Treatment--To know that these psychic disturbances are likely to occur

at the time of menstruation is to be prepared for them so as to lessen

their effect upon one's self and others. They are much relieved by

this frank recognition and the patient understands that with the

betterment of the psychic condition by such reassurance the physical

symptoms are lessened. Many a woman gives up her occupation at such

times who would be much better if she bravely clung to it and resisted

the temptation to be moodily occupied with her condition. Above all,

she needs to be in the air. Oxidizing processes within the body are

slower and while much exercise is not beneficial and may be often

harmful, riding in the air, sitting in the air, above all, sleeping

where there is an abundance of fresh air is all-important. Every form

of exertion will be reflected in increased irritability. Shopping,

balls and parties will disturb the woman's mental equilibrium and make

it more difficult for her to stand whatever physical discomforts she

may have, and also make it hard for her to pursue her ordinary

occupation if this is somewhat exacting. Even these, however, must not

be given up if the sacrifice involves the throwing of the patient back

on self and increases introspection. Diversion of mind and

temporizing with symptoms are the basis of therapy at the menstrual period.

{437}

CHAPTER III

AMENORRHEA

No feature of menstrual difficulty shows so clearly the influence of

the mind over bodily function, and especially over those genital

functions that are supposed to be involuntary and spontaneous, as

amenorrhea. Almost any kind of mental trouble may produce a cessation

of the menstrual functions. Profound grief or a severe fright nearly

always does. Every physician of large experience has seen cases of

women who have missed their period because they were disturbed by a

fire, or a runaway, or an automobile or railroad accident within a

short time before their menstruation should normally occur. Even

slighter shocks may have a similar effect, and a profound shock of any

kind will seriously disturb menstruation. The most frequent effect is

to inhibit it, but it may be anticipated or delayed, and where there

is a tendency to too profuse a flow, it may produce menorrhagia.

Every physician knows that much less serious mental influences than a

profound shock or fright may somewhat disturb menstruation and, in

young women at least, this disturbance is nearly always in the

direction of lessened flow and amenorrhea. Home-sickness, for

instance, will often have this effect. Many of the foreign-born

domestics who come to this country have serious disturbances of their

menstrual flow, usually a diminution, during the first three or four

months after they arrive in America. This may, of course, be due in

part to change of climate, change of food and change of habits of

life. These girls while in their European homes have often been

accustomed to be much more out of doors and to have more exercise in

the open air than they have here.

That the mental state has much to do with menstruation may be

appreciated from the fact that serious changes of her state of life

may be accompanied by amenorrheal symptoms even when the patient stays

in the same climate and under conditions not different physically from

those under which she has lived. Country girls who come to the city

often suffer from such symptoms. Young women who enter convents

sometimes have these symptoms for some months, and this is so well

recognized as to be expected in a certain number of cases. Indeed,

there is danger that it should be attributed too much to the change of

mental state, and that other factors, such as incipient tuberculosis,

or disease of the ductless glands, or anemic states, which are

responsible for it, may fail to be appreciated because of the ready

explanation afforded by the mental factor. General experience shows

that the attitude of mind of a patient toward menstruation, the

expectancy of it at a particular time, and a good general physical

condition that predisposes to it, are quite as important for its

regularity as the specific physiological conditions which naturally

bring it about.

Fright and Amenorrhea.--Fright particularly may disturb menstruation

in many ways. Occasionally the disturbance of menstruation consequent

upon shock lasts for months or even years. At times when a woman

between thirty-five and forty is seriously frightened, especially by

terror that endures {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 attitude had

produced the series of symptoms that proved so deceptive. These cases

of pseudocyesis are so likely to occur that a physician in dealing

with a woman, who being rather well on in years when she marries is

anxious to have children, must be on his guard and he must always take

into account the possibility of a pseudo-pregnancy and must be careful

not to be deceived by symptoms that would ordinarily indicate beyond

doubt the beginning of pregnancy. Even experts have been deceived in

such cases, and it is in them that accurate rules for the certain

detection of pregnancy are most needed.

