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Therapeutic Persuasion





It is not only in the distant past, however, but also in quite modern
times that these therapeutic persuasions have existed among
physicians, and as a result physicians have frequently recommended and
employed remedies that we now know not only to have been quite
useless, but sometimes even harmful. A typical example of this is the
use of antimony, originally discovered and studied by Basil Valentine,
an alchemist who had busied himself much with the nature of
substances, vegetable and mineral, and with their action as remedies
for disease. Sir Michael Foster hailed him as the first of
pharmacologists, and said: "The old monk did not care for the problem
of the body; all he sought to understand was how the constituents of
the soil and of plants might be treated so as to be available for
healing the sick and how they produced their effect."


Suggestion and Antimony.--This was an eminently scientific research.
It brought the father of pharmacology to certain supposed discoveries
which continued to occupy men's minds for centuries, yet ultimately
proved to be utter misunderstandings of drug action, because
suggestion played so large a role that it vitiated all the
conclusions. The best known of Basil Valentine's books is the
"Triumphal Chariot of Antimony," which contains many interesting
scientific observations that were probably new at the time and which
show their author's investigating spirit and his interest in
scientific research.

In spite of his scientific advances, however, Valentine was wholly
mistaken with regard to antimony. He used it in various diseases, and,
of course, it always produced very definite effects on the bowels.
These effects the physician could easily foretell. It was for the
patient a proof that the physician knew much, both about his disease
and his remedies, since he could prophesy the results. After the
antimony had exerted its influence the patient was much more ready to
think that he must get better, and the influence of this suggestion
worked strongly in all cases where the affection was not serious, and
undoubtedly helped the patient's resistive vitality to throw off
disease. In weak patients its physical effect was lamentable. It still
further reduced vitality, and when used by thoughtless physicians must
have done great harm. In spite of this, however, antimony continued to
be used for centuries. Shortly after the middle of the
seventeenth century, when it was beginning to be neglected, antimony
received a new lease of life as a consequence of its employment in a
lingering illness of Louis XIV. The French king was attacked by what
has since been recognized as typhoid fever. Many remedies were tried,
but all in vain; the fever continued. When the fever had nearly run
its course and the physicians were on the point of acknowledging that
they could do nothing, and when a fatal termination seemed near, it
was decided at a consultation to follow the advice of an old
practitioner and use the old-fashioned remedy, antimony. Almost
immediately the king began to get better. His improvement was quite
naturally attributed to the last drug that he had taken, and antimony
regained and held its remedial reputation for the next two centuries.

Such stories have always worked wonders in producing popular faith and
even professional confidence in drugs. When great personages seem to
be cured by certain remedies, ordinary logic ceases to act, and the
strong power of suggestion comes in to strengthen whatever remedial
influence there may be.


Calomel and Suggestion.--Such mistaken notions as to therapeutic
efficiency are not confined to centuries before our own. During much
of the nineteenth century calomel was employed as extensively as
antimony had been in preceding centuries. Calomel was often given in
doses which produced effects resembling those of antimony. Even in the
small doses we now employ, it is apt to be a thorough purgative. In
the twenty and forty grain doses, commonly administered by the country
doctors of two generations ago at the beginning of practically every
ailment, it was purgative--and worse. Its effects could, of course, be
very strikingly seen, and what patients wanted were just such visible
results of the doctor's prescription. Undoubtedly, then, the calomel
did good, but not by its effect upon the patients' bodies, but upon
their minds. Calomel is still used in ways that partake more of the
old-fashioned ideas than we care to confess. Some of its supposed
effects in stimulating the flow of bile have been placed in doubt by
modern investigation, but we still use it empirically, and undoubtedly
its effectiveness is partly due to the fact that many patients see the
results in the purgation in dark coloration of the stools and are
confident that improvement must follow--and it does. Perhaps at a
subsequent operation we find the bile ducts effectively blocked and
then learn for certain that the stool coloration observed was not
biliary but due to a chemical reaction of the calomel itself.


