All physicians are convinced of the good that has been done by the extension of the application of surgery to women's diseases during the pest generation. On the other hand, there are probably very few, except the ultra-specialists, who are not quite sure that there has been too much surgery in gynecology, and that many a woman has been operated on without sufficient reason and without definite indications. In suitable cases surgery is sometimes life-saving and is often the only means of relief for suffering that is seriously disturbing the general conditions and is making life unbearable. Its very possibilities of good, however, have led to abuses. From the abuse of a thing, the old Latins used to say, no argument against its proper use can be derived, and this is eminently true of gynecological surgery. It will not belittle the great benefit that operative work has been to state how much of auxiliary good may be accomplished by the use of psychotherapy in gynecology.
Many a woman who is operated on is benefited only for the time being, and her old symptoms return after a time. Dr. Goodell, one of our first great gynecologists, used to warn his students insistently that women had many organs outside of the pelvis. The individuality in gynecology is extremely important. Some women suffer what they describe as excruciating pain or unbearable torture from pathological conditions that other women do not notice at all. Very often these women either have no real interest in life and are so self-centered that they emphasize their feelings by dwelling on them, or else their attention has been attracted to some sensation not necessarily pathologic and then by concentration of mind on it they so disturb vasomotor conditions and the nutrition of nerves that the condition does become a veritable torture and apparently demands surgical intervention. It is possible to cause a hyperemia in the skin by thinking about certain portions of it, and the genital organs are particularly prone to be influenced by mental states. If for any reason a woman gets her mind on her genital tract and becomes persuaded that there is a pathological condition in it, symptoms will develop until an operation seems inevitable. But the operation will bring relief only for a while, and then her mind will find something else to dwell on and produce similar symptoms.
Place of Psychotherapy.—To fail to try to sway the mind by all the methods and auxiliaries outlined in the earlier chapters of this work before suggesting an operation to a woman is to neglect a most important means for relief in many gynecological cases. There is scarcely any pathological condition from which women may suffer that does not become worse as the result of the depressing influence of much thinking about it, and that is not made better by a change in their mind that makes them realize the possibility of being well again. The most important preliminary to operation is the promise of complete relief through surgery. The acme of suggestion is reached in the preparation for operation with its constant encouragement and then the congratulations after the operation. Then come the weeks of convalescence during which the same strong suggestion is constantly at work making the patient sure that she must be better. All this serves to add tone to the system, invigorates the appetite and puts patients in the best possible mental attitude to bring about a favorable result. Indeed, the ten or fifteen pounds in weight that such patients gain during their convalescence, especially when they have been under weight before, is often the most beneficial result of their hospital experience.
If the same patients had been given the same promise that they would surely be cured, and then had been removed from depressing home influences and bothersome trials and labors, and been told that what they needed for complete recovery was to gain in weight; if they had then been visited by friends who congratulated them on the fact that now at least they were going to be better and their symptoms were going to disappear, and if they had gained the fifteen pounds that came in convalescence after their operation, most of them would have recovered quite as completely as by the operation from many of their vague gynecological difficulties. This is, of course, true only of cases where there are not very definite indications for surgical intervention. But in a certain number the symptoms are so vague that operation is decided upon rather with the hope than the assurance of benefit; and it is particularly in these that psychotherapy is useful and must be given a thorough trial.
Pain Relief.—It is often set down as a maxim of gynecologic practice, that pain which cannot be relieved except by recourse to dangerous or habit-forming drugs is an indication for operation. Pain, however, is a relative matter and, as we have shown in the chapter on Pain, its intensity depends not a little on the patient's attitude of mind towards it. When there is discouragement and depression, pain becomes insufferable, and what was borne quite well at the beginning may now prove intolerable. Whenever occupation of mind can be secured, however, pain is diminished in intensity.
Reputed Remedies and Suggestion.—Probably the most striking indirect testimony to the value of mental influence and especially of frequently repeated suggestion in gynecology is found in the recent history of various much-advertised remedies that have been sold in enormous quantities for all the ills of women. The composition of these remedies is not, as is popularly supposed, a great mystery. They have all been analyzed and their ingredients are well known. As a rule, they contain only simple tonic drugs that have absolutely no specific effect on the genital organs, but that are stimulating to the general system. There has been much surprise at the definite evidence {432} furnished by expert investigators, that the principal ingredient in most of them—certainly their most active element—is the alcohol they contain, which, until the passage of the pure food and drug law, was in such considerable quantities that practically each tablespoonful of these favorite remedies for women was equal to half an ounce of whisky. No wonder that this gave an immediate sense of well-being which rose in most of those unused to alcohol to a feeling of exaltation. The patient was sure beyond contradiction that she could feel the effects of the medicine! Of the after effects, the less said the better, but there is no doubt that many women acquired the alcohol habit through indulgence in these nostrums.
