Psychotherapy

There are, indeed, so many different causes suggested, sometimes of quite opposite or even contradictory effects, that it seems evident that the main element in the disease is some predisposition to sensitiveness in this region which is exaggerated and emphasized by the cause that is blamed. It occurs particularly in women, though it is occasionally seen in delicate or neurotic men. Sufferers from it sometimes find it impossible to sit for any length of time. Even lying down, especially if they lie on their backs, becomes a source of pain. Various operations, such as the reposition in place of the bent coccyx, or even the removal of the tip of the coccyx, have been suggested. Some reported cures are to be found in the literature. These are mainly surgical cures, however, that is to say, the patient recovered from the operation, was seen for a month or two afterwards, and was then on a fair way to complete recovery. Some of us who have had to treat these cases afterwards for painful conditions apparently due to the scar of the operation, or to a neurotic condition closely corresponding to the old coccygodynia, are not so confident of the value of an operation, though probably in purely traumatic cases surgical intervention is of value.

In most cases the sufferers are women who have little to do, who have much time on their hands to think about themselves, and who usually receive abundant sympathy from friends and relatives. In one case under my observation the death of a husband and the discovery that his estate was much less than had been anticipated, so that his widow had to take up a wage-earning occupation, did more in a short time than all the treatment that had been employed before to relieve her discomfort. She had been quite unable to move around at times, especially in rainy weather, and was something of an invalid during all the winter, but now she was able to go out to work every day and had very little trouble. Her affection originally dated from a fall on an icy sidewalk and her fear to go out in the winter seemed to be dependent on the dread of another fall. She realizes now that practically all her former trouble was due to over-attention to a discomfort which is still present, but which she is now able to forget, except at times when she is alone after there have been worries and troubles that have reduced her power to control her nerves. In young girls an injury to the coccyx by a fall on the buttocks will often leave tenderness for months or even years, but if attention is distracted from this and the patient is not allowed to concentrate her mind on it and does not hear of the awful possibilities of coccygodynia—a mouth-filling Greek name in which we map out our ignorance, and which seems to carry with it such a weight of pathology—she will probably recover completely.

Coccygodynia often resembles hysterical coxalgia or the hysterical arthritises, and seems sometimes to be due to the fact that there is a natural or traumatic abnormal mobility of the coccygeal vertebrae which, owing to concentration of attention, has developed into a neurosis analogous to the corresponding condition in a joint. There are undoubtedly cases in which a real pathological lesion exists, but these are comparatively few. In this, as in other joint and bone affections with vague pains likely to be worse on rainy days, the word rheumatism is often mentioned, but it has no proper place. Treatment that will put the patients into good general condition—never local unless there is objective indication—outdoor air and exercise with reassurance of mind and distraction of the attention are the important therapeutic agents. Patients with much time on their hands do not readily get well, while those who are busily occupied seldom suffer for long.

SECTION X

GYNECOLOGICAL PSYCHOTHERAPY

CHAPTER I

MENTAL HEALING IN GYNECOLOGY

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 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 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.

CHAPTER II

PSYCHIC STATES IN MENSTRUATION

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 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.