Psychotherapy Part 53

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 antic.i.p.ation 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 appet.i.te 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 {441} 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 a.s.sociated 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 advertis.e.m.e.nts that tell of how women suffer in silence, but a.n.a.lysis 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 att.i.tude 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 {442} 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 appet.i.te unless there is a daily evacuation, and partly also because the presence of an acc.u.mulation 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 {443} 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 circ.u.mstances 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 {444} 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.

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 windla.s.ses 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 sh.e.l.lfish. 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 sh.e.l.lfish 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 circ.u.mstances, 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 circ.u.mstances, 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, {445} 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, appet.i.te, 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 circ.u.mstances 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 guiac.u.m 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 a.s.sociated 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 cla.s.sic 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 {446} 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 a.n.a.lyze 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 {447} a.s.sociation 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 quant.i.ties 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 {448} resumed, appet.i.te 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 quant.i.ty 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 rea.s.suring 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 {449} 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.