I was on duty when our first experimental subject arrived. I randomly pulled a treatment card from the file. Injection. I approached the patient and said, “This will sting, but it will make you much better. Big and strong.” He gritted his teeth as I gave the injection. The next evening he returned to the clinic looking for the same doctor who gave him the injection. With him were six friends, all wanting the same treatment. Our trial was doomed to fail as the word was out on the street.
It’s a pity we were not in today’s environment of the Internet, flim-flam, snake oil, and rampant charlatanism. One could make a fortune with this “muti” (aka medicine), much like homeopathy.
One patient forever changed the way I viewed medicine and healing. He was referred to us from a rural mission hospital. The number of indigenous languages in South Africa made taking a history a challenge, sometimes requiring at least two translators. Most nurses were reasonably fluent in English, Afrikaans, Xhosa, Zulu, and Fanagalo (fanakalo). The latter was a mishmash of multiple languages devised on the goldmines for simple communication. Based largely on Zulu, Fanagalo was the lingua franca of the mining industry. The word means to do “like this,” and it is the instruction to mimic what the supervisor did. There are eleven official languages in South Africa and any number of regional dialects and variations, so sometimes things get lost in translation. Some nurses did considerable editorializing, telling us what they thought we wanted to hear.
This particular patient arrived on a Thursday with a confusing story about an argument he had had with a neighbor. His antagonist went to the local witch doctor, who put a curse on the patient. He was told that he was going to die and that the only thing that could save him was an operation in a white man’s hospital. He had arrived for his operation. Physically, he looked awful, and he was admitted to our ward.
There was nothing on the physical examination to account for his condition, and a few simple laboratory tests and X-rays were normal. I presented the case on ward rounds the next day. Dr. Seftel, the attending physician, instructed, “Benjamin, reserve the operating room for Monday morning. We will open his belly, suture him back up, and he will be fine. I have seen this before, and these patients will die.”
By Saturday, he looked even worse. He had lost more weight despite eating and was getting weaker. On Sunday, the registrar (aka senior resident) called me. “Come over to the ward,” he said, “I have an idea.” We told the patient that his body was filled with demons and we were going to burn them out of him. To prove it, I took five cc of his blood and mixed it with hydrogen peroxide. Giant pink bubbles frothed out of the test tube. His eyes widened in horror. “See,” we said, “that is what we will get rid of.” We then gave him a hefty dose of intravenous nicotinic acid (Vitamin B3 or niacin). Given this way, it causes immediate flushing and a sensation of heat because of the vasodilatation of vessels in the skin. He lay there “on fire” for about an hour before we returned. “We need to make sure that there is nothing left behind.” Once again, I drew some blood, this time mixing it with water. No bubbles or effervescence. The nurse called me that evening to say the patient looked much better. We canceled the operating room and discharged him after a couple of days. At follow-up clinic three months later, he was fine.
We were taught to understand and appreciate a patient’s culture and beliefs about illness by Dr. Seftel, the attending physician, who was later promoted to Ad hominem Professor of African Diseases in 1971. These dual lessons of being sensitive and knowledgeable about every patient’s culture, ideology, worldview, and the importance of the mind-body axis became my touchstones for medical care.
The placebo effect is one of the most powerful instruments in a physician’s black bag. We were instructed to use it wisely. It could be as potent as the other mainstay of healing — “the tincture of time.”
Future essays will examine the placebo in a lot more detail. It is crucial for the understanding of clinical trials and the assessment of the effectiveness of any therapy.
Muti is a traditional medicine practice in Southern Africa that uses plants and animals to prepare spiritually curative medicines and magic charms. The word muti comes from the Zulu word umu t “tree, shrub, herb.”