These symptoms have reference not only to the uterus, but also at

times to other organs. They are not merely subjective, but sometimes

become so objective as almost to demonstrate the diagnosis of

pregnancy, and yet a mental condition is the only source of the

changes. For instance, cases of false pregnancy have been reported in

which, besides the gradual enlarging of the abdomen with many of the

signs of pregnancy accompanying that phenomenon, there has been an

enlargement of the breasts and even the secretion of milk. In a few

cases the enlargement of the abdomen has been accompanied by

pigmentation and the areola of the nipple has also become pigmented.

This is not surprising, since corresponding changes take place in

connection with fibroid tumors, and the deposit of pigment is not a

symptom of pregnancy, but only a result of the congestion which takes

place in these structures during their enlargement.

{439}

Amenorrhea from Dread.--In some cases all the symptoms of pregnancy

develop, or at least there is complete cessation of menstruation, as a

consequence of nervousness and dread of the occurrence of pregnancy.

Unmarried women who fear that they may have become pregnant by

indiscretion, sometimes become so worried over their condition that,

without any physiological reason, they miss one or more periods and

thus add to their nervous state and further inhibit menstruation,

though usually two months is the limit of such amenorrhea and the

menstrual flow commonly makes its reappearance shortly before or after

the time of the third period. Occasionally, however, in the case of

anxiously expectant married women further symptoms of pregnancy may

appear and the case becomes more complicated. Every physician of

considerable experience has seen such patients, and doubtless much of

the harvest which advertisers reap from drugs that are supposed to

produce abortion comes from nervous young women who are not really

pregnant, but have inhibited their menstruation by worry, and who take

these medicines with confidence and have the menstrual flow restored

by trust in their efficacy.

Ductless Gland Disease.--Of course, in many cases of amenorrhea there

are serious underlying constitutional conditions which may or may not

be amenable to treatment, but the possibilities of which must always

be thought of. One case of amenorrhea I saw in recent years proved to

be due to a beginning acromegaly. There was no sign of enlargement of

the hands, though there had been a coarsening of the face which was

attributed to growth and to the fact that the girl was taking much

horseback exercise in all weathers. She had a headache for which no

remedy seemed to be of any avail, and when the amenorrhea developed it

was naturally thought that the headache must be due to gynecologic

conditions. Nothing was found on investigation, however, and

eventually the gradual development of the symptoms of acromegaly

showed what was really the basic cause. Occasionally diseases of other

ductless glands, as the thyroid, may have amenorrhea as one of the

first symptoms. It is seldom that any serious thyroid condition

develops without disturbance of menstruation, but this is less

frequently in the direction of diminution than toward profusion and

prolongation. In some cases, however, one or more periods is missed in

the early development of the disease. In this, however, others of the

characteristic tripod of symptoms--rapid heart, tremor,

exophthalmes--are sure to be present even though the enlargement of

the thyroid is not noticeable.

Tuberculosis.--But more important than these causes of amenorrhea is

the early development of tuberculosis. In some cases, even before

there is any cough that calls attention to the condition, or when the

cough has been considered to be one of those myths now fortunately

passing, "a cold that hangs on," the cessation of menstruation may

depend entirely on the weakness and anemia due to the growth of

tubercle bacilli in the lungs.

Inanition Amenorrhea.--Sometimes indigestion, or what is supposed to

be indigestion, may be at the root of the amenorrhea. In many cases it

really is not true indigestion that is present, but a disinclination

for food which has increased to such a degree as to bring about a

lowered state of nutrition. In nervous young women and, above all, in

nervous spinsters beyond forty, disturbances of menstruation

consequent upon lack of nutrition are not infrequent. Often their

indigestion is considered to be a reflex from their genital {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.

