Psychotherapy

Working Women.—With regard to painful menstruation, the habits of many country people, and of the European peasantry generally, furnish valuable indications of the power of work to dissipate discomfort. During my medical student days in Vienna I had the opportunity to know rather well a group of women who were engaged in working on a building. They carried up the bricks and mortar for the men and worked the windlasses by which heavy materials were carried to the different stories, and they mixed the mortar and prepared the building materials generally. These women, living constantly in the air and working very hard, had almost no symptoms of menstrual difficulty. They never laid off at this time except in a few cases in which subinvolution after pregnancies and genital infections had left conditions that made it hard to understand how they worked at all.

I learned in addition from them, for most of them came from the country, that the women who work so commonly in the fields in central Europe have little difficulty with menstruation and practically do not know that it is coming on them until the show indicates its presence. I had known before how true this was for the Irish peasant women. This seems to be the normal healthy condition, and the state of mind of these women aids this satisfactory state of affairs. They rather look down upon women who complain at this time as being of such inferior health as to be despised. Doubtless if they were persuaded, as so many seem to be, that a woman must expect to have a serious time, or at least a great deal of discomfort about this period, they would have it, too. Of course, they have some difference of feeling at this time. They feel more tired in the evenings, and they awake in the morning less rested, but that is no more than the changes in the weather bring to men.

On the coast of Brittany and Normandy many of the women rake for shellfish. Their custom is to wade into the water and, standing with the water often above the knee and waves sometimes washing as high as the waist, to rake all day for the shellfish that they are seeking. They do not lay off from this occupation, as a rule, when their menstruation is on them, but continue as if nothing were the matter, and there are very few complaints of menstrual troubles among them. Such occupation would seem to be positively counter-indicated, but long years of experience have shown them that there is no need of interruptions in their work and as they need every centime that they can obtain in this way for the support of their families, they continue even in very cold weather, when it would seem inevitable that this must produce serious results.

It is not uncommon for a young woman, who, while her family was in good circumstances, was a severe trial to everyone for a week more or less, every month, to become quite free from trouble for herself and others when, owing to a change in the family circumstances, she has had to take up some occupation for a living. I have notes of cases of this kind in which the pain was so severe that, after several years of medication and external applications, it was decided to dilate the cervix uteri in the hope of affording relief. The relief thus afforded, however, was only temporary. A little later in life, however, the necessity of earning a living has in some cases quite freed these young women from the torments that sent them so frequently to their physicians.

We need the report of many more of such gynecological conditions which get better as a consequence of occupation of mind without any other treatment. We have any number of reports of benefits derived from operation, but not infrequently these reports refer only to a few months after the operation, when the strong mental suggestion of the performance of the operation and the general betterment of health consequent upon care during convalescence are still acting upon the patient, and she has the benefit of the gain in weight and strength that usually follows because of hope, appetite, exercise in the air, etc. Not infrequently in these cases there are, later on, sad relapses into painful conditions quite as severe as before, while, on the other hand, some change in the circumstances of the individual, or some intense preoccupation of mind a few years after, brings lasting cure, thus showing that it was the mental state which was at the root of the condition rather than any bodily affection.

Spasmodic Dysmenorrhea.—There are two forms of dysmenorrhea that have been the subject of much study. One of them consists of cramp-like pains which occur some time before menstruation, are relieved if the flow is copious, but continue if it is scanty. This affection has often been attributed to mechanical obstruction. Nearly twenty years ago Dr. Champneys in his Harveian Lectures on Painful Menstruation discussed this subject, and showed that the mechanical explanation while very simple and popular was probably not correct. His conclusion was that the dysmenorrhea was more frequently due to conditions outside of the uterus than in that organ. He recommended plenty of healthy exercise between the periods and especially riding if the patient were not a working woman, regular activity of the bowels with epsom salts as probably the most valuable single remedy, and then a number of drugs such as guiacum and sulphur that are not specifics but have a general effect. In his experience castoreum, a strongly suggestive remedy, gave more relief than anything else. He advised against local treatment unless there was a very definite reason for it and frankly expressed the opinion that the complaints were often due more to an incapacity to stand the slight discomfort that is more or less inevitably associated with the congestive state that precedes menstruation than to any pathological lesion.

