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US drug sales continue to rise

BMJ 2003; 326 doi: https://doi.org/10.1136/bmj.326.7388.518/c (Published 01 March 2003) Cite this as: BMJ 2003;326:518

Therapeutic nihilism

Sir,

When John Foley says, “I often wonder if dispensing drugs does more
harm than good,” [1] he raises an interesting and very old issue. He then
goes on to state that, “drugs never cured a thing,” [1] and that “only
that nerve energy that runs through you and controls every function and
autonomic process of your being every second of your life is capable of
healing you. No drugs of doctors can do that. We can only facilitate it.”
[1]

Firstly, we can consider the historical background to this matter. In
the first half of the 19th century, medicine had been heroic, primarily
involving the purging and bleeding of patients: "parallel with the belief
in the certainty of medicine went a disdain for the vis medicatrix
naturae." [2; 60] There was a widespread "ignorance of the power of nature
to cure diseases...and to prescribe remedies when they are either useless
or injurious." [2; 61] This came to a head when Holmes said, "if all the
medicines were thrown into the sea it would be so much the better for
mankind and so much the worse for the fishes." [3; 304] It was also
"rumoured that the whole materia medica, with Skoda, was nothing but
cherry brandy or something of the sort...French influence on the one hand,
and the success of homeopathy on the other, were inclining critical men to
abstain from drugs and to depend more and more upon 'nature'..." [3; 184-
5] Is this what John Foley is hinting at today?

In the 1820s and 1830s, “Americans who went to Europe to study
medicine increasingly went to Paris and brought back with them the
therapeutic skepticism of the French...Jacob Bigelow of
Harvard...maintained...that the amount of death and disaster in the world
would be less if all disease were left to itself." [4; 55] Bigelow "called
upon physicians to recognise nature as 'the great agent of cure'...others
called it 'therapeutic nihilism'..." [4; 55-6] With Jacob Bigelow’s,
“inclination toward therapeutic moderation…he made clear his desire to
reduce rather than extend the therapeutic armamentarium…[and] a penchant
for simplicity in materia medica.” [5; 27] He was also possessed of “a
favourable attitude toward the healing power of nature…recognising the
natural course of diseases.” [5; 27]

In the 1840s and 1850s, "the therapeutic nihilism of the French and
Austrian clinicians," [3; 205] "dominated the best informed medical
circles - when critical physicians doubted the ability of medical art to
do much against cholera or any other serious disease." [3; 212] This
spawned a pervasive medical uncertainty: "opium was employed in Glasgow
and condemned in London." [3; 213] In a certain sense, "therapeutic
nihilism was really a sign of progress in 1850, but it discouraged the
generation which witnessed its appearance. Hence the paradox, that the
most hopeful period in the history of medicine [was]...when critical
physicians refused to promise all things, when learned doctors made the
shocking announcement that medicines were useless, many patients turned to
quacks for cures." [3; 242] In this way, orthodox medicine became burdened
with "the therapeutic skepticism of their own leaders." [3; 250] The
“nihilism of 1850…found its chief service in disclosing the uselessness of
traditional remedies." [3; 303]

By the 1850s "many regular physicians had subscribed to...the 'nature
-trusting heresy'...sectarian challenges to medical orthodoxy may have
encouraged the shift toward less violent remedies." [4; 56] What started
as a critique of the dangers of unpopular heroic drugging soon snowballed
into an entire, though brief, medical movement, the flames fanned in the
US by homeopaths, eclectics and Thomsonians. In the 1850s and 1860s, it
became increasingly realised that greater emphasis ought to be placed upon
“the patients’ recuperative powers, and less on interference by the
physician.” [2; 61] In the same period, one can note “a reduction in dose
size, the decline of polypharmacy…[and] the greater reliance on the
healing power of nature.” [2; 242] For example, it was suspected “that the
prostration which was so apt to ensue in the progress of fever was in part
the result of the medicines used.” [2; 61] Success of sectarian medical
systems like homeopathy certainly contributed to this change in attitude.
As homeopaths “seemed to be curing people with very small doses of
medicines [Jacob Bigelow was able] to draw the conclusion that the
customary large doses used by orthodox physicians were probably
unnecessary.” [2; 242] Now, it seems, John Foley, makes a similar claim
today.

