skin was pale but they belonged to the most extraordinary hands I had ever seen. They seemed to have a wisdom and a grace of their own. When he played Mozart, he was clearly the interpreter and not just the performer; yet it was difficult to imagine how the piece could be played in any other way.

  After he got up from the piano he apologized for having taken up so much time in our talk with music, instead of discussing the affairs of the world. I told him I had the impression that what he had been saying and doing were most relevant in terms of the world’s affairs. In the discussion that followed there seemed to be agreement on the proposition that the most serious part of the problem of world peace was that the individual felt helpless.

  “The answer to helplessness is not so very complicated,” Don Pablo said. “A man can do something for peace without having to jump into politics. Each man has inside him a basic decency and goodness. If he listens to it and acts on it, he is giving a great deal of what it is the world needs most. It is not complicated but it takes courage. It takes courage for a man to listen to his own goodness and act on it. Do we dare to be ourselves? This is the question that counts.”