Psychotherapy

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.

CHAPTER III

AMENORRHEA

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 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 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.

CHAPTER IV

DYSMENORRHEA

Practically every woman of menstrual age has more or less discomfort during menstruation. In most cases this does not rise beyond a heavy depressed 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 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 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 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.