A few months later this same woman had to undergo a much more serious operation for multiple fibroids of the uterus and removal of the appendix. This time I advised the surgeon against the use of any purgative, and he took my remarks so seriously that he did not even allow an enema to be given. This time the patient showed no signs of exhaustion and had very few gas pains. I firmly believe that the day will soon come when a patient under operation, or a patient after childbirth, will no longer be depleted by a weakening and dehydrating cathartic and by a period of starvation, at a time when he needs all the energy he can summon.

A Question of Evacuation. Much of the misconception about constipation arises from the mistaken idea that this is a disorder of the whole intestine or at least of the whole colon. As a matter of fact, the trouble is almost wholly in the rectum. There is no trouble with the general traffic movement, but only with the unloading at the terminus. In my experience, the patient reports that he feels the fecal mass in the lower part of the rectum, but that he is unable to expel it. Examination by finger or by X-ray reveals a mass in the rectal pouch. If there is a piling up of freight further back on the line, it is only because the unloading process has been delayed at the terminus.

Meddlesome Interference. In the natural state the little human, like the other animals, empties his bowel whenever the fecal mass enters the lower portion of the rectum. The presence of the mass in the rectum constitutes a call to stool which is responded to as unthinkingly as is the desire for air in the taking of a breath. But the tiny child soon has to learn to control some of his natural functions. At the lower end of the rectum there is a purse-string muscle called the Sphincter-ani, an involuntary muscle which may with training be brought partly under voluntary control. Under the demands of civilization, the baby learns to tighten up this muscle until the proper time for evacuation. Then, if he be normal, he lets go, the muscles higher up contract and the bowel empties itself automatically, as it always did before civilization began.

Just as people often find it hard to let go the bladder muscle and urinate when in a hurry or under observation, and just as an apprehensive woman in childbirth tightens up the purse-string muscle of the womb, so the little child, or the grown up who catches the suggestion of difficulty in the bowel movement, loses the trick of letting go. Instead of merely exercising control by temporarily inhibiting the function, he tries to carry through the process itself by voluntary control—and fails. Constipation is a perfect example of the power of suggestion, and of the troublesome effect of a fear-idea in the realm of automatic functions.

Food and Constipation

Once the sense of power comes, once the mind forgets to be doubtful or afraid, then the old automatic habit invariably reasserts itself. Meddlesome interference may throw the mechanism out of gear, but fortunately it cannot strip the gears. Constipation is an inhibition or restraint of function, but is never a loss of function. No one is too old, no one is too fixed in the bad habit to relearn the old trick. I have had a good many patients with chronic constipation, but I have never had one who failed to learn. Real conviction speedily brings success, and in many cases success seems to outrun conviction. So efficient is Nature if she has only half a chance!

A Fifty-year Habit. Another old lady was not quite so easily convinced. She ridiculed the idea that her son of fifty, who had been "constipated in his cradle" could be cured of his lifelong habit, but he was cured. As long as there is life and the light of reason, so long may Nature's functions be reëstablished.

A Record History. When Miss H. first came to my house, she told a story that was almost incredible. She said that for many months she had been taking eight tablespoonfuls of mineral oil three times a day besides a cathartic at night, and an enema in the morning. No wonder she was a little dubious over such mild treatment as mine seemed to be!

Constipation was only one of this young woman's troubles. She could not sleep and was so fatigued that she believed herself at the end of her physical capital. When she first came to me she had tears in her eyes most of the time and used to confide to various people that she was sure she was a patient that I could not cure,—a very common belief among nervous invalids! She was sure that I did not understand her case, and that she could not get anything out of this kind of treatment.

Living up to a Suggestion. Mrs. T. had not had a natural movement of the bowels in twenty-five years. After the birth of a child, twenty-five years before, her physician had told her that her muscles had been so badly torn in labor that they could not carry through a natural movement. After that she had never gone a day without a pill or an enema. I explained to her that when any muscle of the rectum is injured in childbirth, it is the sphincter-ani, and that since this is the muscle whose contraction holds back the bowel content, its injury would tend to over-free evacuation rather than to constipation. She saw the point and within two or three days regained her old power of spontaneous evacuation.