Illusory as was this sense of well-being, it sufficed in many cases to relieve women of discomfort that had become so serious, to their minds at least, that they feared an operation would be necessary. Undoubtedly many of the testimonials given to such remedies are founded on actual experiences of this kind in which patients were sure that they were cured of serious ills. Where alcohol is not the chief ingredient of these remedies, some other tonic stimulant is employed, and it has proved sufficient to make the patients feel, or at least suggest to themselves, that they must be better. This has given them courage to take more exercise and get more out into the air, and consequently relieves them of many physical symptoms that had developed because they thought they were the subjects of some serious ailment and must be solicitously careful of their health. The idea of care for the health in many persons' minds seems to be to do as little as possible of external, useful work and to occupy themselves principally with their internal concerns. They stay in the house too much and in so doing disturb nearly every physical function. Perfectly well people, if confined with nothing to interest them, become short-circuited on themselves and develop all sorts of symptoms, physical and mental.
The Mind as a Factor in Gynecological Affections.—A gynecologic incident of any kind may become to many women such a center of attention that it is impossible for them to distract their minds from it, and every symptom or feeling that can by any stretch of thought be connected with the genital system becomes greatly exaggerated. Young women, whose menstruation has been perfectly regular, may have it disturbed by fright, grief, a change of environment, getting the feet wet, or something of that kind. At immediately succeeding periods their fear of bad effects will of itself influence unfavorably the conditions in their genital system. They have always had more or less discomfort, but now this discomfort becomes difficult to bear because of the fear that there may be further serious consequences of the disturbing incident in their menstrual life. It occupies all their attention; instead of deliberately trying to disregard it, they fear that, if they should do so, they would be allowing some progressive condition to gain a hold on them which would lead to serious results.
One is apt to see this condition in young married women who have had a miscarriage in their first pregnancy and who fear that there will be serious results from it. If they have been much disturbed by the miscarriage, they may lose in weight, and then a number of subjective symptoms in their genital life will appear. Though their menstruation appears regularly, lasts the usual time, and is neither more scanty nor more profuse than before, and {433} though their physical conditions are normal as ever, they suffer from bearing down pains and feelings and backache just before menstruation begins; their ovarian regions become sensitive and, if they are constipated, their right ovarian region is likely to become tender, and they develop a set of symptoms that seems to call for surgical interference. If, however, they are put in conditions where they have some other occupation besides themselves and their ills, it is surprising how the case will clear up. They gain in weight, their subjective symptoms disappear and especially they lose the persuasion, so common among them, that any betterment of their symptoms is due to their getting used to the pathological condition present and not to any real improvement of it.
Treatment.—In the treatment of gynecological conditions such as are not necessarily indications for operation, the most important consideration is to reassure the patient's mind and secure the discipline of self-control. If patients are under weight this condition must be corrected. If they are in an unfortunate environment it must be modified, as far as possible. If they are without occupation this must be provided for them. Dominant ideas and morbid auto-suggestion must be overcome—not always an easy task, yet always possible if patience, tact, and skill are exercised. They must be made to realize that the women of the past, before the development of modern gynecology, not only lived useful lives without any of the modern gynecological operations, but that most of them were quite happy in so doing. Even though many of them had physical symptoms, the lack of unfavorable suggestion as to the significance of these prevented mental exaggeration, and morbid dwelling on them was not allowed to produce such a deterioration of the physical condition as to emphasize the pathological conditions. This does not mean that women may not have to be operated on, and, when that is necessary, the operation should be determined on and performed with no more delay than is proper to put the patients into suitable physical condition. But many operations that are undertaken without definite indications merely because the women complain, and it is hoped that an operation will somehow prove of relief, would be replaced with much more final satisfaction and relief by properly directed psychotherapy.