Membranous Dysmenorrhea.—This affection like membranous colitis remains one of the mysteries of pathology and etiology. There is no doubt, however, that there are large nervous elements in its production and that it is worse at times of worry, while mental factors of many kinds influence its occurrence and also its relief. In his Harveian Lectures Dr. Champneys discussed the questions connected with it very well and his monograph is a classic on the subject. Many drugs have seemed successful and then have failed. Castoreum has done good in this as in spasmodic dysmenorrhea. A number of gynecological methods of treatment have been successful when first applied, when physician and patient were both confident of their value, and then later has failed. Probably nothing does more good than getting the patient's mind off her condition, securing such occupation as will not permit of introspection to any extent, though of course treating surgically whatever requires operation. It must not be forgotten that while many of those suffering from the disease complain of pain, not a few sufferers from it have no symptoms of this kind and their condition is discovered more or less by accident. After this there is likely to be much more discomfort from it. All this must be borne in mind in its treatment.

Minor Ovarian Lesions.—In many cases there is vague discomfort in the ovarian region about the time of menstruation, and the ovary is found to be somewhat enlarged or perhaps dislocated. In these cases if there is continued complaint of pain, operation will almost surely be advised and frequently cysts are found. This is considered to be justification enough for the removal of the ovaries or at least for their resection. It is doubtful, however, whether ovarian cysts in the majority of cases are really a pathological condition. Those who are engaged in spaying cattle think it almost if not quite normal for cysts to exist in the ovaries. Whether this is not also true of women we have not the data to determine. In a number of the patients who are operated upon for this condition there is a relapse of symptoms, and there seems to be no doubt but that whatever good is accomplished comes from the expectation of relief followed by the weeks of rest and quiet in bed and very often the gain in weight which succeeds the operation. Whether something of this kind would not follow from the simpler procedure of improving the general health is an open question.

It is sometimes insisted that the general health will not improve in gynecological cases unless the offending pathological condition is removed. This is true if the patient is persuaded that there is some pathological condition present which must be corrected or else she will not be better, and if favorable suggestion cannot be used to advantage. If, however, these patients understand from the beginning that probably the local condition, which gives the symptoms, is due rather to their general health than to a definite lesion, there is more probability of improvement. It is surprising how many of these cases are relieved by an improvement of the general health, by the relief of constipation, by the decrease of congestion by laxatives, and by the persuasion that there is nothing which will go on to serious developments (this is the most disturbing of dreads) but only a condition that will probably get no worse and the symptoms from which may yield to general treatment.

The popularity of many so-called remedies for women's diseases is due to their success in lifting the veil of discouragement and, by alcoholic and other tonic stimulation, helping the women into a better general condition and a more favorable frame of mind.

The Individual.—In all cases of dysmenorrhea, then, it is important not to be influenced too much by the complaints (for here, as Broadbent insists with regard to angina pectoris, the more complaint we have the less serious the condition will often be), but to investigate the patient's condition and, where there is not some definite and serious pathological lesion, to analyze the beginning and the development of the individual case and eliminate the neurotic elements. Often the menstrual difficulty is due to suggestion, as the patient has been in contact with others who were sufferers and caught her complaint from them by psychic contagion. Special investigation is needed as to her occupation of mind. This must be provided for her. Nothing else will save her from herself. Travel may do it, exercise may be helpful, but an occupation in which she is deeply interested, especially if it involves association with other people, is the best basis of psychic treatment. Improvement of the general health and the relief of various symptoms are auxiliaries.

Unfavorable Suggestion.—After consulting with many women physicians, with many women who have lived active lives, with many superiors of religious orders in consultation about their religious women, I cannot but conclude that painful menstruation is ever so much oftener a result of mental and nervous states than of organic disturbances. Unfortunately a tradition has now been established that women suffer much at this time, so many of them give in to their feelings, exaggerate their discomfort, dwell on their sensations, affect the blood supply to the genital organs through the sympathetic nervous system, actually produce functionally pathological hyperemia where only physiological was present (the simile of the blush makes this easy to understand), and finally set up a condition that is actually painful, though there was only some discomforting sense of compression and congestion before. We have been educating young girls in disease, not in health. Plato pleaded for the opposite. After these 2,400 years we might take it up seriously.

CHAPTER V

MENORRHAGIA

While the influence of the mind in producing painful menstruation and a much diminished menstrual flow is well recognized, the connection between the mind and an increased menstrual flow is not so generally appreciated. Usually profuse menstruation (especially when it reaches a height where it would properly be called menorrhagia) is considered to be due to some serious pathological condition. Its most frequent cause is undoubtedly subinvolution of the uterus after pregnancy, or an overgrowth of the uterine mucosa because of some pathological condition—usually an infection. While menorrhagia is often attributed to colds or to getting the feet wet (and undoubtedly the disturbance of the circulation consequent upon wet feet is an active factor in the production of an increased menstrual flow) there is no doubt that in most cases there is some more distinctly local cause at work. Another important cause of profuse menstruation is the presence of a fibroid tumor or other neoplasm which brings an increased blood supply to the uterus and a consequent greater elimination at the menstrual epoch.

