Anatomy of an Illness: As Perceived by the Patient - Reflections on Healing and Regeneration

Anatomy of an Illness As perceived by the Patient Reflections on Healing and Regeneration by

Norman Cousins is senior lecturer at the School of Medicine, University of California at Los Angeles, and consulting editor of Man and Medicine, published at the College of Physicians and Surgeons, Columbia University. For almost all his professional life, Norman Cousins has been affiliated with the Saturday Review. He became its editor in nineteen forty, a position he held for more than thirty years. He is presently its editorial chairman.

Mr. Cousins is the author of eleven books, including Dr. Schweitzer of Lambarène, The Celebration of Life, Present Tense, In Place of Folly, The Good Inheritance, and Modern Man Is Obsolete.

Anatomy of an Illness is the story of Norman Cousins and his successive fight against a crippling disease. It is the story of a partnership between a physician and a patient in beating back the odds. The doctor's genius lay in helping the patient to use his own power - laughter, courage, tenacity. The patient's talent was in mobilizing his body's own natural healing resources - improving what powerful weapon all the positive emotions can be in the war against disease. Norman Cousins's story has been told in major medical and lay journals around the world. It gives a striking example of how one man responded to a challenge. It demonstrates what the mind and body, working together can do to overcome illness.

Introduction

The basic theme of this book is that every person must accept a certain measure of responsibility for his or her own recovery from disease or disability. This notion of patient responsibility is not new, of course, but the general philosophy behind the notion has seldom been stated better than in this book. Though the author is a layman, his ideas have achieved wide acceptance by the medical profession: His perceptions about the nature of stress and about the ability of the human mind to mobilize the body's capacity to combat illness are in accord with important findings at leading medical research centers.

It is inevitable, of course, that any book about the healing phenomenon will lead to considerations of longevity. To be sure, this book is as much concerned with the quality of life as it is with the prolongation of life. Nevertheless, this dual emphasis of this volume fits in with one of the significant trends in modern society, namely, the general increase of life expectancy into the seventies and eighties. Indeed, according to a Social Security Administration report, there were ten thousand seven hundred centenarians across the nation in nineteen seventy-six. The percentage of centenarians to total population is probably much the same in several other countries.

Admittedly, it is often difficult to prove the exact age of very old persons because records of their birth dates tend to be inexact or lacking altogether. In the United States, for example, the fully authenticated number of real centenarians may not reach ten thousand. Yet there are enough well-documented cases of very old people to prove that longevity can be achieved under many different climatic and social conditions.

In sixteen thirty-five, an Englishman, Thomas Parr, was summoned to London by Charles the First because it had been reported to the king that church records and other circumstantial evidence showed "Old Parr" - as he was affectionately called - to be one hundred fifty-two years old. Old Parr was dined and wined, but died shortly thereafter, while still in London. An autopsy was performed by none other than William Harvey, who pronounced Parr's organs to be quite sound, "as healthy as the day he was born." Harvey attributed Parr's death to surfeit and to the pollution of London's air.

The air was certainly as polluted in nineteenth-century Paris as it was in seventeenth-century London. Yet the illustrious French chemist Michel-Eugène Chevreul had reached one hundred three years of age when he died in eighteen eighty-nine, after more than seventy-five years of residence in the French capital. The photographs taken by Nadar on the occasion of Chevreul's centenary show him to be wiry and spry, as full of joie de vivre as a child. When asked how he felt, a short time before his death, he complained only of une certaine indisposition de vivre. He was ninety-nine when he published his last scientific paper.

Charles Thierry was born in eighteen fifty and practiced his silversmith trade in Cambridge, Massachusetts, until the age of ninety-three. Every day he took long, vigorous walks in the country, a habit that he kept up after his retirement. At the age of one hundred three he contracted influenza and had a stormy convalescence. He was then seen by Dr. Paul Dudley White, who urged him to resume his daily walks, regardless of the weather. Thierry recovered but later died of pneumonia at one hundred eight years of age, largely due to his own negligence.