There are many minor pathological conditions such as slight cystic enlargements, hyperemias with tenderness, slight displacements of the ovary, slight dislocations of the uterus or twistings of it that can often be successfully treated the same way. After all, what is considered the normal condition of the feminine internal organs is only an average reached from observation and many deviations from this average cannot be considered abnormal. Many a woman living practically without symptoms, or certainly without such symptoms as to justify an operation, has pathological conditions of her internal organs worse than those for which operations are sometimes suggested because over-sensitive women complain of their symptoms. The rule must be first to relieve the over-sensitiveness and then to determine whether an operation is necessary or not. Pain alone, unless it is of a disabling character or reacts upon the physical health, is not a sufficient indication for operation.
One does not need to be a physician to be familiar with the curious psychic states which develop or are accentuated during the menstrual period. Practically all the peculiarities of the individual are emphasized at this time and if there are any special neurotic conditions or psychic anomalies these become quite marked. All the dreads, for instance, are more noticeable at this time. Women who at all times feel uncomfortable on looking down from a height are likely at this time to be quite overcome by fear and be unable to approach any position from which they might look down for a distance. Women who are afraid of horses, yet conquer their dread sufficiently to ride behind them, cannot do so, or only with great difficulty, during the menstrual period, and the same is true of the dread of cats or other animals. Misophobia, the dread of dirt, may be particularly emphasized at this time and servants are puzzled as to what has come over a woman who was not so punctilious in the matter a short time before.
Irritability.—Dr. Charcot, the famous French nerve specialist, used to say that for a day or two before menstruation and during the first day or two of their period many women were not quite responsible. This is not merely an exaggeration of French contempt for women, for Möbius, the distinguished German neurologist, insisted that there is a certain physiological mental disturbance with distinct hampering of the faculty of judgment (Schwachsinn) normally associated with menstruation.
Few physiologists or gynecologists agree with these extreme views, but there is no doubt that many of the troubles which business men experience with women in their employ begin with hasty words spoken at these periods when the real reason for the irritability is not known. The consciousness of this on the part of some women saves them from much undesirable friction by making them more careful at these periods. Many a domestic misunderstanding begins at these times and is unfortunately allowed to continue because the real reason for it—the instability of disposition due to menstruation—is not recognized.
Lack of Inhibition.—There is no doubt that, except in women of the most stable physical and psychic character, a notable lack of inhibition characterizes all their actions at this time. To think that this is universal, however, would be a mistake. Healthy women deeply occupied with something they like often pass through menstruation absolutely undisturbed, and this is particularly true of the mothers of families. In spite of its exaggeration, it is well to keep the great French specialist's expression in mind, for it helps to explain many things that produce much suffering in the world. This is particularly true now that women are working more and more out of their homes at occupations which often make strenuous calls on them just at periods of the month when they should have more rest than usual. The consequence often is the development of a highly neurotic condition in which psychic {435} symptoms are likely to be prominent as well as a tendency to exaggerate the significance of their feelings which is disturbing to the patient and may even disturb the physician.
Exaggeration of Sensitiveness.—The most striking feature of this is the tendency to exaggerate the meaning of physical symptoms which they have often borne with for a good while without much inconvenience, but which now appeal to them as of serious significance. Any uncomfortable feeling is likely to be dwelt on to such an extent as to be called an unbearable ache or even an excruciating pain, and the patient is prone to connect it with some serious pathological process in the region in which it is felt. If a woman has been reading about some special ailment, or, above all, has been listening to the tale, usually neither plain nor unvarnished, of a friend's medical woes, she is almost sure to think that there must be something seriously wrong with herself. Many a supposed chronic indigestion had its origin in nothing more than the uncomfortable feelings in the stomach region during menstruation, which call attention to that organ and then, by morbid introspection, lead to the exaggeration of various sensations that have always been present but have hitherto been disregarded.
It is a good rule to neglect symptoms that develop during the menstrual period and not to treat them directly until it is plainly seen that they persist afterwards; for symptomatic treatment at this time will cause an over-attention to the condition. And we should be careful not to suggest to a woman at this time that her symptoms may be due to some pathological condition in an important organ. Such a suggestion will almost surely be accepted seriously and dwelt on so much as to become an auto-suggestion that may lead to the disturbance of the function of the organ in question because of the surveillance over it. The diagnosis must be put off until menstruation is over in order that the exaggeration of this period may be eliminated. If this were more commonly done and if women were advised to counteract their feelings at this time as far as possible by occupations of interest to them, there would be much less need of medication. As between rest and strenuous work during the menstrual period, work is probably always the better. Rest with nothing to do emphasizes morbid introspection to such a degree as to make even ordinary feelings unbearable.