1 Eat three square meals a day.

2 Drink when thirsty, having conveniently at hand the facilities for drinking.

3 Heed the call to stool as you heed the call of hunger. When the stool passes the little valve between the upper and lower portions of the rectum, it gives the signal that the time for evacuation has come. If this signal is always heeded, it will automatically start the machinery that leads to evacuation. If it is persistently ignored because one is too busy, or because the mind is filled with the idea of disability, the call very soon fails to rise to the level of consciousness. The feces remain in the rectum, and the bad habit is begun.

4 Choose a regular time and keep that appointment with yourself as regularly as possible. In all the activities of Nature, there is a rhythm which it is well to observe.

5 Take time to acquire the habit. Do not be in a hurry. Do not strain. No amount of effort will start the movement. Just let it come of itself.

Summary

If you would have in a nutshell an epitome of the truth about constipation, indigestion, insomnia, and the other functional disturbances common to nervous folk, you can do, no better than to commit to memory and store away for future reference that choice limerick of the centipede, which so admirably sums up the whole matter of meddlesome interference:

"Since the War." Nothing is quite the same since the war. Among other things we have learned that many of our so-called handicaps were nothing but illusions,—base libels on the female body. Under the stern necessity of war the women of the world discovered that they could stand up under jobs which have until now been considered quite beyond their powers. Society girls, who were used to coddling themselves, found a new joy in hard and continuous work; middle-aged women, who were supposed to be at the time of life when little could be expected of them, quite forgot themselves in service. Ambulance drivers, nurses, welfare workers, farmerettes, Red-Cross workers, street-car conductors and "bell-boys," revealed to themselves and to the world unsuspected powers of endurance in a woman's body. Although some of the heavier occupations still seem to be "man's work," better fitted for a man's sturdier body, we know now that many of these disabilities were merely a matter of tradition and of faulty training.

"Nerves" Again. Despite the organic disturbances which may beset the reproductive organs, and despite the havoc wrought by venereal diseases, it may be said with absolute assurance that the majority of feminine ills are the result neither of the natural frailty of the female body, nor even of man's infringement of the social law, but are the direct result of false suggestion and of false attitudes toward the facts of the reproductive life. The trouble is less a difficulty with the reproductive organs than a difficulty with the reproductive instinct. "Something wrong" with the instinct is translated by the subconscious mind into "something wrong" with the related generative organs, and converted into a physical pain.

That this relation has always been dimly felt is shown by the fact that the early Greeks called nervous disorders hysteria, from the Greek word for womb. It is only lately, however, that the blame has been put in the right place and the trouble traced to the instinct rather than to the organs of reproduction.

No one who thoroughly knows human nature would attempt to deny that woman is as strongly endowed as man with the great urge toward the perpetuation of the race, or that she has had to repress the instinct more severely than has man. The man insists on knowing that the children he provides for are his own children. Whatever the degree of his own fidelity, he must be sure that his wife is true to him. Thus has grown up the insistence that, no matter what man does, woman, if she is to be counted respectable, shall control the urge of the instinct and live up to the requirements of continence set for her by society.

Young men are not so often taught to repress, but neither are they taught to swing their vital energies into altruistic channels through sublimation. Since the woman of his class will not marry him until he has money, the young man too often satisfies his undirected instincts in a commercial way. The statistics of venereal diseases prove that here, as elsewhere, goods subject to barter are subject to contamination. In a late marriage, too often a contaminated body accompanies the material possessions which the standards of society have demanded of a husband.

