Psychotherapy / Including the History of the Use of Mental Influence, Directly and Indirectly, in Healing and the Principles for the Application of Energies Derived from the Mind to the Treatment of Disease

by James J. Walsh

Prognosis in Young Patients.—Some of the cases, especially in young people, are likely to seem quite discouraging and apparently to justify even a serious operation. I have in mind a young woman seen some fifteen years ago when she was about seventeen. The prominence of the eyes, the enlargement of the thyroid, the tremor and the rapid heart were all marked. The symptoms had been growing worse for over a year and the outlook was serious. Ten years later I saw her in another city in perfectly normal health, married and happy and the mother of two healthy children. The only trace [{503}] apparently of the disturbance of the thyroid to be noted in the family was that her children got their teeth very late, her first child, a boy, not cutting his first tooth until after he was fifteen months old. In every other way, however, the boy was perfectly well, rugged and strong, having passed through his summers without any serious disturbance and not being a particularly nervous or excitable child. Such complete relief from symptoms after the condition had been so grave would ordinarily have seemed quite out of the question. It emphasizes the fact that for Graves' disease as it occurs among young growing people, where perhaps the thyroid does not grow in proper proportion to the rest of the body, but for some reason overgrows, the prognosis of the case may seem to be much worse than it really is.

Treatment.—The story of the various methods of treatment that have been reported as successful for Graves' disease serve to show very well how much the affection must depend upon psychic and neurotic conditions, for most of them have been positive in action at the beginning when their suggestive influence was strong, and quite inert after they had lost their novelty and their power to influence the mind. Sometimes even slight operations as on the nose, the removal of polyps, or of a spur on the septum, or an enlarged turbinate, have been found to bring relief of the symptoms of Graves' disease even in marked cases. Operations upon the tonsils have had a like effect and even shortening of the uvula has been reported as curative. A generation ago applications of iodin to the goiter were reported to have good effects. In lancing the goiter, sometimes evidently a cyst was punctured, but sometimes the lance was only followed by a slight issue of blood, yet the affection was favorably modified. More serious operations have followed by complete relief of symptoms for a time, though relapses are not infrequent and occasionally the patient was not relieved, though apparently all the conditions present were similar to those of other patients in whom the operation produced excellent results.

The medical treatment of Graves' disease demonstrates interestingly the power of suggestion. About fifteen years ago a distinguished English observer announced that he was getting good results in the treatment of Graves' disease by the administration of thyroid substance. At that time our present theories with regard to hyperthyroidization as the etiology of the affection had not been formulated, though some vague connection between the thyroid secretion and the symptoms had been accepted. A number of patients were improved by taking thyroid. Other observers found, however, that not only were their patients not improved, but they seemed to be worse as the result of the thyroid feeding. The English physician therefore was asked to say exactly how he obtained his material and prepared it for his patients. Organo-therapy was then new and it was found that the orders given to the butcher for thyroid had been filled by him according to the directions by furnishing portions of a large gland situated in the neck of the calf. This was the thymus, and not the thyroid. Thymus was then deliberately used for a while and there were some reported good successes while the treatment was new and strongly suggestive. After a time it proved to be of no avail.

A number of biological remedies were tried after this. Personally, after having made some studies of the parathyroids while in Virchow's laboratory, I resolved to try material from those glands. The first two patients to whom [{504}] the material was given, with a careful explanation of the theory on which it was administered, proceeded to obtain relief from their symptoms and an intermission in their disease. Just as soon as I purposely omitted to explain to patients how much might be expected from this new remedy and failed to make suggestions founded on the parathyroids, no improvement was noted. In the first two cases this had been more or less necessary in order to determine whether the patients could stand the doses suggested, which began very low and were gradually increased. The material seemed to have no ill effects, however, and a definite dosage could be used without the necessity of taking patients into one's confidence.