Symptomatic Conditions.—It is interesting to note how often affections that are always present give symptoms only during the menstrual period or just before it. Many women, however, suffer considerably about the time of the menstrual period from an extremely tired, painful condition of the leg below the knee which is really due to flatfoot. At other times it gives them little annoyance. Old dislocations and sprains are particularly likely to give bother at this time. All the occupation pains and aches are emphasized. Tiredness becomes a torment. This extreme over-sensitiveness extends to physical ills of all kinds, even those that are trivial. For instance, corns and bunions become almost unbearable, especially if there is any change of the weather with moisture in the air about the time of menstruation. Teeth become sensitive and often will ache when there is little that the dentist can find the matter with them. Women are often suffering from teeth that are supposed to be quite intractable because of over-sensitiveness, while in reality it is only at these certain times that the over-sensitiveness is present.
Over-reactions.—Even habitual actions which are accomplished without much difficulty at other times are likely to be a source of annoyance about this period. If a young woman has to call out figures or read off lists of names, she soon becomes hoarse, her voice becomes husky and it requires more effort to accomplish her work than at other times. Complaint of sore throat is common about this time, and if there have been any recent changes in the weather this is almost sure to be a premonitory symptom of menstruation. Singers and elocutionists are likely to find their occupations particularly trying at this time and actresses are seldom without considerable physical discomfort that makes playing difficult and unsatisfactory. This happens in all occupations requiring frequently repeated use of particular muscles. Piano-players and typewriters find that their fingers become sensitive at this time. This sensitiveness of the ends of the fingers may become so marked as to prevent these usual occupations, or at least may require their limitation.
Physical Basis of Psychic States.—The physical basis of these troubles is probably more responsible for them than has been thought, though the mental state renders the individual more susceptible to annoyances of any and every kind. Careful weighing seems to show that there is a gain in weight amounting sometimes to three to five pounds toward the end of the menstrual month. This is accompanied by a sense of fullness that is perhaps an actual plethora, as if nature were manufacturing a superabundance of blood in anticipation of the loss. This produces a systemic hyperemia. It is well known that hyperemic areas are more sensitive than tissues in ordinary condition and this seems to be the case in menstrual life. This renders the nervous system more active and irritable and the nerve endings more sensitive. With the menstrual loss this physical condition is relieved and then there is a return to normal with a loss of weight only partly due to the actual blood loss and somewhat to increased excretion in perspiration, in transpiration through the lungs and through all the emunctories.
Treatment.—To know that these psychic disturbances are likely to occur at the time of menstruation is to be prepared for them so as to lessen their effect upon one's self and others. They are much relieved by this frank recognition and the patient understands that with the betterment of the psychic condition by such reassurance the physical symptoms are lessened. Many a woman gives up her occupation at such times who would be much better if she bravely clung to it and resisted the temptation to be moodily occupied with her condition. Above all, she needs to be in the air. Oxidizing processes within the body are slower and while much exercise is not beneficial and may be often harmful, riding in the air, sitting in the air, above all, sleeping where there is an abundance of fresh air is all-important. Every form of exertion will be reflected in increased irritability. Shopping, balls and parties will disturb the woman's mental equilibrium and make it more difficult for her to stand whatever physical discomforts she may have, and also make it hard for her to pursue her ordinary occupation if this is somewhat exacting. Even these, however, must not be given up if the sacrifice involves the throwing of the patient back on self and increases introspection. Diversion of mind and temporizing with symptoms are the basis of therapy at the menstrual period.
No feature of menstrual difficulty shows so clearly the influence of the mind over bodily function, and especially over those genital functions that are supposed to be involuntary and spontaneous, as amenorrhea. Almost any kind of mental trouble may produce a cessation of the menstrual functions. Profound grief or a severe fright nearly always does. Every physician of large experience has seen cases of women who have missed their period because they were disturbed by a fire, or a runaway, or an automobile or railroad accident within a short time before their menstruation should normally occur. Even slighter shocks may have a similar effect, and a profound shock of any kind will seriously disturb menstruation. The most frequent effect is to inhibit it, but it may be anticipated or delayed, and where there is a tendency to too profuse a flow, it may produce menorrhagia.