Venesection and Its Suggestiveness.--Between the periods of antimony
and calomel popularity venesection was the favorite remedy of
physicians. It is hard to understand now the extent to which this
practice was carried by the medical profession. People were bled for
nearly every combination of symptoms. In severe cases the amount of
bleeding practiced was almost incredible. Mirabeau, the great French
orator, suffering from angina pectoris, was bled some eighty ounces in
the course of forty-eight hours. In spite of this heroic treatment,
which his physicians thought ought to have cured him, he died. We find
it hard to understand how he lived so long. This, of course, was an
exceptional case at the very height of the venesection furor, but it
helps us to realize how convinced physicians were of the curative
power of the practice.

Thoughtful physicians like Morgagni did not accredit it, or at least
refused to allow it to be practiced on themselves, but its acceptance
was practically universal. Probably no remedial measure ever generally
used was calculated to be so effective as bleeding in producing a
strong mental influence. The rather sacrificial preparations for it,
the sight and the prick of the lancet, then the sight of the blood,
the languor that followed, the reaction on nature's part to reproduce
the lost material, all united to impress the patient's mind so deeply
that it is easy to understand that all the reserve of mental force was
now directed toward helping nature in the cure of whatever disease was
present. Venesection itself in nine out of ten cases probably did more
physical harm than good, but all the good came from its suggestion.

We are now apt to think of venesection as consisting only in the
removal of some blood from a favorably situated vein, but we must not
forget that in the olden time they bled from many veins, and that a
particular vein was picked out because it was supposed to be connected
in some way with the seat of the special trouble under treatment, and
as a result there was a particular appeal to mental influence. A vein
on the forehead was opened for the treatment of migraine and diseases
of the eyes, on the nose in case of discharge from the eyes, back of
the ears in chronic headache and in stuporous conditions, or beneath
the chin when there was pain in the eyes, or in the nose, or in the
jaws. The cephalic vein was opened for headache and for certain
affections of the eyes and ears. Altogether there were thirty
different veins opened for as many maladies. It was thought extremely
important in the drawing of blood from the arm that that arm should be
chosen which, for some anatomical or other reason, was supposed to be
the more intimately connected with the affected part of the trunk or
head. The psychotherapeutic factors at work in these cases are easy to
understand, and their beneficial effects gave the practice a firm
foothold in medicine.


Quinine and Suggestion.--Whenever any drug has secured a reputation
its use has always been extended to many other diseases besides that
for which it was definitely indicated. Quinine is a typical example.
It is a specific for malaria and, properly administered in suitable
doses, breaks up the fever--not because of any action upon the febrile
condition itself, but because it kills the Plasmodium malariae whose
reproduction in the blood brings about the paroxysms of fever. It was
argued, however, that since quinine was good for one kind of fever it
would probably be good in others, and all sorts of theories were
invented and supported by supposed observations of the effect of
quinine on various organs and tissues, even on the white blood cells,
by which its efficacy in fever was supposed to be explained. Quinine
was used in all sorts and conditions of fever, and acquired a
reputation as a remedy that had the power even to abort conditions
leading to all fevers. It was used in large doses for such conditions
as cold, incipient pneumonia, or indeed any disease with a chill at
the beginning, and was supposed to be a powerful prophylactic.

Now it is settled that while quinine in small doses is an excellent
tonic, it has no effect at all upon fevers in themselves nor upon
fever-producing conditions. Yet it is still administered by many who
have not quite abandoned the old teachings as if it were a general
febrifuge. In the meantime, the use of quinine as a prophylactic of
colds and other minor febrile conditions has spread so that many
people make themselves very uncomfortable by taking a large dose of
quinine and whiskey whenever they fear they are going to have a cold.
As a consequence they feel dull and heavy the next day, but assume
that they would have been much worse than they are had they not taken
the potent remedy the night before. Undoubtedly some of them are
enabled by the suggestive value of the remedy and the continued
suggestion of its unpleasant effects to throw off the lassitude that
comes from some minor infection and are encouraged to get out into the
air, when they might otherwise have stayed in the house. This enables
them to get rid of their colds sooner than would be the case if they
allowed themselves to be confined. Most of them, however, are harmed
rather than benefited, and the cold runs its course, unaffected except
that the patient is more miserable and depressed for the first day or
two than he would otherwise have been. There are physicians who still
use quinine as a febrifuge in typhoid and other essential fevers, and
doubtless its bitter taste helps their patients because of the
suggestive value of an unpleasant medicine.


