Whenever she worked hard, or whenever she was much worried, she would have alarming flooding. Under ordinary circ.u.mstances, 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 dest.i.tute 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 circ.u.mstances. 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 role in controlling the symptoms.

Before operation it is important to put the minds of these patients into an att.i.tude 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 {450} 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 rea.s.surance, by regulation of the general health, by resumption of exercise and toning up of appet.i.te 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 rea.s.sured 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 rea.s.surance, 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 s.e.xual life which involves the cessation of menstruation is physiological and not morbid, it is so commonly a.s.sociated 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 s.e.x qualities are modified and even masculine physical peculiarities may a.s.sert 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 Att.i.tude.--Psychotherapy can do more {451} 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 p.r.o.ne 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 att.i.tude 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.

Favorable Suggestion.--After the menopause women are less disturbed by emotional strains and troubles of any kind than before. They settle down into more placid, easy-going lives. They are not subjected to the monthly interruption of their routine of work or amus.e.m.e.nt, everything comes a little easier to them, and they are not, to use the word in its physiological sense, so irritable--that is, so responsive in reaction. They are not so likely to respond to slight irritations, and are often physically and mentally more content with life. This must be insisted upon, for, at the present time, unfavorable suggestion with regard to the menopause is the universal rule. Women look for the worst from it, and their expectation makes conditions less tolerable than they really are. Most women dread it as if it were the beginning of the end of life, the first descent into old age, while it is often the dawn of a larger and broader life free from s.e.xual and other irritations, and with better possibilities of accomplishment.

Definite Prescriptions.--These patients are best rea.s.sured by being told that every woman who has lived to the age of fifty has gone through a similar experience and that they have all, with rare exceptions, revived with health of both body and mind. It is more important to insist on the patients cultivating a certain gaiety of disposition, to plan for regular diversions two or three times a week, to see that they are not too much alone and that they find abundant occupation of mind and body, than to try to combat their manifold symptoms by drugs or local measures. Of course, their physical functions must be kept normal. It is surprising, however, how much improvement can be brought about in the menopause symptoms by definite prescriptions as to the time to be spent in the open air--at least two or three hours a day--with regard to having a definite diversion of some kind in mind two or three days ahead to which they look forward with pleasure, and by convincing them that whenever they allow themselves to dwell much on their condition, their symptoms of discomfort will become so severe as to be intolerable, while when they are occupied with other things they will find them quite easy to bear.

As a rule, mothers of families with many cares and diversions of mind, with little time to think of themselves, do not suffer much at this period, or at least not nearly so much as do those who are without these diversions. The more time a woman has to think about herself at this period, the worse for {452} her. Her irritability of mind will be reflected upon her physical condition and make it worse. In the olden time mothers of families went through it and no one knew about it, or even noticed that there was anything the matter with them except possibly a little increased irritability at certain periods. Neither menstruation nor the menopause is necessarily connected with more than pa.s.sing discomfort, if the patient is in good health. This is perfectly true if symptoms are not brooded over, if there is not too much expectancy of evils, and the feelings and manifestations which do not deserve the name of symptoms are taken as a matter of course. Best of all, let the woman keep her mind well occupied with many duties--with care for others, the helpless, the ailing, around her, instead of with herself and her pa.s.sing ills.

Dread of Insanity.--There are few women who go through this period without the hideous thought that possibly they may go crazy. This is especially likely if, as a consequence of the exaggerated desire for seclusion that many women have at this time, they do not get out into the air nor exercise as much as they should. As a consequence, they suffer from constipation, from lack of appet.i.te, and capriciousness of taste for food, and they may have a series of symptoms that, when dwelt on during the hours of solitude, very seriously disturb the good feeling that is so important for the normal accomplishment of physiological functions.

Diversion of Mind.--This tendency to withdraw from social relations with their friends and from the occupations that take them out of doors and which are often a helpful diversion of mind is one of the worst symptoms of this time and must be strenuously combated. It superinduces a series of physical symptoms which are attributed to the menopause but are really due to lack of air, to inactivity, to absence of interest and the consequent opportunity provided for unfortunate auto-suggestion and introspection. These superadded physical symptoms can be readily relieved by directions for rational living and then the genuine menopause symptoms may be so diminished as to be scarcely noticeable. It is impossible for the ordinary human being to stay much in the house, to lie down a large part of the time, eat irregularly and let the bowels become sluggish without having many symptoms of depression.