In most cases of subinvolution a curettage, at least, will have to be done. Often the use of extremely hot douches, that is, just as hot as can be borne, may accomplish much. Such quantities as a quart or two are useless; several gallons should be taken, and that not in the awkward cramped postures in which douching is sometimes done and in which it cannot be expected to accomplish its purpose, but in the reclining position and to be followed by an hour or two of rest with the hips elevated. This treatment will be more effective if women do not get the idea that an operation will surely have to be done on them. Operations are now so much spoken about that some women apparently do not feel that they have had quite all the experience that is coming to them in life unless they have at least one to their credit. If they can be made to realize that, in the past before the days of operative gynecology, most such cases recovered of themselves and that now if courage is resumed, appetite strengthened through the will, constipation relieved, an abundance of outdoor air secured (exercise is not so necessary), recovery will probably be more complete than after an operation, there would be much less need of operations than at present.

The material conditions based upon pathological changes which usually produce menorrhagia hardly seem amenable to influence by the patient's state of mind, yet experience demonstrates that much can be done for these patients by setting their minds at rest, by improving their general condition, by soothing their worry as to what the profuse flow means. Many nervous patients have quite normal menstruation, as regards the length and quantity of flow, until some serious disturbance occurs in their mental state. I have had patients who for months would have a perfectly normal menstrual flow of three to five days to whom a serious mental disturbance always brings a profuse menstruation. The arrest of a woman by mistake just before or at the beginning of her menstrual period will often cause a greatly increased flow and great weakness will follow. Women approaching the menopause already have a tendency to an increased flow though not beyond the bounds of what might be considered normal, and at this time almost any shock will produce profuse menstruation and lead to prostration. If the secondary anemia from this is not overcome during the interval profuse menstruations may succeed each other for many months.

The necessity for reassuring these women, therefore, becomes evident. Most of us have seen women who were worried at having a slightly increased menstruation, and who had been told that they had a fibroid tumor which was producing the increased menstruation, and which would have to be removed if it continued to bring on this serious condition. Such a suggestion inevitably leads to a series of more profuse menstruations during the following months. Such women worry over their state and dread an operation. They do not eat well and, even though they do not lose much in weight, they often become distinctly anemic. This anemia adds to the tendency to a freer flow and as a consequence the menstrual period is lengthened in time and increased in amount. This soon brings them to operation, though very often there has been no increase in size of the fibroid tumor and there is no more reason for operation than there was when they were first examined.

I have had under observation during the last two years a patient in whom the diagnosis of a fibroid brought this unfortunate result. Her menstruation had been profuse and prolonged before but now it became still longer and lasted nearly fifteen days each month. As she lost much in weight, was run down in strength, became self-centered, stayed more at home, and took less exercise, the resultant depression in her general condition emphasized the menorrhagia. As soon as it was made clear to her that her case had but one indication for operation—the loss of blood and that the fibroid was so small that it might well be allowed to remain until after her menopause, when involution would probably prevent further unfavorable action, she took heart, began to exercise, ate more heartily, her marked constipation was relieved, she slept better and in three months her menstruation was almost normal. For many months she had no menorrhagia.

I have seen other cases in which amelioration of symptoms came just as soon as the patient learned that, by improvement in the general health, there was a possibility of lessening the tendency to hemorrhage and thus of putting off the necessity for operation for a time at least, if not until such natural changes occurred in the system as to lessen the danger from the growing tumor. I have in mind the wife of a physician whose menopause was delayed for some ten years as a consequence of a good-sized fibroid growth. She had it when she first came to me, and I watched the case for some seven years, and she absolutely refused to entertain the idea of operation. I set her mind at rest as to the seriousness of the growth provided the bleeding was not injurious and no infective conditions occurred through the intestinal walls to complicate the condition and cause adhesions. Whenever she worked hard, or whenever she was much worried, she would have alarming flooding. Under ordinary circumstances, however, when things did not go awry, she had a menstruation somewhat more profuse than normal and of five or six days in length. This continued from her fiftieth to her fifty-fifth year, and then gradually subsided. She is still alive at the age of sixty and, though she has had many trials and hardships at the end of her life, she is healthy and considers herself much better off than if she had had an operation. I doubt whether this is true, that is, if the operation had been done twenty years ago. But, after watching such a case and realizing that operations on fibroids are more often fatal than any other of the gynecologic operations that do not involve serious conditions, a physician is justified in tiding women over the time to their menopause and then letting nature dispose. Infective incidents pointing to the formation of adhesions are a contraindication to this policy, however.

