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 ad 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.