To the Editor:
I write to congratulate Florence A. Ruderman for her penetrating analysis of the Norman Cousins case [“A Placebo for the Doctor,” May]. Anatomy of an Illness is a destructive and misleading book. That the medical profession should latch on to this case history, and proceed to legitimize it, is to celebrate a fad. As a doctor (I practice surgery in New Haven) I am outraged by the shabbiness and lack of control that Norman Cousins exhibits in his presentation. I am sadder, even, at the sheep-like acquiescence of the New England Journal of Medicine (which first published Cousins’s article), the UCLA School of Medicine (where he now lectures), and, more personally, the Johns Hopkins University School of Medicine.
Recently, I took part in a “Symposium on Medicine and Literature” sponsored by the Humanities Program at Johns Hopkins. I was one of four participants whose moderator and keynote speaker was Norman Cousins. The four participants had agreed to attend, understanding that the subject to be discussed was medicine and its relationship to literature. Two of us are physician-writers; two, literary scholars. To my dismay, Cousins delivered as his keynote address a scathing attack on the medical profession, replete with stale jokes in each of which the doctor was the butt, and the patient, the victim. At each of these jokes, the polite audience laughed. Whenever the doctor was not being lampooned, it was the hospital, particularly the kitchen, laboratory, and nursing services. And this at Johns Hopkins, where so much great medicine has been practiced for well over a century. The ensuing discussion was manipulated by Cousins so that it dealt only with matters of medical deficiency. . . .
Later, many of the visitors to the symposium, among them faculty of Johns Hopkins, confided to me their shock at the subversion of the conference for Cousins’s own promotional purposes, and at the gratuitous attack on the medical profession as well. Of course, I have laid primary blame on Johns Hopkins for inviting Norman Cousins to be something which he is not, and for showing again that the medical profession is not immune to the power of the media.
[Dr.] Richard Selzer
New Haven, Connecticut
To the Editor:
An admirer and obsessive reader of both the New England Journal of Medicine and COMMENTARY, I was pleased to see Florence A. Ruderman comment on a book which was an outgrowth of an article that had originally appeared in the NEJM.
Most NEJM readers read Norman Cousins’s article with amusement, and I suspect far fewer of us than Miss Ruderman thinks were taken in by his theories. . . .
I think most of us physicians really did believe that Cousins’s article was pleasant, well-written nonsense. He said he received letters from thousands of physicians, but I think that those of us who didn’t take him seriously did not bother to write. . . . On reflection, however, the fact that the article was published in such an excellent journal as the NEJM makes me now think that Miss Ruderman is correct in taking us to task for our silence.
Miss Ruderman has done her homework well and her concept of disease and treatment is sounder than that of Norman Cousins. . . .
[Dr.] Harvey N. Mandell
The William W. Backus Hospital
To the Editor:
Florence A. Ruderman neatly takes apart (dissects?) the Norman Cousins phenomenon and discloses all its inner workings. . . .
Why was Cousins’s essay published in the New England Journal of Medicine and why did so many physicians supposedly praise it? I really don’t know, but I will hazard a guess. . . . Doctors, who as everyone knows can barely read or write, are terribly in awe of intellectuals and artists. I should imagine that this is particularly true of the very clever and guilt-ridden people who edit the NEJM. . . .
There were parts of Cousins’s essay that physicians could sympathize with unreservedly. Many people, myself among them, agreed fully with the portion dealing with the horrors of the workups. I for one cheered him when he defied the tedious rules. I know well that these have more to do with mass production than with the welfare of individual patients. . . .
Physicians responded to Cousins for yet another reason. . . . More people than is commonly believed go into medicine to be liked and respected. Many of us are spending a great deal of time and effort these days beating our breasts and pleading guilty to charges that we are insensitive to patients as people. (Sometimes in our zeal for remedies we go too far. At a recent week-long medical meeting I attended, a physician attired in ambiguous—hermaphroditic?—garb appeared on three different panels. Before he settled down to the business of the panels, he solemnly explained each time that his dress was meant to communicate that he was untainted by sexist bias.)