In the nineteen sixties a very old man was brought to New York Hospital from a village in the mountains of Colombia, not for treatment, but for examination by medical scientists, as a curiosity. He was certainly more than one hundred years old, and might have been, from circumstantial evidence, approximately one hundred fifty. He had spent his entire life under primitive conditions, was short and spry, and spoke Spanish with volubility and gusto. I was at the time a patient on the very hospital ward where he was staying as a guest, and can testify to his liveliness, which I greatly envied. He died shortly after returning to Colombia.

In his book, Old Age, published in nineteen oh four, Elias Metchnikoff presents a cheerful picture of the many very old people he had studied in Russia and in France. According to his accounts, most of them remained active to the very end of their lives, their chief complaint being, as in the case of Chevreul, the kind of lassitude one experiences at the end of a long, full day.

The very existence of healthy, vigorous centenarians, whose lives were spent long before the advent of modern medicine, proves that the potential duration of human existence exceeds the biblical three score and ten, and that longevity can be achieved without medical care. It is probable that the ability to reach a very old age requires a certain genetic constitution, but it is certain that it depends even more on the ways of life. Dr. Alexander Leaf, of Harvard Medical School, has recently made extensive clinical and social observations of very old people in several parts of the world. His studies have led him to suggest that longevity is correlated with a rather frugal diet but of well-balanced composition, vigorous and continued physical activity, and involvement in community affairs to the end of one's life. Complete retirement from active life does not seem to be a good way to reach a very old age.

Healthy centenarians who do not need medical care seem at first sight of no relevance to Norman Cousins's thesis that sick people should share in the responsibility for their treatment. I believe, however, that people can reach a very old age only if they possess some of the physical and psychological attributes that contributed to Cousins's recovery; they must have the will to live that mobilizes the body's natural mechanisms of resistance to disease.

Even under the most urbanized conditions we retain the genetic constitution of our Stone Age ancestors and therefore can never be completely adapted, biologically, to the environments in which we live. Wherever we are and whatever we do, as Cousins says, we cannot avoid being exposed to a multiplicity of physio-chemical and biological agents of disease. We survive only because we are endowed with biological and psychological mechanisms that enable us to respond adaptively to an immense diversity of challenges. This adaptive response may be so effective that most challenges do not result in disease. If disease occurs, the adaptive response commonly brings about spontaneous recovery without the need of medical intervention. Ancient physicians were so familiar with this natural power of the organism to control disease that they invented for it the beautiful expression, vis medicatrix naturae, "the healing power of nature."

In his Anatomy of an Illness, Cousins identifies the natural recuperative mechanisms of the body with the processes that Walter B. Cannon called homeostatic responses -- namely, the natural processes that enable the organism to return to the "normal" state in which it was before being disturbed by a noxious influence. In reality, vis medicatrix naturae is much more complex, more powerful and more interesting than Cannon's homeostasis. The response of the organism to disturbances is but rarely homeostatic. Its outcome is more likely to be a lasting change that makes the organism better adapted to future challenges. For example: the development of scar tissue is not a truly homeostatic response; it makes the scarred part of the body better able to resist the insult that caused scarring. Recovery from a given infectious disease is usually accompanied by persistent cellular changes that produce a lasting immunity to that particular infection. Persons who have lost a limb or have become blind tend to develop compensatory skills that become part of their new personality. Instead of being simply homeostatic, the response of the organism corresponds rather to a creative adaptation that is achieved by a permanent change in the body or the mind.

Whether resulting in homeostasis or in creative adaptation, the mechanisms of vis medicatrix naturae so effective that most diseases are self-terminating. Good medical care does of course make the healing process more complete, more rapid and more comfortable, but in the final analysis, as Cousins says, recovery depends upon the mobilization of the patient's own mechanisms of resistance to disease. Herein lies the explanation for the puzzling fact that all ancient and primitive societies have had successful healers, even though medicine had little to offer in the way of really effective therapy until a few decades ago.