Every physician knows that much less serious mental influences than a profound shock or fright may somewhat disturb menstruation and, in young women at least, this disturbance is nearly always in the direction of lessened flow and amenorrhea. Home-sickness, for instance, will often have this effect. Many of the foreign-born domestics who come to this country have serious disturbances of their menstrual flow, usually a diminution, during the first three or four months after they arrive in America. This may, of course, be due in part to change of climate, change of food and change of habits of life. These girls while in their European homes have often been accustomed to be much more out of doors and to have more exercise in the open air than they have here.
That the mental state has much to do with menstruation may be appreciated from the fact that serious changes of her state of life may be accompanied by amenorrheal symptoms even when the patient stays in the same climate and under conditions not different physically from those under which she has lived. Country girls who come to the city often suffer from such symptoms. Young women who enter convents sometimes have these symptoms for some months, and this is so well recognized as to be expected in a certain number of cases. Indeed, there is danger that it should be attributed too much to the change of mental state, and that other factors, such as incipient tuberculosis, or disease of the ductless glands, or anemic states, which are responsible for it, may fail to be appreciated because of the ready explanation afforded by the mental factor. General experience shows that the attitude of mind of a patient toward menstruation, the expectancy of it at a particular time, and a good general physical condition that predisposes to it, are quite as important for its regularity as the specific physiological conditions which naturally bring it about.
Fright and Amenorrhea.—Fright particularly may disturb menstruation in many ways. Occasionally the disturbance of menstruation consequent upon shock lasts for months or even years. At times when a woman between thirty-five and forty is seriously frightened, especially by terror that endures {438} intensely for some hours, the sort that is said to blanch the hair in a single night—and there are well-authenticated instances—menstruation never recurs or if it does recur it is vicariously from some other portion of the body than the genital tract. Among my notes is a case of a woman frightened by a revolver which a maniac had flourished for hours at her while she dared not make a move nor a sign. Her menstruation stopped completely for a time and then came back irregularly and usually from the ear. The bleeding was from the pierce in the lobule which had been made for earrings, and before it started a large swelling of this would come on in the course of an hour, often not subsiding for days. In another case a woman who was frightened during menstruation by an insane person flourishing a knife near her had for several years after an extremely irregular menstruation, and usually only the molimina in the genital tract, while the bleeding was from the nose. Deep emotion can very seriously affect menstruation.
Pseudocyesis.—The mind may bring about a cessation of menstruation in another way without any other factor interfering and in spite of the fact that physiological conditions would all seem to be favorable to its regular occurrence. We have many cases in medical literature in which married women anxious to have children have concluded that they were pregnant, and have had complete cessation of their menstruation for months with all the symptoms of beginning pregnancy, so as to deceive even careful physicians. The best known historical instance is that of Queen Mary, the eldest daughter of Henry VIII of England, who, nearly forty when she married Philip II of Spain, was very anxious to have children. Not long after her marriage menstruation stopped and all the ordinary symptoms of beginning pregnancy developed. Her condition was widely heralded throughout the kingdom; then, after a time, to the intense disappointment of the Queen and her friends, it proved that she was not pregnant but that her mental attitude had produced the series of symptoms that proved so deceptive. These cases of pseudocyesis are so likely to occur that a physician in dealing with a woman, who being rather well on in years when she marries is anxious to have children, must be on his guard and he must always take into account the possibility of a pseudo-pregnancy and must be careful not to be deceived by symptoms that would ordinarily indicate beyond doubt the beginning of pregnancy. Even experts have been deceived in such cases, and it is in them that accurate rules for the certain detection of pregnancy are most needed.
These symptoms have reference not only to the uterus, but also at times to other organs. They are not merely subjective, but sometimes become so objective as almost to demonstrate the diagnosis of pregnancy, and yet a mental condition is the only source of the changes. For instance, cases of false pregnancy have been reported in which, besides the gradual enlarging of the abdomen with many of the signs of pregnancy accompanying that phenomenon, there has been an enlargement of the breasts and even the secretion of milk. In a few cases the enlargement of the abdomen has been accompanied by pigmentation and the areola of the nipple has also become pigmented. This is not surprising, since corresponding changes take place in connection with fibroid tumors, and the deposit of pigment is not a symptom of pregnancy, but only a result of the congestion which takes place in these structures during their enlargement.