I hope that Norman Cousins continues in health and happiness. If his beliefs make him feel better, I am all for them. . . . If people whom medicine cannot help are helped by reading Cousins, that is also fine. [But] if patients who can be helped by medicine begin to reject their doctors to follow Cousins, then indeed we will have a problem. But that problem will not have been caused by Cousins’s appearance in the NEJM . . . but rather by the PR people working for Cousins and by the media which have been popularizing his views.
[Dr.] Edith T. Shapiro
Englewood, New Jersey
To the Editor:
Here is at least one physician’s appreciation and endorsement of Florence A. Ruderman’s perceptive and sensible criticisms of Norman Cousins’s Anatomy of an Illness. I must confess that I too was taken in at first by the smooth persuasiveness of his NEJM article. But I soon recognized its underlying inaccuracies, intended or unintended omissions or distortions, and particularly the disservice Cousins’s views could do to patients and physicians in general. Perhaps his book should have been called: Travesty of an Illness, Its Wondrous Cure by the Victim.
The tremendous applause which Cousins received from the profession, crowned by his tragi-comic appointment to the faculty of a medical school, is probably best understood as an expression of guilt feelings on the part of physicians for having forsaken the art of medicine and having become technicians instead. I wonder whether it is because of such feelings that none of the various well-known and highly respected physicians who attended Cousins has come forward to comment on his book, his illness, or its management.
[Dr.] Martin G. Goldner
Palo Alto, California
To the Editor:
Norman Cousins has cited the work of my group in his book and in a Saturday Review article. But both Cousins in his citations and Florence A. Ruderman in her COMMENTARY article indicate a lack of understanding of the physical/ chemical basis of vitamin-C therapy and thus of its effects on temperature, sedimentation rate, and on cells. . . . All cells in our body are continuously coming together and then moving apart. If the cells begin to move apart permanently, an edematous condition develops and one could be described as becoming “unstuck.” Mr. Cousins’s condition, however, indicated that his cells were coming together permanently and thus were pathologically “stuck” together. This was shown particularly by his sedimentation rate.
The monitoring of a patient’s blood-cell settling rates is analogous to the monitoring of a patient’s temperature. Apart from some exceptional situations, the temperature measurements in themselves are not crucial. What is important in such measurements is that they reflect the state of the body and the bodily responses. By a similar logic, the rates at which red cells settle have no special importance in affecting the degree of health. Their special importance lies in their providing an index of the ability of any given substance, in this case vitamin C, to overcome the abnormal forces binding red cells together and even more importantly to disrupt the abnormal binding of the cells in any pathological tissues of the body. . . . While vitamin C is a relatively weak “unsticking” agent, Mr. Cousins’s “intuition” served him well in using this agent in such large amounts. Miss Ruder-man knows that a chemical’s lack of recognition as an accepted treatment can well reflect medicine’s lack of understanding of that chemical’s mode of action.
Joy or depression or any emotion is accompanied by fluctuations in the level of agents (adrenalin, etc.) which disrupt contacts between cells and agents (macro-molecules composing collagen, etc.) which promote sticking. There is thus a psychological component which is constantly and intimately involved in the physical/chemical action of any therapy.
To the Editor:
Florence A. Ruderman’s article, “A Placebo for the Doctor,” raises a number of important questions concerning the reception accorded Norman Cousins and the book he has written about his recovery from a debilitating, possibly fatal, illness. That these questions do not appear to have been raised by members of the medical profession is indeed troubling. But also disturbing is Miss Ruderman’s apparent lack of any sense of responsibility to seek answers to the questions she has formed prior to their publication in COMMENTARY. Did she, for example, attempt to ask Cousins whether his sedimentation rate was ever tested when he was not taking vitamin C? Did she pose her questions to his doctor, or to any of the other doctors whose praise of Cousins’s efforts has aroused her scorn? . . .