Cousins refers to the work of William Osler, who was considered the greatest clinician of the Anglo-Saxon world at the turn of the century and taught his students that most of the drugs and other methods of treatment available to the physicians of his time were essentially useless. Yet Osler enjoyed an enormous reputation as a healer during his chairmanship of the Department of Medicine at the Johns Hopkins Hospital in Baltimore. On repeated occasions, he expressed the view that the cures of organic diseases he had brought about were due essentially, not to the treatment he used, but to the patient's faith in the effectiveness of the treatment and to the comfort provided by good nursing care. After he had become Regius Professor of Medicine at Oxford University in England, Osler restated once more his conviction that much of his success as a healer was due to aspects of his personality and behavior that were independent of his scientific knowledge of medicine. In an article entitled "The Faith that Heals" he stated amusingly, in nineteen ten, "Our results at the Johns Hopkins Hospital were most gratifying. Faith in Saint Johns Hopkins, as we used to call him, an atmosphere of optimism, and cheerful nurses, worked just the same sort of cures as did Aesculapius at Epidaurus" (Osler's italics). When he used the expression "faith healing," Osler referred to the psychological influences that set in motion the restorative mechanisms of vis medicatrix naturae -- in reality self-healing.

The effectiveness of Osler's "faith healing" was acknowledged even by Doctor William Henry Welch, the main architect of scientific medicine in the United States. Of his father, who practiced medicine in Norfolk, Connecticut, he wrote: "The instant he entered the sick room, the patient felt better. The art of healing seemed to surround his physical body like an aura; it was often not his treatment but his presence that cured." Francis Peabody's famous remark, "The secret of the care of the patient is in caring for the patient," is another way of stating that there is a miraculous moment when the very presence of the doctor is the most effective part of the treatment.

The therapeutic successes of non-medical healers throughout the ages must be evaluated in the light of the capacity for self-healing that exists in all living forms and particularly in human beings. Although the mechanisms of spontaneous recovery from organic and mental disease are not completely understood, it can be assumed that they all operate through a few common organic pathways and that the organism has only a limited repertoire of responses to healing agencies as diverse as ataractic drugs, the laying on of hands, transcendental meditation, the use of biofeedback techniques, Zen and yoga practices, faith in a Saint, a person or a drug -- and of course the proper patient-doctor relationship.

Cousins repeatedly states that the mental attitudes of patients have a lot to do with the course of their disease and illustrates this theme with examples taken from clinical material. It is common knowledge, of course, that the mind influences the body and vice versa, but there needs to be more scientific experimentation on this interplay. The examples that I shall mention correspond to different types of immunological and physiological processes which have been studied by the experimental method and which are of a type that can affect the course or the perception of disease.

The body's defense against infection depends in large part on the mechanisms of humoral and cellular immunity, but these mechanisms themselves are influenced by the mental state -- as demonstrated by the effect of hypnosis on the Mantoux test. This test consists in the intradermal injection of tuberculin, an extract of tubercle bacilli. It is used to evaluate the likely response of the body to tuberculosis infection. A famous English immunologist has recently established, however, that hypnotic suggestion can obliterate the vascular manifestations of the Mantoux test -- as neat a proof as one could wish of the influence that the mind exerts over the body. The tuberculin Mantoux reaction pertains to the kind of body response that immunologists designate "cell-mediated immunity." Since this form of the immune response plays an essential role in resistance to important infectious diseases such as tuberculosis, and probably also in resistance to cancer, there is good reason to believe that the patient's state of mind can affect the course of all pathological processes that involve immunological reactions.

The digestion of fats after a meal can be seen as a purely biochemical process involving only the breakdown of the fat particles (chylomicra) by the appropriate enzymes, and the assimilation of the breakdown products into the bloodstream and organs, but here again the digestive process is affected by the mind. Observations made on a teacher of anatomy in his forties revealed that the mere prospect of having to lecture to medical students slowed down the rate at which chylomicra disappeared from his bloodstream. More generally, it was found that the digestion of fat particles was retarded by almost any disturbance in the life routines. Thus, mental processes can affect the course of physiological processes as seemingly simple as the digestion of food.