Psychotherapy and Treatment.--The treatment of amenorrhea on

psychotherapeutic principles will be readily understood from the fact

that there is a distinct psychic element in practically all the cases

touched on in this chapter. This psychic element is generally

appreciated and admitted. If a woman is accustomed to connect certain

physical incidents with disturbances of menstruation, then those

disturbances are almost sure to recur. As a rule, many an incident

said to be disturbing to the function would probably have no influence

upon it but for the dread connected with it and the anticipation of

some interference. In all cases of amenorrhea, then, the patient's

mind must be put into a favorable state and suggestions must be made

that will lead to the expectancy of menstruation at the next regular

period. If the mind can cause menstruation to cease, as is clear from

experience, any inhibition from this source must be removed and its

power set to bring relief to these patients. Drugs should not be

neglected, and general physical conditions must be improved, but if

the patient's mind continues to be unfavorably affected towards her

menstruation, its satisfactory return will be delayed until somehow

mind as well as body are co-ordinates for the resumption of the

function.

The best testimony to the value of psychotherapy in amenorrhea is

found in the success of many of the remedies used for the condition,

which, in the successive phases of medical development, have included

all sorts of home treatments, many types of quack medicines, and

innumerable proprietary combinations. Many of these have acquired a

reputation for efficacy not justified by any direct pharmaceutic

effects which we now know them to possess. From the familiar gin and

hot water, through the various combinations of aloes and the tonic

remedies of a later time, only the most general and obvious effects

could have been produced by the medicines, yet apparently specific

reactions have followed them in the menstrual cycle. But this was

because the mind of the patient was prepared by the taking of the

remedies and unfavorable suggestions as to menstruation were removed.

Above all, with amelioration of the general health, constipation being

relieved, the appetite restored and the whole tone of the system

improved, nature became capable of taking up once more the menstrual

function. What was accomplished by indirect psychotherapy in the past

can now be done much better by direct mental suggestion, when at the

same time various remedial measures in other therapeutic departments

are employed as auxiliaries. But the physician must be sure that the

mind of the patient is properly disposed or remedies may fail and

symptoms continue.

CHAPTER IV

DYSMENORRHEA

Practically every woman of menstrual age has more or less discomfort

during menstruation. In most cases this does not rise beyond a heavy

depressed {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 associated with painful conditions in connection with

the menstrual flow. It may be applied, however, to various

uncomfortable feelings, to superirritability, to fatigue, to lack of

energy, or even to more vague discomforts at this period. The

discomforts are usually spoken of as pains, especially after the

patient has been dwelling on them for some time and has been reading

patent medicine advertisements that tell of how women suffer in

silence, but analysis often shows that they are sensations of

pressure, of compression, of achy distress at most, and sometimes only

of unusual feelings--paresthesiae--that having got over the threshold

of consciousness, through concentration of attention upon them, are

occupying the center of the stage of mental activity to the exclusion

of all serious interests.

The serious difficulties of menstruation are due to definite

pathological conditions such as displacements of the uterus,

affections of the uterine mucosa and of the ovaries. There are,

however, many cases where the trouble is merely functional, dependent

on conditions that can be easily corrected without serious surgical or

even lengthy medical treatment, and where the patient's attitude of

mind towards the trouble is the most important factor in the medical

aspect of the case. As a matter of fact, many of the discomforts and

even serious pains complained of in connection with menstruation are

due rather to the patient's incapacity to bear even slight discomfort

with reasonable patience and without exaggerated reaction than to the

actual pain inflicted by whatever disturbance of function and tissue

may be present. People differ very much in their power to stand

discomfort and what seems quite trivial to one becomes unbearable

torture to another. With this in mind it is possible to relieve many

women who suffer from dysmenorrhea from their discomforts so that they

shall only have to bear what is every woman's heritage in the matter.

Successful management of these cases will save them from the supposed

necessity of being operated on, which is likely to be constantly

suggested to them in an age when women so often talk of their

operations.

The amount of pain suffered from any cause is dependent on two

factors, the pathological condition and the power of the individual to

withstand {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

appetite unless there is a daily evacuation, and partly also because

the presence of an accumulation of fecal material in the lower bowel

is likely to produce congestion in the pelvic region. This added to

the normal congestion due to the menstrual function may cause undue

pressure upon sensitive nerves in the ovaries and uterus. Indeed a

regulation of the function of the bowels is immediately followed by a

lessening of the menstrual discomfort as well as by a general

improvement. Many women find that the taking of a gentle purge a day

or two before the menstrual period serves to make that period a source

of less discomfort than it would otherwise be, and undoubtedly the

suggestive value of such a remedy persuades many women that their

discomfort should be lessened.