Having stated that she does believe “positive emotions” play a role in health, Miss Ruderman then demeans the substance of her article by focusing on Cousins’s choice of what may be called “the Candid Camera cure” as an indication of how superficial the presumed causes of the disease—and, by extrapolation, the man himself—must be. She dismisses as irrelevant the important point that Cousins used laughter to help him regain his equilibrium. If Cousins’s mental fatigue had been brought about by his too closely personalizing the ills of the larger world, it certainly seems conceivable that some unsophisticated escapist humor could have provided his mind—and body—with much-needed rest. (As for the choice of Candid Camera, well, de gustibus non est disputandum.) To maintain that “there is nothing in what Cousins tells us (or what we know or can infer of the man himself) to suggest any serious emotional or intellectual strain, any stressful life circumstances” is to describe gratuitously an individual who has devoted his adult life to the pursuit of world peace. . . .
Anne L. Finger
Teaneck, New Jersey
To the Editor:
Florence A. Ruderman’s remarks on Norman Cousins certainly make sense to me. The phenomenon of Norman Cousins has been bothering me for a long time, and I was beginning to wonder what had happened to our critical faculties. . . .
Miss Ruderman’s comments on the reactions of physicians are not unreasonable, but there is more to it than she indicates. Isn’t it conceivable that people feel they don’t have the whole story, and that, therefore, a certain amount of tolerance is indicated, even in the face of outraged plausibility? After all, nobody wants to squelch another Galileo, although it isn’t enough to fly in the face of accepted knowledge to become one—you have to be right, too. . . .
Alexander L. Nussbaum
Boston Biomedical Research Institute
To the Editor:
Florence A. Ruderman needed one additional bit of information to assess Norman Cousins’s Anatomy of an Illness—the correct diagnosis. The disease Cousins described is polymyalgia rheumatica, not ankylosing spondylitis, and it is often self-limited, lasting several months or longer. Cousins’s bizarre and naive attempts at biochemical and physiological explanations are meaningless. Polymyalgia rheumatica may require cortisone-like drugs and often can be treated with bed rest and mild drugs such as aspirin.
Cousins’s comment that patients should participate in their own care is commendable, but it does not follow from his argument; this recommendation, moreover, should stand on its own merit without having to be accompanied by the need to attack and embarrass medicine and physicians.
Cousins’s book was reviewed in nearly every medical journal that reviews books and all the reviews came to the same lugubrious and masochistic conclusion—doctors should heed this man and “there is much to be learned here.” Miss Ruderman has incisively defogged Cousins’s attempt to be an amateur physician. It is incumbent on those accomplished in one field to recognize their limitations. The New England Journal of Medicine and the UCLA medical school will forever have the albatross of Cousins about their egregious necks.
[Dr.] Richard D. Smith
[Dr.] Marvin Epstein
Walnut Creek, California
Florence A. Ruderman writes:
I want to thank all of those who wrote to support and even to add to my analysis of the Cousin’s case. I am particularly grateful to the doctors whose letters have helped to make clear the quite wide dissatisfaction with medicine’s role in this affair.
To Bernard Ecanow: There is no satisfactory evidence of a therapeutic role for vitamn C in the treatment of arthritic disease, or even of its symptoms, such as an elevated erythrocyte sedimentation rate. There is evidence of risks with high dosages of vitamin C. But even if these issues were in dispute, the fact would still remain that in the absence of any kind of controls in Cousins’s case, he has no basis for claiming that his gradual and partial recovery—even the drop in the sedimentation rate—is due to anything he did, rather than to a natural process of remission, in a condition naturally subject to remission.
To Anne L. Finger: Miss Finger has the shoe on the wrong foot. No reader has any obligation to try, privately, to fill in the holes, or plaster over the discrepancies and evasions, in Cousins’s account. It is Cousins who has made his story and his “message”—a distorted story and a pernicious message—as public as his article, his book, repeated appearances on nationwide television, and other skillful uses of the media could make them. And it is Cousins who has an intellectual—and ethical—responsibility to answer, publicly, the questions which his public story and his public claims raise.