Summary of Treatment.--The treatment, not of the menopause but of the patients pa.s.sing through the menopause, then, must consist, first, in putting them in as good physical condition as possible and keeping them in it; second, in maintaining such normal natural habits of life as will enable them to keep up this physical condition without disturbance; thirdly, in putting off solicitude with regard to the menopause and realizing that it is a normal natural process with a definite place in human life and not at all representing a terminal stage of human existence. Nature meant that the mature woman, formed by precious experience, with sympathies broadened by years, should be able to devote herself without s.e.xual irritation to the many things that naturally come to her at this period. There is a place in life for the grandmother and even for the grandaunt, though a French visitor recently declared that he thought there must be no grandmothers in America since all the women seemed to dress in the fashion of the young girl. If this submission to natural conditions is recognized and accepted there are long years of happiness and helpfulness in store for the woman of middle age and the menopause may be welcomed as an important step towards a larger development of life.

{453}

SECTION XI

_PSYCHOTHERAPY IN OBSTETRICS_

CHAPTER I

SUGGESTION IN OBSTETRICS

In no department of medicine is favorable or unfavorable mental influence more important than in obstetrics. Unfortunately, unfavorable suggestion has here played a serious role and must be controlled, modified, neutralized. Suggestion is valuable in its every phase, during the course of pregnancy, in labor itself, in _post-partum_ convalescence, and with regard to nursing. Many women in our time are p.r.o.ne to persuade themselves that labor is a more serious incident than it usually proves to be and the consequence is an unfortunate suggestion of pain to come that so exaggerates sensitiveness as to make the actual suffering seem more than it really is. Sympathy expressed for women in pregnancy and in antic.i.p.ation of their labor is sure to do more harm than good. Pain instead of being lessened by sympathy is increased and capacity to bear it is diminished. Anything that calls attention more particularly to the pain removes distracting conditions that might modify it favorably.

Animals have the admirable instinct of withdrawing to some quiet corner when they are in pain, preferring to be alone. In this they follow nature and imitation of them is worthy of consideration, at least so far as the avoidance of opportunities for the expression of sympathy is concerned.

PREGNANCY

Maintenance of Health.--Women must keep up their normal health and strength during pregnancy. By not taking sufficient exercise and by being too much indoors, many women develop a morbid mental state in which every discomfort is less bearable than it was before. Lack of air and of exercise, furthermore, makes them p.r.o.ne to constipation, makes their sleep less restful, and reduces the appet.i.te. For the sake of the being within them, they force themselves to eat, but this often serves only to make them obese, without improving their general health. If a woman in her ordinary condition, who was accustomed to going out-of-doors several hours every day and having reasonable diversion of mind and exercise of body, were to adopt the habits of life that many pregnant women form, she, too, would become morbidly introspective, fearful of the future, irritable over little things, restless at night, and even have certain physical symptoms, such as constipation, tired feelings, loss of {454} appet.i.te, etc. Many of the discomforts and symptoms of which women complain during pregnancy are really due to unfortunate habits and to their mental att.i.tude toward their conditions, rather than to any specific influence of pregnancy on the general health. As a rule, women who live naturally are in somewhat better physical health during pregnancy that at other times.

Obesity and Pregnancy.--It is important that women should not become obese during pregnancy. The woman who is taking too much fat in her diet and acc.u.mulating fat is likely to have a fat baby, and with these there is more difficulty in labor itself, and the infants have less resistive vitality than if they were unenc.u.mbered with useless adipose tissue. Her will must overcome the tendency to la.s.situde and the p.r.o.neness to inactivity that comes over her, and she must feel that labor and her condition after it are dependent on normal, healthy life at this time.

Delayed Labor and Suggestion.--One phase of maternal impressions or of suggestion for the mother's mind that I have always been interested in has been that of the possibility of preventing delay in parturition by frequent suggestion of the time that delivery should be expected.