Some clinicians believed in “therapeutic nihilism, claiming that the
role of the physician was to assist nature.” [6; 180] Yet, “practising
therapeutic nihilism required courage and self-restraint in the face of
the demands of patients for active therapy.” [6; 185] As the orthodox
system “came under increasing public criticism, and its physicians were
compelled to reduce their doses, their writing tended increasingly to
stress reliance on the healing power of nature.” [6; 252] Bigelow defined
“the self-limited disease…which receives limits from its own nature…and
not known to be shortened, or greatly changed, by medical treatment.” [6;
243] Even Sir John Forbes, consulting physician to Queen Victoria,
“accepted the homeopathic cures as the result of the Vis medicatrix
naturae…the less the physician does, the better chance the patient has of
recovering.” [6; 243]

In 1860, when Oliver Wendell Holmes famously “promoted the healing
power of nature in a widely known annual address,” [5; 28] this was dubbed
in some circles as “the nature-trusting heresy.” [5; 29] Holmes “is most
well known for having said…that if the whole materia medica, as now used,
could be sunk to the bottom of the sea, it would be so much the better for
mankind – and all the worse for the fishes.” [6; 178; 5; 33; Porter, 680]
This notion had taken root in the USA from “the development of genuine
nihilism in the Viennese school of the 1840s, most vividly expressed by
the fears that it was possible for an eminent regular physician to
renounce medical art.” [5; 32] Those who “first advocated the healing
power of nature and questioned the efficacy of art,” [5; 32] were French
and Austrian physicians.

By the 1860s, “the destination of most American physicians travelling
to Europe for study had begun to shift from Paris to German cities and
especially Vienna,” [5; 198] which at that time had “the largest
[teaching] hospital in the world.” [5; 198] Many doctors “knew that their
medicines were eyewash, which is one reason why the therapeutic nihilism
associated with Paris was an honest option…and Vienna seems to have gained
notoriety in this respect…therapeutic nihilism might be dressed up in more
palatable form as acclaim for nature’s healing ways [vis medicatrix
naturae] and rejection of classic heroic therapies of bleeding and
purging.” [7; 680]

However, some orthodox physicians “denounced the therapeutic
nihilism…represented by the Viennese clinician Joseph Dietl.” [5; 35]
There existed a “tacit association between nature trusting and [medical]
sectarianism. Many physicians maintained that the rising emphasis on
nature’s role in healing was an injudicious response to sectarian
therapeutics, and especially homeopathic infinitesimals…[which were
therefore seen as] an illegitimate source of therapeutic change.” [5; 20]
Holmes’ comments were condemned by some medical men of the day, he being
described as a “disgrace to medicine…they are pseudo-philosophers who in
their conceit and vanity, never hesitate to deride legitimate medicine
whenever an opportunity offers.” [5; 34] In this scenario, “homeopathic
treatment…was tantamount to relying entirely on nature for
cure…illustrated the power of the vis medicatrix naturae…[yet] growing
faith in the vis medicatrix naturae coincided with the perception of many
physicians that the standing of their profession was declining in American
society.” [5; 20-21]

By the 1890s, medicine had witnessed "two generations of nihilistic
medicine," [3; 375] and the last decades of the nineteenth century "were
characterised by much discussion of the 'uncertainty of medicine' as well
as by persistent 'therapeutic nihilism' in the orthodox ranks." [2; 257]
And this notion of medicine doing more harm than good surfaced once again
in the mid 1970s: "Ivan Illich agreed that medical care caused more
disease than it cured and that people would be healthier if they liberated
themselves from dependence on the entire malignant apparatus of modern
medicine." [4; 409] In a similar vein, "the economist, Victor Fuchs argued
that...more medical care now would reduce neither mortality nor disease."
[4; 409]

Exploring the points raised here in more detail is a worthwhile
exercise, if we provisionally accept the contention that Foley raises. If
drugs truly "never cured a thing" [1] then a number of contentions
inevitably flow from this position. First, it means that drugs are largely
unnecessary and ineffective. In which case, the entire pharmaceutical
industry becomes something of a fraud and any alleged healing effects of
drugs are really due to the Vis medicatrix naturae, [8] i.e. the innate
self-healing powers. Second, it means that all the metabolic pathway idea
about how drugs works is also thrown into doubt. Third, it means we might
not even get ill in the way we think, but only occasionally, not when
metabolic pathways go wrong, but more when the self-healing powers are
diminished in strength. Sickness would then hinge much more upon the
varying individual susceptibility that a person manifests through in time,
and less upon external disease triggers.

