_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 att.i.tude 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 quant.i.ties for all the ills of women. The composition of these remedies is not, as is popularly supposed, a great mystery. They have all been a.n.a.lyzed 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 princ.i.p.al ingredient in most of them--certainly their most active element--is the alcohol they contain, which, until the pa.s.sage of the pure food and drug law, was in such considerable quant.i.ties 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 princ.i.p.ally 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 rea.s.sure 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.

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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 Mobius, the distinguished German neurologist, insisted that there is a certain physiological mental disturbance with distinct hampering of the faculty of judgment (Schwachsinn) normally a.s.sociated 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 pa.s.s 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 p.r.o.ne 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.

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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 hoa.r.s.e, 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 antic.i.p.ation 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 rea.s.surance 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, b.a.l.l.s 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.

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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 antic.i.p.ated 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 att.i.tude 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 att.i.tude 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 b.r.e.a.s.t.s 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.

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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 const.i.tutional 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 coa.r.s.ening 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 pa.s.sing, "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.