There seems to be no doubt that expectation has some influence on the time of delivery. We do not know just why, after the uterus has tolerated the presence of the fetus for nine calendar months, it should then refuse to do so any longer and contract and expel it. Any number of theories have been suggested and even now our best obstetricians are not agreed as to the reason for this action on the part of the uterus. In some cases this contraction does not take place normally. The due term of labor is past and as a consequence fetuses grow too large within the uterus, greatly increasing the difficulties of parturition and adding to the risk of both mother and child. It is the custom to announce with pride the birth of twelve- and fifteen-pound babies, but it is doubtful whether nature intended that growth to this extent should take place before birth. There is in this, as in other phases of pride with regard to children, a curiously perverted feeling.

Many obstetricians feel that the babies who weigh much more than the average of seven pounds have probably been delayed in the uterus for a lunar month beyond the time when they should, or at least could have been normally born. It is a question whether this delay would have occurred if the mother's expectation of the birth had been directed to a date a month ahead of that on which her mind became fixed as the time of labor. Parturition usually takes place about the period of the recurrence of the menstrual molimina, or at least of that monthly cyclic feeling which many women experience, though there is no flow.

It is not always easy to say at which of two monthly periods the birth should be expected. While physicians have warned patients of the possibility of the child being born at the first of the two possible periods, they have been inclined to dwell on the fact that it will probably be delayed until the later term. Women themselves are more p.r.o.ne to take the later than the earlier termination of their pregnancy. Both physician and patient are timorous of the ridicule that may follow if they make premature announcements. Whether we have not in this way created a tradition tending to delay parturition by a lunar month in many cases, is a problem that requires careful study.

The suggestion of as early a period as is compatible with the data provided, so as to create a definite expectancy in the mother's mind, seems well worth {455} deliberate attention. This is a role that psychotherapy has to play in lessening the dangers and the difficulties of parturition. With most healthy women, as indeed with most sensible normal women in life as regards all things, no suggestion is needed and nature will take her course promptly and properly. It is the nervous women, over-anxious about themselves, often of lax physical fiber because of their nervous condition, that need this phase of psychotherapy. It is in them that the unfavorable or mistaken suggestion may be emphasized to such a degree as to delay labor for a lunar month or even more.

Vomiting of Pregnancy.--One of the dreaded complications of pregnancy is serious prolonged vomiting. We know now that this is of two kinds, toxic and neurotic. The toxic variety may be a.s.sociated with kidney changes, but is more commonly the consequence of certain rare forms of degeneration of the liver. The pathological picture after death is not unlike that of phosphorus poisoning. These cases are due to some serious disturbance of metabolism or to the absorption of some little understood poison. They are probably always fatal. The cases of neurotic vomiting are rather common. They are exaggerations, of the ordinary familiar vomiting of pregnancy which is exhibited by nearly all women at the recurrence of the menstrual times in the early portion of pregnancy. In some of these cases, however, the vomiting is so persistent and so prolonged that the patient's nutrition suffers severely, and there seems to be danger of a fatal termination. The condition has received the unfortunate name of "pernicious vomiting."

In these cases there is sometimes question of the advisability of terminating the pregnancy lest the woman should die. Unfortunately this question has been so commonly discussed that most prospective mothers are likely to know something about it, so that when vomiting begins they are fearful lest they should have to lose their child.

This becomes an obsession in some minds and an unfavorable suggestion that helps to maintain the vomiting.

A number of remedies have been highly recommended for this at various times. Nearly every alterative drug has had its period of popularity.

In the older time nitrate of silver was said to be efficacious. Small doses of ipecac were highly recommended at one time. Small doses of cocain were suggested, and the painting of the back of the throat with cocain. Small doses of morphin had a vogue; codein had its turn after its introduction, and heroin also had a time of popularity. Oxalate of cerium was highly recommended. Any obstetrician of experience will remember many other remedies that have been supposed to be efficacious. Various gynecological procedures have been suggested: the touching of the _cervix uteri_ with a mild caustic, with iodin or with nitrate of silver, slight dilatation of the cervix, sometimes the application of a tampon with just enough glycerin to produce a reaction, but not enough to terminate the pregnancy. Occasionally local applications over the stomach region, a mustard leaf, or certain plasters, or finally even a piece of sized paper bound on over this region have been known to be followed by the cessation of the vomiting. When as many different remedies are recommended and seem for a time to be successful and then later prove to be inefficacious, it is reasonably clear that it is not the remedies but the effect produced by these on the mind that is the important therapeutic factor.