A number of serums of one kind or another were reported as beneficial for Graves' disease. It was admitted that they did not benefit all the cases, but that in certain cases they did much good. Practically all of these were strikingly more efficient in their discoverers' hands than when used by anyone else. Thyroids were removed from animals and after some time serum from these animals, supposed to be of lower thyroid content, was injected into human beings with the idea of reducing the hyperthyroidization or perhaps neutralizing it by some substance present in the serum. One very interesting observation on most of these cases deserves remark. The animals deprived of their thyroids, such as goats and sheep, lived on absolutely unhurt by the operation, and as one experimenter expressly noted, sold for more money after being kept for a year under observation than they had cost him before dethyroidization.

Most of our biological remedies for Graves' disease then are strongly reminiscent of the therapy of the affection in older times. It was particularly for Graves' disease, or at least for nervous symptoms closely resembling Graves' disease—those of fright, nervousness, irritability and tremor—that various more or less terrifying procedures and particularly deterrent substances were employed in medicine. These patients, for instance, were cured by the touch of a hanged criminal, and particularly by the touch of their goiter to the mark on his neck. It was especially for them that Usnea, the moss gathered from the skull of a criminal who had been hanged, was of benefit when administered internally. Mummy as a remedial substance remained in common use until well on into the latter half of the eighteenth century in England.

In older times a dead snake wrapped around the neck was said to be an excellent remedy for goiter and especially those cases of goiter that caused symptoms of fright and nervousness. Evidently anything that produces a strong effect upon the patient's mind may prove helpful. Perhaps the suggestion enables the mind to control the cervical sympathetic and by that means the circulation in the thyroid gland, thus lessening the amount of blood that flows through and therefore the amount of secretion that is carried out. There is no doubt but that the sympathetic is largely under the influence of the emotions and that through it very important effects may be worked out in various structures. There seems no other possible explanation for the uniformly reported success of remedies when their suggestive power is strong and their failure quite as invariably later even in the same cases.

Operations.—In recent years operations for the removal of portions of the enlarged thyroid have become popular and some very successful results have been reported. Those of us who know how easy it is to influence the minds of [{505}] patients in Graves' disease favorably hesitate as yet to pronounce definitely with regard to the indication for operation except under such conditions of pressure in the neck or projection of the eyeballs as may lead to serious symptoms. Not all the operators have been as successful as some who made a specialty of the affection. I have personal information which shows a number of unsuccessful cases after operation and the records of conservative surgeons as published indicate this. Unfortunately, a great many cases have been reported within a few months as cured; if they were comparatively without symptoms, surgical intervention is considered to have been eminently successful. For, be it noted, very few are entirely without symptoms, even after operation.

Dr. William H. Thompson in his book on "Graves' Disease" points out that even so good an operator and so thoroughly conservative a surgeon as Kocher reports cases of Graves' disease as cured, which are still exhibiting symptoms that would make the medical clinician hesitate to agree with him and, indeed, rather lead him to expect that under the stress of worry and excitement there may be redevelopment of the symptoms. As the number of cases operated upon has increased there has been a growing feeling that relapses might be expected in certain cases even after removal of large portions of the thyroid gland. The fact of the matter is that we do not understand as yet what is the underlying pathological significance of the symptoms grouped under the term Graves' disease. When there are severe symptoms, as extreme exophthalmos, greatly enlarged thyroid pressing upon the important neck structures, or serious disturbance of nutrition, an operation is always needed; but as yet we cannot be sure that it will produce even complete or lasting relief.

Many patients have been greatly benefited by operation, some of them perhaps permanently, but we need more of the after-history of these patients covering a long period of time, to be sure that the results flow entirely from the operation. There was a time when operations were reported as doing quite as much good for epilepsy as they are now for Graves' disease. As we have pointed out, a number of operative procedures that had nothing to do with the underlying basic pathology of the disease have proved the occasion for considerable improvement or sometimes what might be called a cure for a prolonged period. We can be sure, as a rule, that patients will be benefited immediately after operations. The rest, with care, the strong suggestion, the aroused feeling of expectancy, the confidence in the surgeon, all this would do much of itself. It remains to be seen how much more than this the operation does.