Amenorrhea from Dread.—In some cases all the symptoms of pregnancy develop, or at least there is complete cessation of menstruation, as a consequence of nervousness and dread of the occurrence of pregnancy. Unmarried women who fear that they may have become pregnant by indiscretion, sometimes become so worried over their condition that, without any physiological reason, they miss one or more periods and thus add to their nervous state and further inhibit menstruation, though usually two months is the limit of such amenorrhea and the menstrual flow commonly makes its reappearance shortly before or after the time of the third period. Occasionally, however, in the case of anxiously expectant married women further symptoms of pregnancy may appear and the case becomes more complicated. Every physician of considerable experience has seen such patients, and doubtless much of the harvest which advertisers reap from drugs that are supposed to produce abortion comes from nervous young women who are not really pregnant, but have inhibited their menstruation by worry, and who take these medicines with confidence and have the menstrual flow restored by trust in their efficacy.
Ductless Gland Disease.—Of course, in many cases of amenorrhea there are serious underlying constitutional conditions which may or may not be amenable to treatment, but the possibilities of which must always be thought of. One case of amenorrhea I saw in recent years proved to be due to a beginning acromegaly. There was no sign of enlargement of the hands, though there had been a coarsening of the face which was attributed to growth and to the fact that the girl was taking much horseback exercise in all weathers. She had a headache for which no remedy seemed to be of any avail, and when the amenorrhea developed it was naturally thought that the headache must be due to gynecologic conditions. Nothing was found on investigation, however, and eventually the gradual development of the symptoms of acromegaly showed what was really the basic cause. Occasionally diseases of other ductless glands, as the thyroid, may have amenorrhea as one of the first symptoms. It is seldom that any serious thyroid condition develops without disturbance of menstruation, but this is less frequently in the direction of diminution than toward profusion and prolongation. In some cases, however, one or more periods is missed in the early development of the disease. In this, however, others of the characteristic tripod of symptoms—rapid heart, tremor, exophthalmes—are sure to be present even though the enlargement of the thyroid is not noticeable.
Tuberculosis.—But more important than these causes of amenorrhea is the early development of tuberculosis. In some cases, even before there is any cough that calls attention to the condition, or when the cough has been considered to be one of those myths now fortunately passing, "a cold that hangs on," the cessation of menstruation may depend entirely on the weakness and anemia due to the growth of tubercle bacilli in the lungs.
Inanition Amenorrhea.—Sometimes indigestion, or what is supposed to be indigestion, may be at the root of the amenorrhea. In many cases it really is not true indigestion that is present, but a disinclination for food which has increased to such a degree as to bring about a lowered state of nutrition. In nervous young women and, above all, in nervous spinsters beyond forty, disturbances of menstruation consequent upon lack of nutrition are not infrequent. Often their indigestion is considered to be a reflex from their genital {440} organs, when, on the contrary, whatever disturbance of their genital organs is present is due to the inanition which has developed because they have not been eating enough. Many of these women literally starve themselves, and they, must be persuaded to eat once more and taught what to eat, and their weight must be watched until it gets up to what is normal for their height.
Psychotherapy and Treatment.—The treatment of amenorrhea on psychotherapeutic principles will be readily understood from the fact that there is a distinct psychic element in practically all the cases touched on in this chapter. This psychic element is generally appreciated and admitted. If a woman is accustomed to connect certain physical incidents with disturbances of menstruation, then those disturbances are almost sure to recur. As a rule, many an incident said to be disturbing to the function would probably have no influence upon it but for the dread connected with it and the anticipation of some interference. In all cases of amenorrhea, then, the patient's mind must be put into a favorable state and suggestions must be made that will lead to the expectancy of menstruation at the next regular period. If the mind can cause menstruation to cease, as is clear from experience, any inhibition from this source must be removed and its power set to bring relief to these patients. Drugs should not be neglected, and general physical conditions must be improved, but if the patient's mind continues to be unfavorably affected towards her menstruation, its satisfactory return will be delayed until somehow mind as well as body are co-ordinates for the resumption of the function.
The best testimony to the value of psychotherapy in amenorrhea is found in the success of many of the remedies used for the condition, which, in the successive phases of medical development, have included all sorts of home treatments, many types of quack medicines, and innumerable proprietary combinations. Many of these have acquired a reputation for efficacy not justified by any direct pharmaceutic effects which we now know them to possess. From the familiar gin and hot water, through the various combinations of aloes and the tonic remedies of a later time, only the most general and obvious effects could have been produced by the medicines, yet apparently specific reactions have followed them in the menstrual cycle. But this was because the mind of the patient was prepared by the taking of the remedies and unfavorable suggestions as to menstruation were removed. Above all, with amelioration of the general health, constipation being relieved, the appetite restored and the whole tone of the system improved, nature became capable of taking up once more the menstrual function. What was accomplished by indirect psychotherapy in the past can now be done much better by direct mental suggestion, when at the same time various remedial measures in other therapeutic departments are employed as auxiliaries. But the physician must be sure that the mind of the patient is properly disposed or remedies may fail and symptoms continue.