The Menstrual Period

Potential Motherhood. Among the normal phenomena of a woman's life is the recurring cycle of potential motherhood. Every three or four weeks a new ovum or egg matures in the ovary and undergoes certain chemical changes, which send into the blood a substance called a hormone. This hormone is a messenger, stimulating the mucous membrane of the womb into making its velvet pile longer and softer, and its nutrient juices more abundant in readiness for the ovum.

During sleep the social inhibitions are felt less distinctly and the sleeper dreams love-dreams woven from messages coming up from all the minute nerve-endings in the expectant reproductive organs. But if no germ-cell travels up the womb-canal and tube to meet and impregnate the ovum, the womb-lining rejects the egg as chemically unfit. All the furbishings are loosened from the walls and slowly cast out, constituting the menstrual flow. The phenomenon as a whole is a physiological function and should be accompanied by a sense of well-being and comfort as is the exercise of any other function, such as digestion or muscular activity. Only too often, however, it is dreaded as an unmitigated disaster, a time for giving up work or fun and going to bed with a hot-water bottle until "the worst is over." Let us see how this perversion comes about.

This recoil of fear interferes with the circulation in the functioning organs, just as fear blanches the face or hinders digestion. There is several times as much blood in the stomach when it is full of food as there is between meals, but we do not for this reason fancy that we have a pain after each meal. There is more blood in the generative organs during their functioning, but this means pain only when fear ties up the circulation and causes undue congestion. Fear acts further on the sturdy muscle of the womb, tying it up into just such knots as we feel in the esophagus when we say that we have a lump in the throat. It is safe to say that ninety-five cases of painful menstruation out of every hundred are caused by fear and by the expectation of pain. The cysts and tumors responsible for pain are so rare as to be fairly negligible, when compared with these other causes.

Sometimes before the period begins, a girl feels blue and upset for a day or two, a sign that the instinct is getting discouraged. The whole body is saying, "Get ready, get ready," but it has gotten ready many times before, and to no purpose. Unsatisfied striving brings discouragement. What reaches consciousness is a feeling of pessimism and a general dissatisfaction with life as a whole. If, instead of giving in to the blues or going to bed and predicting a pain, the girl finds other outlets for her energy, she finds that after all, her instinct may be satisfied in indirect ways and that she has strangely come into a new supply of vim.

The Ounce of Prevention. If young girls had wiser counselors in their mothers and physicians, the misconception would never occur, and such an indirect outlet would not be needed; the organic sensations incident to puberty and the recurring menstrual period would have something of the significance of the annunciation to Mary, bringing wonder and a sense of well-being.

When your little daughter arrives at maturity, give her a joyous initiation into the noble order of women. She will welcome the new function as a badge of womanhood and as a harbinger of wonderful things to come.

The result of this confidential talk may seem fanciful to any one but an eye-witness. We had only a week's association, but the depression ceased, the furtive look and deprecatory manner were replaced by a joyous buoyancy. In a few weeks the thin neck and awkward body rounded out into the symmetry which usually precedes the establishment of puberty, but which was delayed in this case until the unconscious conflict resolved itself.

The "Change of Life"

Another Phantom Peril. As the young girl is taught to fear the menstrual period, so the older woman is taught to dread the time when the periods shall cease. Despite the general enlightenment of this day and age, the menopause or "change of life" is all too frequently feared as a "critical period" in a woman's life, a time of distressing physical sensations and even of danger to mental balance.

As a matter of fact, the menopause is a physiological process which should be accomplished with as little mental and physical disturbance as accompanies the establishment of puberty. The same internal secretion is concerned in both. When the function of ovulation ceases the body has to find a new way to dispose of the internal secretion of the ovary. Its presence in the blood is the cause of the sudden dilatation of the blood-vessels that is known as the "hot flash."

One source of trouble in the menopause is that it comes at a time in a woman's life when she is likely to have too much leisure. In no way can a woman so easily handicap her body at this time as by stopping work and being afraid. Those women who have to go on as usual find themselves past the change almost before they know it,—unless they consider themselves abused, and worry over the necessity for working through such a "critical time."