Many obstetricians of wide experience now teach that most of these cases of vomiting in pregnancy are merely neurotic and are to be treated entirely {456} as if they were hysterical. The patient's mind is to be distracted from her condition; she is to be a.s.sured that even severe vomiting is quite common in pregnancy, that it is annoying, but never serious in its consequences, that it always ends without unfortunate incident for mother or child, and that there need be no solicitude. Above all, no hint of the possibility of the necessity for the termination of the pregnancy, if vomiting continues, should be given. Some physicians are entirely too solicitous in the matter and have by their anxiety made the neurotic condition of their patients worse. Some men see what they call a "pernicious vomiting" in every hundred labors. A well-known obstetrician in New York has had 3,000 births without seeing a single case. He is known for his placidity and lack of over-anxiety. In the great obstetrical clinics in Europe vomiting to the extent that will put mother or child in danger is extremely rare. The greatest obstetrician of the later nineteenth century reports 100,000 obstetrical cases with only one artificial labor.

In foreign obstetrical clinics these cases in recent years have been treated expectantly, without any active interference, especially with pregnancy, and the results have been much more satisfactory than any other method of treatment. There are a number of cases on record now in which pregnant women have lost from twenty to forty pounds as the result of vomiting for weeks, yet after a time the attack has pa.s.sed and they have carried the child to full term. Where vomiting has occurred and relief has once been afforded by the termination of pregnancy, it is very unlikely that succeeding pregnancies will pa.s.s without corresponding conditions in which no remedy will prove effective, except the dreaded obstetrical intervention for the termination of the pregnancy. It is extremely important then that these cases should be treated conservatively and that from the very beginning there should be nothing to arouse the patient's solicitude with regard to herself or above all to give her any hint of the possibility of obstetrical intervention being necessary in her case.

For some women the knowledge that a consultation has been held to discuss such a possibility will of itself prove a persistent unfavorable suggestion, that will surely prolong the vomiting.

This may seem a rather strong opinion from one who is not in practical touch with obstetrics. It has been the growing opinion, however, among the great German obstetricians for the last generation. Ahlfeld, in the _Archiv fur Gynaekologie_ (Band 18 Heft 2 page 310) said that he had seen [in a very large obstetrical practice] three cases of so-called pernicious vomiting (_unstillbaren Erbrechen_) in all of which the patients wanted an abortion because they had previously learned the success of this method of treatment, but all of them recovered without incident and carried their children to term. Kronig, ten years ago, in his monograph on "The Significance of Functional Nervous Diseases for Diagnosis and Treatment in Gynaecology"

[Footnote 36] said: "The excessive vomiting of pregnant patients has for a long time seemed to be a genital reflex neurosis. We thought that the growing uterus irritates certain nerve tracts which are connected with the mucous membrane of the stomach. We owe it to Kaltenbach that this opinion was overturned and _hyperemesis gravidarum_ set down as the result of a functional neurosis, hysterical in character. A large number of gynaecologists have accepted this opinion in recent {457} years (men of all nations) among others Calderini, Charpentier, Schaeffer, Klein, and Graefe."

[Footnote 36: Ueber die Bedeutung der Funktionellen Nervenkrankhelten fur die Diagnostik und Therapie in der Gynakologie von Dr. B.

Kronig. Leipzig, 1902.]

Winkel and the leading obstetricians of Germany, especially the directors of obstetrical clinics in the large cities, must be quoted as of the same opinion, since Winkel has collected the statistics of 100,000 pregnancies in the large German clinics in which 6,555 obstetrical operations were performed and in only one case was artificial abortion produced. German opinion is rather strong in the a.s.sertion that a number of cases of abortion in the practice of an obstetrician indicates over-hastiness in coming to conclusions as to danger, or leaves him open to the suspicion of yielding too readily to the wishes of mothers who would prefer not to carry their children to term. The suggestion of the possible necessity for abortion has done much to make the hysterical vomiting of these patients continue until this remedy is employed. Insistence from the very beginning that vomiting, though it may injure both mother and child, never necessitates abortion--one out of 100,000 cases is practically never--would be the best possible contrasuggestion.