Practically every woman of menstrual age has more or less discomfort during menstruation. In most cases this does not rise beyond a heavy depressed {441} feeling shortly before menstruation begins, followed by a sense of weight and discomfort in the back and then some sensations more or less acutely uncomfortable due to congestion in the pelvis, which begin to be relieved with the commencement of the flow and then gradually disappear. Even in otherwise healthy women, various achy feelings of distention are often felt in the neighborhood of the ovaries, but these would scarcely be described as pain, unless the patient is over-sensitive. The effect upon the disposition is more marked and more universal. Some women are inclined to be irritable and hard to get along with for a few days before their menstruation and sometimes during the whole of its course. The frank recognition of this fact by them and a consultation of the calendar when they find that everything seems to be going against them and that everybody is lacking in sympathy, usually leads to an appreciation of the fact that the trouble is in themselves rather than in those around them, and their condition becomes more bearable. It is curious, however, to note how often this is forgotten, with consequent give-and-take of irritation in their environment that makes the nervous and mental condition worse and emphasizes the physical symptoms.
The term dysmenorrhea, from the Greek, means difficult menstruation and is usually associated with painful conditions in connection with the menstrual flow. It may be applied, however, to various uncomfortable feelings, to superirritability, to fatigue, to lack of energy, or even to more vague discomforts at this period. The discomforts are usually spoken of as pains, especially after the patient has been dwelling on them for some time and has been reading patent medicine advertisements that tell of how women suffer in silence, but analysis often shows that they are sensations of pressure, of compression, of achy distress at most, and sometimes only of unusual feelings—paresthesiae—that having got over the threshold of consciousness, through concentration of attention upon them, are occupying the center of the stage of mental activity to the exclusion of all serious interests.
The serious difficulties of menstruation are due to definite pathological conditions such as displacements of the uterus, affections of the uterine mucosa and of the ovaries. There are, however, many cases where the trouble is merely functional, dependent on conditions that can be easily corrected without serious surgical or even lengthy medical treatment, and where the patient's attitude of mind towards the trouble is the most important factor in the medical aspect of the case. As a matter of fact, many of the discomforts and even serious pains complained of in connection with menstruation are due rather to the patient's incapacity to bear even slight discomfort with reasonable patience and without exaggerated reaction than to the actual pain inflicted by whatever disturbance of function and tissue may be present. People differ very much in their power to stand discomfort and what seems quite trivial to one becomes unbearable torture to another. With this in mind it is possible to relieve many women who suffer from dysmenorrhea from their discomforts so that they shall only have to bear what is every woman's heritage in the matter. Successful management of these cases will save them from the supposed necessity of being operated on, which is likely to be constantly suggested to them in an age when women so often talk of their operations.
The amount of pain suffered from any cause is dependent on two factors, the pathological condition and the power of the individual to withstand {442} discomfort. When we are irritated, when we are very tired, when we have fever, when we suffer from want of food or lack of sleep or any other condition that exhausts vitality, even slight pains become hard to bear. In relieving pain it is as important to remember this lessened capacity to stand discomfort as it is to get at the cause of the discomfort itself. This habit of standing discomfort with reasonable patience is one of the best remedies for lessening suffering, especially when it is known that the discomfort is only temporary and the end of it is in sight.
Physical Condition.—In the treatment of suffering incident to the menstrual period, then, the correction of all conditions that may increase nervous irritability and make patients less capable of standing pain should be the first care. Young women who are thin and anemic, especially if they are more than ten per cent. under weight, are likely to suffer much at their menstrual periods for two reasons—through their lack of power to withstand discomfort and owing to the fact that their ovaries and the uterus itself are especially sensitive, probably through lack of nutrition consequent upon their general condition. In these cases local treatment is not as necessary as improvement of the patient's general condition and the raising of her general bodily tone.