Three Rules. Here are a few pointers which have have been of help to a number of women:

1 Remember that this is a physiological process and therefore abundantly safeguarded by Nature. If you don't expect trouble you will not be likely to find it.

3 Do everything in your power to keep from the public the knowledge that you are no longer a potential mother. If you are past forty, do not mop your face or gasp for breath or carry a fan to the theater! Shun attention and fear, and you will be surprised at the ease with which the "change" is effected.

Nature's Last Chance. While we are on the subject of the middle-aged woman, it may be well to mention a phenomenon sometimes noticed in the early forties. Often an "old maid" who has considered herself settled for life in her bachelor estate, suddenly takes to herself a husband. (I use the verb advisedly!) Mothers who have thought their child-bearing days long past sometimes find themselves pregnant. "The child of her old age" is not an uncommon occurrence. Unmarried women who have "kept straight" all their lives sometimes go down before temptation at this late time. There is a reason. It is as though Nature were making a last desperate attempt to produce another life before it is too late, speeding up all the internal secretions and flashing insistent messages throughout the whole organism.

Other Troubles

A skilled surgeon can cut almost anything out of a person's body, but he cannot cut out an instinct. It sometimes takes great skill to determine whether the trouble is an organic affection or a functional disturbance caused by the misdirected instinct of reproduction. Often, however, the clinical pictures are so different as to leave no room for doubt, provided the diagnostician has his eyes open and is not over-persuaded by the importunity of the poor neurotic, who insists that the surgeon shall remove her appendix, her gall-bladder, her genital organs, and her tonsils, and who finally comes back that he may have a whack at the operation scar.

As it happened, this young woman and her husband came to call on me one afternoon just before the baby was expected. During the visit she began to show signs of being in labor. Again she was in terror. Again I explained the phenomena of labor, telling her that the womb-contractions are caused by the presence in the blood of a chemical secretion (hormone) which continues its good work as long as there is a state of confidence, but which sometimes stops under fear or apprehension. I explained that these womb-efforts are a peristaltic movement, a contraction of the upper muscles and a letting go of the purse-string muscle at the mouth of the womb, and that fear only tends to tie up this purse-string muscle, making a difficult process out of one which was intended by Nature to be much more simple. She seemed to understand and to lose a good deal of her fright.

I give this account for what it is worth, without of course contending that labor could always be as easy as this. It happened that this girl was a normal, healthy woman and that there were no complications of any kind in the process of childbirth. A right attitude of mind could not have corrected any physical difficulty, but it did seem to help her let go of her fear, which would of itself have caused long and painful labor.

A patient once told me that when her first baby came, she happened to be out in the country where she had to call in a doctor whom she did not know. He was an uncouth sort of fellow who inspired fear rather than confidence. She soon found that labor stopped whenever he came into the room, and started again when he went out. She had the good sense to send him out and complete her labor with only the help of her mother. Unfortunate is the obstetrician who does not know how to inspire a feeling of confidence in his patients. Even childbirth may be mightily helped or hindered by the mother's state of mind.

A woman's body has more stability than she knows. It is sometimes out of order, but it is more often misunderstood; usually it is an unobtrusive and satisfactory instrument, quite fit for its daily tasks. The average woman is really well put together. We hear about the ones who have difficulty, but not about the great majority who do not. We notice the few who are upset during the menopause, and forget all the others. To be comfortable and efficient most of the time is, after all, merely to be "like folks."

The special functions which Nature has been perfecting in a woman's body are as a rule, easily carried through unless complicated by false ideas or by fear.

If the woman who has no organic difficulty but who still finds herself handicapped by her body, will cease being either resigned to her languishing lot or envious of her stalwart brothers; if instead she will set out to learn how to be efficient as a woman, she will find that many of her ills are not the blunders of an inefficient Creator, but are home-made products, which quickly vanish in the light of understanding.