St. John Long's Liniment.--An interesting exemplification of the power
of mystery in adding to the curative value of a commonplace remedy is
found in the story of the famous St. John Long liniment. St. John Long
was a well-known quack in London in the early part of the nineteenth
century. Like all quacks at all times, his specialty was chronic
diseases. He claimed to be able by means of external applications to
cure the pains and aches to which the old are so likely to be subject.
St. John soon acquired an immense reputation. He gave a liniment with
a secret formula that was literally a miracle worker. People who used
it found after a few times that they were free from, or at least
greatly relieved of, aches that had bothered them for years. It was
good for sprains and for internal pains of all kinds, as well as for
the so-called chronic rheumatisms, which have as their principal
symptom pains and aches around joints. So great a reputation, indeed,
was acquired by the remedy that an agitation was begun to have
Parliament buy the secret from its inventor in order to present it to
the British nation. The proposition was actually carried through the
legislative chambers and a considerable amount of money, still larger
in those days because of the comparatively greater value of money, was
voted to St. John Long.

His liniment had a place in the British Pharmacopeia under his name
for many years afterwards. It proved to be only a simple old-fashioned
remedy, the basis of which was turpentine, and one of the principal
ingredients was the white of egg. Just as soon as the secret was known
the power of the remedy began to decline. So long as it remained
mysterious and unknown, discovered by a man who supposedly had made a
special study for many years of these conditions, and had finally
worked out the external applications necessary for them, it
accomplished wonders. Just as soon as it was known to be a combination
of familiar turpentine and egg it lost its power. The remedy is, of
course, an excellent counter-irritant, and the gentle rubbing
undoubtedly did much good. The most important element, however, was
the mental influence, the feeling that now things must be better,
which thought distracted attention from the aches and pains and caused
the unfavorable influence of over-concentration of mind on the part to
cease, for the vaso-motor system is particularly under mental
influence. Every now and then since that time some liniment or
oil containing nearly the same ingredients as that of St. John Long's
acquires a reputation as a consequence of a campaign of advertising.
It is the printers ink that counts, however, and just as soon as the
advertising ceases to attract attention the remedy fails in
efficiency.


Alcohol Plus Suggestion.--Alcohol has been employed in medicine with
the persuasion that it is a remedy for many states of exhaustion,
though we have gradually gotten away from its use to a great extent,
because we realize that subsequent physical ill consequences outweigh,
in most cases, the physical good it may do. Its use was undoubtedly
due to the confidence of physicians communicated to patients, and the
sense of good feeling which it gives and which proves a further strong
suggestion to the patient. This sense of well-being is illusory, for
it is sure to be followed by a longer period of dejection, which more
than counteracts it unless the dose of alcohol can be maintained for
some time.

A generation ago few physicians would have cared to treat exhausting
diseases, the continued fevers for instance, without liberal doses of
alcohol. Practically the only treatment for pyemia and septicemia on
which any stress was laid, and in which there was any general
confidence, was the administration of alcohol in large quantities. In
the septicemia consequent upon puerperal infection it was the common
teaching to give alcohol by the tablespoonful or more every hour, or
oftener, until its effects began to be noticed, and ordinarily large
quantities were required, so that sometimes nearly a quart was taken
in the twenty-four hours. Undoubtedly these septic conditions were
accompanied by great mental prostration, and this was emphasized by
the knowledge that they are often fatal. So patients were usually
depressed into a state of mind in which their resistive vitality was
much lowered. Alcohol, then, by producing a sense of well-being as
well as by stimulating hope in other ways and suggesting possibilities
of recovery, undoubtedly exerted a powerful and favorable influence on
the mind. Its use in these cases nearly always did good, in spite of
its inevitable depressive reaction, for the course of these infections
was rapid and the dosage of alcohol could be maintained until there
was a change for the better or the fatal termination was in sight.

Alcohol was frequently used in many other conditions of a similar
nature, and above all in the septic conditions so common in hospitals
before the days of antisepsis and asepsis. When it is recalled that
amputations yielded a mortality from sepsis of at least one in four,
the extensive use of alcohol in hospital practice two generations ago
will be readily understood. We have changed that, however, and Sir
Frederick Treves, at a meeting of the British Medical Association at
Toronto, five years ago, called particular attention to the statistics
of the use of alcohol in British hospitals. During the last forty
years milk and alcohol have exactly changed places in the London
hospitals. Between 1860 and 1870 about four times as much was spent
for alcohol as for milk in these hospitals; during the last decade
about four times as much was spent for milk as for alcohol.