The sufferer in this case was one of the most patient of women. She had had to suffer much in mind and in body as the result of being left almost destitute after a life of luxury, yet she seldom complained. One might almost think her indifferent to hardship if one did not know her well. She was not at all a stoic but she never allowed her imagination to run away with her, she bore the ills of the day without thinking of what was going to come next week and she worried as little as possible under the circumstances. The ordinary woman, nervous and excitable, would have broken down under the strain that was placed upon her but she promises to live to a good age and her trials have not hurt her vitality nor spoiled her disposition and she looks the world in the face with surprising cheerfulness. This state of mind modifies even fibroid menorrhagia favorably.

Fibroids have been reported "cured" by so many different remedies—local applications, acupuncture, hot needles, electricity in various forms, even internal treatment, which afterwards proved quite unavailing—that it is manifest that the mind plays a large rôle in controlling the symptoms.

Before operation it is important to put the minds of these patients into an attitude of confidence, for operators who make it a point to secure the confidence of their patients, or who for some reason have their full faith, have better results in these cases than others of equal surgical skill.

In unmarried women the development of a small fibroid with its reflex disturbances is sure to be followed by excessive reaction in many ways. Nervous symptoms are likely to be marked and the increase in menstruation is usually much more profuse as a consequence of the solicitude than because of the fibroid. Some of these tumors which, though of small size, are so situated with regard to the nervous and circulatory systems of the uterus as to produce profuse menstruation even in women of phlegmatic disposition. In these patients operations will be necessary whenever the loss of blood makes it clear that the drain on the system is producing serious effects. There are cases, however, in which the menorrhagia is not due directly to the fibroid, but rather to its effect upon the general system and this may be lessened very much by reassurance, by regulation of the general health, by resumption of exercise and toning up of appetite and, above all, by relief of the constipation which so often complicates these cases. Fibroids may or may not continue to grow. The removal of one is no guarantee that others will not form, nor that others are not present in very small form which will develop later. As a rule, there can be no question of the removal of the uterus unless conditions are serious.

If in spite of general treatment and the calming of the patient as far as possible profuse menstruation continues, it is an indication for surgical intervention. Psychotherapy may readily be abused in these cases, but it has a distinct use, and its application is more frequently successful than has been thought; but it must be deliberately employed. When, however, menorrhagia is a symptom of some serious progressive condition, psychotherapy will do harm rather than good. I have known women whose menstruation was stopped and then recurred and even became profuse reassured that this was only a symptom of the menopause when it was the first symptom of a cancer. In such cases there must be no temporizing or reassurance, but a careful determination of the actual condition must be made and immediate operation done if it seems necessary. Psychotherapy may have a place in incurable cancer, but in other cases it has none at all except to calm the patient for operation where surgery may be of service.

CHAPTER VI

THE MENOPAUSE

While the phase of feminine sexual life which involves the cessation of menstruation is physiological and not morbid, it is so commonly associated with physical and mental symptoms difficult to bear that, practically always, it sends the woman to a physician. This is as true of the artificial menopause induced by removal of ovaries as it is of the normal process by which, in the course of time, ovarian function comes to an end and changes are brought about in the system consequent upon the absence of ovarian secretion. The ovaries, like many other organs, have two functions. One, that of ovulation, is so prominent that the other, the internal secretion, has been too much neglected. How important this is, however, may be judged from the change that comes over feminine nature after its cessation. Much of the emotionality of woman disappears, not a few of her special sex qualities are modified and even masculine physical peculiarities may assert themselves. The physical effects of the ovarian internal secretion may be inferred from the definite tendency to grow stout which results from its suppression by the menopause. Certain changes in the organism are inevitable then, and the only hope of therapy is to keep them from disturbing life processes.

Neutralizing Unfavorable Mental Attitude.—Psychotherapy can do more for the troubles of the menopause than any other treatment. The symptoms of the change of life in the long ago, if we can trust traditions, were not so troublesome as they are now. Only rarely did women suffer from it as they are supposed to suffer at the present time. Women are so persuaded that there is to be much suffering, or at least prolonged physical discomfort, as to make it difficult for them to be quite themselves. They are prone to think that their physical symptoms are noted, and that their condition is a subject of remark. This adds to the difficulty of bearing in patience whatever symptoms are present. The introspective attitude of our time has reacted upon such affections as occur in the menopause, and, by creating an abnormal susceptibility of mind, has added much not only to its possibility but also to its actuality of suffering. Drugs or other remedial measures will modify the conditions only partially and temporarily. The mental prophylaxis of suggestion must alter the state of mind both before and during the progress of the condition.