The bowels must, of course, be regulated, partly for the sake of the general condition and the fact that it is very hard to have a regular appetite unless there is a daily evacuation, and partly also because the presence of an accumulation of fecal material in the lower bowel is likely to produce congestion in the pelvic region. This added to the normal congestion due to the menstrual function may cause undue pressure upon sensitive nerves in the ovaries and uterus. Indeed a regulation of the function of the bowels is immediately followed by a lessening of the menstrual discomfort as well as by a general improvement. Many women find that the taking of a gentle purge a day or two before the menstrual period serves to make that period a source of less discomfort than it would otherwise be, and undoubtedly the suggestive value of such a remedy persuades many women that their discomfort should be lessened.
Professor Goodell's reminder that women have many organs outside of their pelvis is important in dysmenorrhea. Almost any ailment that drains a woman's strength and brings a series of irritations to bear upon her nervous system will be reflected in her genito-urinary system and will cause discomfort during the menstrual period. Over and over again the physician finds that the true source of the menstrual discomfort is not in the essentially feminine organs, but in the digestive organs or occasionally even in such distant organs as the lungs, and that proper attention to these brings relief during the menstrual period. Just as soon as they realize that this is not a new affection but only a reflex from their other ailment, whatever it may be, they stand it with much better spirit and their complaints diminish.
Anyone who has seen the difference between the reaction to menstrual moliminia when patients are in good condition and when they are otherwise run down will realize how much a matter of over-reaction to symptoms dysmenorrhea may be. Teachers who begin the school year, invigorated by their vacations, scarcely notice their periods, but at the end of the course, when run down by months of hard teaching work and especially by the confinement of the winter, they find the strain extremely hard to bear. In many of these cases an examination by a specialist seems to reveal something that might be {443} benefited by operation. There may be various uterine displacements, sensitive ovaries, perhaps slightly enlarged yet often not distinctly pathological, but just as soon as the physical condition is made normal, the symptoms given by these conditions completely disappear. Women who have nothing particular to do, who talk much about themselves and their ills, who have had friends operated on and heard much talk about the subject, are soon convinced that only an operation will do them good. Once that suggestion is implanted in their minds, the hypnotic dread of the operation and the morbid attraction of being a center of interest and commiseration will make them exaggerate their symptoms to such a degree that operation becomes almost inevitable.
Moral Fiber.—It is often said that modern women, as the result of civilization, refinement, and city life, are of laxer physical fiber and therefore cannot stand the ills that their grandmothers bore with equanimity and considered as nothing more than what was to be expected in this imperfect existence. Most physicians must feel, however, that the increased laxity is not so much of the physical as of the moral fiber. We have not weaker bodies than our forefathers, but weaker wills. This is especially so with those who have much time to think about themselves, and, therefore, is more true, of women than of men, though in our generation men also have become very introspective. I have seen—and I am sure that my experience is a common one among physicians—delicate women who seemed unable to stand any trial or hardship successfully, placed by unfortunate conditions—such as the sudden death of a husband, or his failure in business—in circumstances that were extremely hard to stand up bravely against. Not only did they stand it, but they had better health, they had less complaint of pains of all kinds, particularly in this matter of dysmenorrhea, than they had before.
Pain and Occupation of Mind.—The more claims a woman has on her attention the less likely is she to be bothered at her monthly periods. If she does not have to get up in the morning because there are no insistent obligations upon her, she is likely to lie in bed and worry about herself and by concentrating her attention on her ills will make them worse than they are. But if she has to be up and doing, if household cares cannot be put off, if she has to earn her living by working every day, she not only succeeds in doing it, but often also forgets her ills to a great extent in her occupation. Of course, there are pathological conditions that cannot be put off in this way, and if there are serious uterine changes, or if an infection has spread along the tubes to the ovaries, there will be symptoms that cannot be distracted away. Even where there are minor pathological conditions, however, occupation of mind will make pain less annoying and even make it quite negligible. We know our own experience with toothache. This is a real pain and with a real pathological condition of the most material kind. The congestion of the sensitive dentine or the irritation of an exposed nerve filament causes about as severe pain as it is given to mortals to bear. Even with toothache, however, we can by occupying ourselves with friends, or with a pleasant book, or a game of cards, or the theater, so diminish the annoyance consequent upon the pain as to be comparatively comfortable. If anything completely occupies our attention as, for instance, a fire or an accident, or bad news from a friend, then it may be hours afterwards before we realize that we were suffering from a toothache. Since this will happen with a dental nerve, why should it not {444} happen to branches of the genital nerve? There is no reason why one should be more sensitive than the other, and whatever reason there is is rather in favor of the dental nerve giving more bother, since it is nearer the center of the nervous system and these nerves are usually said to be more sensitive.