A corresponding change has taken place in many other phases of
treatment in which alcohol was commonly used. The physician of fifty
years ago would have thought that one of his most efficient remedies
had been taken from him if he could not use alcohol freely in
tuberculosis. There are practically no well-known specialists in
tuberculosis now who recommend the use of alcohol. On the
contrary, most of them point out the dangers from its use and consider
that the depression which follows even a moderate dose is likely to do
much more harm than the temporary and fleeting stimulation which it
gives can do good. In the treatment of phthisis in recent years milk
has done much more than take the place of alcohol: it has displaced it
entirely. The medical profession realizes now that what the
consumptive needs is not more stimulation--for more of that than is
good for him is forced upon him by the toxins of the disease--but more
nutrition to enable him to resist the progress of the disease and
raise his resistive vitality against its toxemia. The one stimulant
that is of service in the affection is oxygen, and even that should be
given in nature's dosage rather than by artificial means.


Alcohol in Pneumonia.--A corresponding change has taken place in the
professional attitude towards the use of alcohol in pneumonia. There
was a time not so very long ago when alcohol was considered the sheet
anchor of our therapeutics for pneumonic conditions, especially those
in which from the beginning a fatal termination seemed inevitable,
because of the age of the patient or some complication. There were
physicians who said that if they had to choose between all the drugs
of the pharmacopeia on the one hand without whiskey and whiskey
without all drugs whatsoever, for the treatment of pneumonia, they
would make the latter choice. We are not as yet entirely away from the
point of view that attributes a certain value to alcohol in pneumonia,
though even those who still employ alcohol are less emphatic in their
advocacy of it. Any one who has seen the result of the fresh air for
pneumonia patients will think less and less of alcohol. One well-known
clinical authority declares that the very best place to treat
pneumonia in our cities would be beneath the trees in the parks. Our
patients are being treated at the ends of wards with the windows up,
on the balconies, and on the roofs, and the death rate is much reduced
and the necessity for any other than oxygen stimulation seems much
less.


Alcohol in Vague Affections.--The suggestive influence of the effect
of alcohol is unconsciously obtained in a number of vague and rather
chronic affections. Among these the most noteworthy are women's
diseases. Various alcoholic home remedies, gin and whiskey, usually
disguised by some bitter, used to be popular. But the known presence
of alcohol in these discredited them. Then the nostrum vendors
proceeded to supply something just as good. They were, in fact, the
same things under another name. Many of the much-advertised remedies
that are supposed to cure the ills the weaker sex is liable to, have
been found to be little more than dilute whiskey, for in alcoholic
strength they were about equal to whiskey diluted once with water, and
the other substances were added only to disguise the taste and the
odor of this principal ingredient. Many of these remedies have
elicited innumerable flattering testimonials and not all of these were
fraudulent or obtained by questionable means, but many of them were
given because of results secured through the remedies. The alcohol
gave the well-known sense of well-being, and the suggestive influence
of this increased the appetite, tempted the patient to move around
more, and to get more into the air than before, and the consequence
was an improvement in the general health, in the midst of which many
symptoms that seemed to the excited imaginations of run-down
individuals to be serious were relieved. In a great many cases,
however, the result was the formation of a whiskey habit; hence
the crusade which has discredited these remedies.

Other patent medicines, and, indeed, some of the proprietary
preparations, commonly recommended as nutrients and the like, and
supposed to be ethical, are found to owe whatever efficiency they have
to their alcoholic content. Here once more the suggestive elements
were the more important, and enabled substances of little physical
efficiency to produce effects that seemed to indicate the presence of
powerful energizing materials.