Fourth, it also means that medicine should not so much be about
'fixing things,' but about raising the general level of health and thus
enhancing the innate self-healing potential of the whole person. This is
precisely what the CAM therapies also aim to enhance, such as cold water
[hydrotherapy], fasting [diet reform], foot massage [reflexology], saunas,
exercise, acupuncture needles, homeopathic remedies, etc. These aim to
stimulate and enhance the innate self-healing powers rather than directly
intervening in metabolic pathways to try and eliminate disease, which
seems to be the main basis of modern therapeutics. Further, stimulation of
the innate healing powers would not constitute intervention as envisaged
by modern therapeutics, which seeks not only to control the organism, but
also to replace various of its non-functional activities and by so doing
engenders increasing forms of medical dependency.

Fifth, if all this is true then it serves as a validation for the
comments Hahnemann makes in The Organon about the nature of medicine and
the way drugs operate. Sixth, that we should not look for the causes of
disease in things external to the patient [such as ‘germs’], but more at
those internal aspects of susceptibility and the innate healing powers.
Treatment, likewise, should be redirected accordingly. Seventh, there
might well be an important emotional, social, psychological context within
which all 'disease' occurs and concerning episodes of 'failure' and loss.
In addition, that sickness might therefore have a meaning in relation to
the life of the patient and their general sense of purpose in life,
against which they generally interpret illness as some vaguely defined
‘punishment by God’ for supposed misdemeanours or imagined shortcomings.

When John Foley says, “only that nerve energy that runs through you
and controls every function and autonomic process of your being every
second of your life is capable of healing you. No drugs of doctors can do
that. We can only facilitate it,” [1] then he clearly inclines towards a
validation of the vitalist views of homeopathy and acupuncture. When he
further contends that “drugs, if anything, interfere with that innate
ability to heal from within,” [1] and that mere “covering up symptoms with
pharmaceuticals has done little,” [1] then he tilts towards the ancient
claim of homeopaths that drugs not only do not cure but delay healing and
complicate disease by suppressing symptoms.

In all the above senses, it strikes me that if "drugs don't cure a
thing," [1] then much hard thinking needs to be done in order to more
carefully envisage a safer and gentler system of true healing that not
only removes and alleviates sickness, but which is at once both health-
enhancing and life-enhancing. In the opinion of increasing numbers of
clinicians and patients, the answers to these questions do not lie within
the domain of molecular medicine, but outside it, in the more ancient
‘sectarian’ healing systems now called CAM.

Sources

[1] Drugs never cured a thing, 14 June 2003, John S. Foley, BMJ e-
letter,
http://bmj.com/cgi/eletters/326/7388/518/c#33299

[2] Harris L Coulter, Divided Legacy - the Schism in Medical Thought,
Washington: Wehawken Books, 3 Vols. 1973, references are to Volume III:
Science and Ethics in American Medicine 1800-1914.

[3] Richard H Shryock, The Development of Modern Medicine, an
Interpretation of the Social and Scientific Factors Involved,
Philadelphia: Univ. Pennsylvania Press, 1936

[4] Paul Starr, The Social Transformation of American Medicine, New
York: Basic Books, 1982

[5] John H Warner, The Therapeutic Perspective: Medical Practice,
Knowledge and Identity 1828-1885, Cambridge: Harvard Univ. Press, 1986

[6] William G Rothstein, American Physicians in the Nineteenth
Century from Sects to Science, Baltimore: Johns Hopkins Univ Press, 1972

[7] Roy Porter, For the Benefit of All Mankind – A Medical History of
Humanity, New York: Norton, 1998

[8] Vis Medicatrix Naturae, Andrew Lockie, BMJ e-letter, 9 May 2003
www.bmj.com/cgi/eletters/326/7396/S151#32089

Competing interests:  
None declared

Competing interests: No competing interests

20 June 2003
Peter Morrell
researcher, medical history,
UK