Emotional states have long been known to affect the secretion of certain hormones for example, those of the thyroid and adrenal glands. It has been recently discovered that the brain and the pituitary gland contain a heretofore unknown class of hormones which are chemically related and which go by the collective name endorphins. The physiological activity of some endorphins presents great similarity to that of morphine, heroin, and other opiate substances which relieve pain, not only by acting on the mechanisms of pain itself, but also by inhibiting the emotional response to pain and therefore suffering. Acupuncture can trigger the release of pituitary endorphin which, somehow gains access to the cells of the spinal cord and can thus exert an opiate-like effect on the perception of pain. It is not too farfetched to assume that, as in the case of other hormones, mental attitudes can affect the secretion of endorphin and thereby the patient's perception of disease.

Cousins correctly points out that a very large percentage of diseases are self-terminating. If can be assumed that much of medical care is useless. In practice, however, most patients can be helped by a physician for several different reasons. Only an accurate diagnosis, arrived at through medical acumen, can determine whether a particular disease is self-terminating or is potentially dangerous and therefore requires a particular therapy. Even in the case of a truly self-terminating disease, professional medical care can hasten the process of recovery and make it more bearable. Furthermore, there are many diseases-hypertension or arthritis, for example -- that cannot be cured but for which there exist methods of treatment -- medical or surgical -- that enable the patient to function more or less normally by correcting the symptoms. Curing the disease is only one aspect of medical care; alleviating the manifestations of disease is often the most important role of the physician.

In view of the diversity of medical intervention, the phrase "good doctor-patient relationships" can be interpreted in several different ways. It can mean that the patient surrenders to the authority of the physician, considered as a father figure. There are many situations in which this type of relationship is necessary, for example in difficult problems of diagnosis or in the application of specific therapies. When I suffered from sub-acute bacterial endocarditis some seven years ago, the only course for me was to accept the strict regimen of antibiotic therapy which alone can achieve the cure of this otherwise fatal disease. Acceptance of the physician's authority probably facilitates also the operations of what Osler called faith healing, which results in self-healing.

Blind acceptance of the physician's authority, however, seems to be losing ground. Cousins is not the only one to advocate partnership between the physician and patient in the search for a cure. In the summer nineteen seventy-seven issue of Man and Medicine, of which Cousins is now advisory editor, Professor Eli Ginzberg of Columbia University states, "No improvement in the health care system will be efficacious unless the citizen assumes responsibility for his own well-being. There are substantial potential gains to be made in linking the individual citizen to the health system through more sophisticated education." In general, the patient's responsibility has been limited to the practice of wiser life styles -- giving up smoking, watching one's diet, being more active physically, driving more slowly, learning to live with a chronic ailment such as arthritis or heart disease. But Cousins has a broader view of the patient-physician interplay. According to him, the responsibility of patients goes beyond the practice of healthy ways of life; when possible, it includes sharing with the physician the responsibility for the choice and application of therapy. In my opinion, few are the lay people who can at present usefully take such a creative role in the therapeutic process, except by trying to be objective and truthful in reporting the effects of the treatment. On the other hand, it is all but certain that active participation in the treatment, were it only through laughter or the cultivation of the will to live, as in Cousins's case, helps to mobilize the natural defense mechanisms of the patient which are the indispensable agents of recovery. This is true not only for the cure of an organic disease, but also for reeducation to compensate for a disability of innate or accidental origin. Like cure, rehabilitation implies participation of the mind as well as of the body, integrated through volition for a creative process of adaptive changes.

The questions raised by Cousins should not be read as casting doubts on the validity of scientific medicine. He does not hark back to the days of folk medicine, though he has ample respect for the old-fashioned family doctor. I have always felt that the only trouble with scientific medicine is that it is not scientific enough. Modern medicine will become really scientific only when physicians and their patients have learned to manage the forces of the body and the mind that operate in vis medicatrix naturae. This book is a service to that scientific tradition.