Whiskey in Snake-Bites.--A typical example of a remedy which owes
its efficacy to mental influence over the patient is the use of
whiskey for snake-bites. It is generally recognized that whiskey is
not only of no special beneficial effect for snake-bite, but that when
taken in the large quantities usual in such cases it probably produces
an ill effect by disturbing the patient's general condition and
lowering his resistive vitality. I have no doubt, however, that its
use in considerable quantities has in these cases proved of value
because of the mental effect upon the patient. Ordinarily a snake-bite
is followed by a sense of extreme terror and prostration that lowers
the resistive vitality. This is overcome by the temporary stimulation
of the alcohol. The generally accepted idea that whiskey is almost a
specific remedy for snake-bite takes away from most people this dread
and consequent depression, and does this especially at a time when the
acuter symptoms of the venom are making themselves felt. Only about
one in six even of those bitten by large rattlesnakes are likely to
die. Many circumstances are in their favor. The bite is not likely to
be fatal unless the full contents of the poison sac is injected--which
will not be done if the sac has been emptied in the preceding
twenty-four hours--and if there are any obstacles, such as clothing or
even hair, on the part struck by the snake. Most people, however,
would almost die from fright, and such a thing is quite possible, if
they thought there was no remedy. The fact that they understand that
alcohol is an almost infallible remedy gives them courage, and as soon
as they receive some whiskey and it begins to take effect this intense
depression is relieved.

It would be better if the knowledge we now have as to snake-bites were
more generally used, and if people understood that only rarely is such
an accident fatal. In this way there would be no necessity for an
appeal to mental influence through whiskey. It is probable, however,
that alcohol will still be used for many years, at least in the
country districts, because the supposed knowledge is too widely
diffused for a correction to come soon, and then other modes of
treatment have not that persuasive mental influence which whiskey has
as the result of the long tradition. There are many other popular
remedies for snake-bite not quite so inefficient as whiskey, but that
will continue to enjoy a reputation and really have a certain
efficacious result as a consequence of the expectant attitude evoked
by the fact that for as long as the patient has heard anything about
these things this particular remedy has been mentioned always as the
one thing sure to do good.


Other Cures.--Fontana, toward the end of the eighteenth century, was
sure that he had discovered in caustic potash an absolute specific for
snake poisoning. He had had a series of cases, and felt that he had
actually observed this substance following the snake poison into the
system and neutralizing it. Its active effect on the external tissues
proved eminently suggestive for the patient and good results
followed. We have had many specifics since, and yet we are not quite
sure how much any of them avail unless recent biological remedies
prove lasting in their effects and are really of therapeutic
efficiency.


Antidotes and Suggestion.--For many other poisons beside snake venom
there have been announced supposed antidotes of all kinds. The
literature of the antidotes used for opium is extremely interesting
and even in recent times contains many disillusions. Twenty years ago
our medical journals contained any number of cases in which a solution
of potassium permanganate seemed to have proved effective in
neutralizing not only opium itself but its alkaloids and derivatives.
Not only was it efficacious, then, if taken while the opium was still
in the stomach but, just as with Fontana's caustic potash and the
snake venom, it followed the opium into the tissues and at least
blunted its action. Numbers of cases were reported in which potassium
permanganate was supposed to have had this desirable effect. The
effect of alcohol in neutralizing carbolic acid attracted as much
attention as did potassium permanganate for opium. Here there was no
doubt that alcohol immediately after the external application of
carbolic acid did prevent its corrosive action. It was supposed to do
the same thing in the stomach and even, as some enthusiastic observers
thought, followed the carbolic acid into the tissues. Here once more
the claim is not proven and it is evident that the influence on
patients' minds when small doses of carbolic acid were taken, was the
real therapeutic factor at work.


Poultices in Suggestive Therapeutics.--Poultices represent another
phase of the value of suggestion in medicine and surgery, though for
many centuries those who used them were sure that the reasons for
their employment were entirely physical and not psychic. All sorts of
poultices have been used and each was supposed to do specific curative
work. New forms of poultice material have been introduced, and
physicians and patients have been certain that each worked wonders of
its own. The drawing power of the poultice was extolled until patients
dwelt on the idea that this external application was literally engaged
in extracting from them, even from distant portions of their anatomy,
virulent material that would do harm if allowed to remain in them.
Poultices in suitable cases, because they represent moist heat, do
good by counter irritation, by bringing about the expulsion of gas, by
diverting internal hyperemia to external tissues, but most of their
supposed efficacy has been really due to the bother required to
prepare and apply them, the discomfort of having them on, and the
feeling that now something had been done and the aches and pains must
get better. They are still used, but to a much less degree than
before. Now the ordinary teaching is that a hot water bag wrapped in
dry flannel, if dry heat is the agent desired, and in moist flannel,
if moist heat is the desideratum, is much more efficient. It takes but
a few minutes for a poultice, no matter how hot when applied--and
occasionally in the olden time they were applied so warm as to burn or
scald--to decrease in temperature to that of the body. After that they
represent only a moist compress.

