American journalist Norman Cousins became editor in chief of the Saturday Review in 1942 at the age of twenty-seven and held the position until 1972. In the 1960s Cousins was stricken with a life-threatening collagen disease. Together with his physicians he developed a regimen of high doses of vitamin C and daily belly laughter prompted by Marx Brothers films. He made a full recovery and chronicled his experiences in a collection of best-selling nonfiction books on illness and healing. Cousins died in 1990 at the age of seventy-five. The following is excerpted from Anatomy of an Illness as Perceived by the Patient by Norman Cousins. Copyright © 1979 by W.W. Norton & Company, Inc. Used with permission of W.W. Norton & Company, Inc.
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 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 function 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 the 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.
Placebo 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 little point or prospect. In this sense, the doctor himself is the most powerful placebo of all. . . .
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 Doctor 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. . . .”
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 Mount 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. . . .
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 Albert Schweitzer Hospital at Lambaréné, 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.”