It is easy to understand that the suggestive influence of poultices
might serve for an age that knew less about the realities of the
efficacy of external applications than ours. As a matter of fact, we
have, nevertheless, shown ourselves to be quite as credulous and ready
to receive analogous remedies as the past generation. With the waning
of the popularity of the poultice, not only among the profession,
but also among the people generally, there came into use various
plasters which were supposed to have even more wonderful efficacy than
the poultice of the olden time. These required a good deal of trouble
to apply and once applied remained on for hours, and so continued to
produce a definite curative effect on patients' minds. When first
introduced, exaggerated claims were made for their therapeutic value
and a regular crusade to diffuse correct information regarding them
had to be made, in order to set them in their proper place as mere wet
compresses, without any therapeutic efficiency beyond that of cloths
wrung out in water and kept in touch with the skin.


Poultices and the Doctrine of Signatures.--There was a general
impression in the past that the indication of the ailment for which
substances are medically useful has been set on them by nature, either
through the color, or the form of the plant, or other qualities. In
general, the law of similars is supposed to hold in the doctrine of
signatures--like cures like. Hence the cornmeal poultice for light
jaundice, the flax-seed meal poultice for darker jaundiced conditions
and for tendencies to gangrene. The charcoal poultice was employed for
this same purpose with no better reason, though some of its efficacy
may have been due to oxygen present in the pores of the charcoal. I
have already spoken of the appeal to the patient's mind in the use of
the cranberry for erysipelas, and various other berries were used in
like manner on the doctrine of signatures.


Deterrent Materials and Suggestion.--Another basic principle in the
making of poultices was the use of deterrent, repulsive materials,
because these were more effective on the patient's mind. All the
ordures were so employed. Goose and chicken excrement was supposed to
be particularly efficacious for many of the purposes for which we now
use iodine. It was applied over sprains and bruises on the unbroken
skin. Cow-dung was employed as a poultice for sprains of the larger
joints, especially on the feet and legs, but to be efficacious it had
to be applied fresh. I have known, within twenty years, of physicians
in two so supposedly cultured parts of the country as Pennsylvania and
Maryland, to employ such ordure poultices for the cure of sprains and
dislocations, and these physicians had a great reputation among the
people of their countryside. They were known especially as good bone
doctors, and their use of such deterrent materials instead of
decreasing their practices rather added to them.


Ointments.--In the Middle Ages ointments made of the most far-fetched
materials were employed even by distinguished surgeons. That, indeed,
is the one serious flaw in the surgery of the thirteenth and
fourteenth centuries, when they did everything else so well. These
ointments contained all manner of materials that were likely to
impress patients and make them feel that something wonderful was being
done for them. Crushed insects of all kinds were employed for external
lesions. Here the doctrine of similars seems once more to have been in
play. Insects gave creepy feelings, and whenever such feelings, or the
paresthesiae generally, were complained of, a poultice or ointment
made of insects seemed to be the natural remedy. The more repellent
the materials, the more efficient they were likely to be. Many of the
paresthesiae are due to neurotic conditions and it is not surprising
that when an ointment of crushed lice--these insects being collected
from barnyard fowls or from hogs--was used, the suggestive
influence was strong. Another important ingredient in ointments were
portions of dead bodies. A bit of a mummy from the East was supposed
to be particularly efficacious. Portions of the bodies of men who had
been hanged, or of the moss that grew on the skulls of malefactors
whose bodies had been long exposed in chains to the air, were also
favorite ingredients. Plants and shrubs gathered in graveyards,
especially in the dark of the moon, because on account of the terror
of the place they were then harder to get, also had a great
reputation.





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Previous: Genuine Remedies And Suggestive Exaggeration



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