Professor Goodell's reminder that women have many organs outside of

their pelvis is important in dysmenorrhea. Almost any ailment that

drains a woman's strength and brings a series of irritations to bear

upon her nervous system will be reflected in her genito-urinary system

and will cause discomfort during the menstrual period. Over and over

again the physician finds that the true source of the menstrual

discomfort is not in the essentially feminine organs, but in the

digestive organs or occasionally even in such distant organs as the

lungs, and that proper attention to these brings relief during the

menstrual period. Just as soon as they realize that this is not a new

affection but only a reflex from their other ailment, whatever it may

be, they stand it with much better spirit and their complaints

diminish.

Anyone who has seen the difference between the reaction to menstrual

moliminia when patients are in good condition and when they are

otherwise run down will realize how much a matter of over-reaction to

symptoms dysmenorrhea may be. Teachers who begin the school year,

invigorated by their vacations, scarcely notice their periods, but at

the end of the course, when run down by months of hard teaching work

and especially by the confinement of the winter, they find the strain

extremely hard to bear. In many of these cases an examination by a

specialist seems to reveal something that might be {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

circumstances that were extremely hard to stand up bravely against.

Not only did they stand it, but they had better health, they had less

complaint of pains of all kinds, particularly in this matter of

dysmenorrhea, than they had before.

Pain and Occupation of Mind.--The more claims a woman has on her

attention the less likely is she to be bothered at her monthly

periods. If she does not _have_ to get up in the morning because there

are no insistent obligations upon her, she is likely to lie in bed and

worry about herself and by concentrating her attention on her ills

will make them worse than they are. But if she has to be up and doing,

if household cares cannot be put off, if she has to earn her living by

working every day, she not only succeeds in doing it, but often also

forgets her ills to a great extent in her occupation. Of course, there

are pathological conditions that cannot be put off in this way, and if

there are serious uterine changes, or if an infection has spread along

the tubes to the ovaries, there will be symptoms that cannot be

distracted away. Even where there are minor pathological conditions,

however, occupation of mind will make pain less annoying and even make

it quite negligible. We know our own experience with toothache. This

is a real pain and with a real pathological condition of the most

material kind. The congestion of the sensitive dentine or the

irritation of an exposed nerve filament causes about as severe pain as

it is given to mortals to bear. Even with toothache, however, we can

by occupying ourselves with friends, or with a pleasant book, or a

game of cards, or the theater, so diminish the annoyance consequent

upon the pain as to be comparatively comfortable. If anything

completely occupies our attention as, for instance, a fire or an

accident, or bad news from a friend, then it may be hours afterwards

before we realize that we were suffering from a toothache. Since this

will happen with a dental nerve, why should it not {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 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, {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, 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 {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 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 {447} 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 {448} 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 {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.

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 role 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 {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 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

{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 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.

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 amusement, 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 sexual and other

irritations, and with better possibilities of accomplishment.

Definite Prescriptions.--These patients are best reassured 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

passing 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 passing 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 appetite, 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 passing 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 sexual 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 prone 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 anticipation 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 prone to constipation,

makes their sleep less restful, and reduces the appetite. 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} appetite, etc. Many of the

discomforts and symptoms of which women complain during pregnancy are

really due to unfortunate habits and to their mental attitude 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 accumulating 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 unencumbered with useless adipose

tissue. Her will must overcome the tendency to lassitude and the

proneness 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

prone 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 associated 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 assured 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 passed

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 pass

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 fuer 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

fuer 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

assertion 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.

Kronig thinks that the vomiting of pregnancy is an especially

favorable subject for suggestive treatment. He inclines to the opinion

that the remedies that have been reported to do good and so many of

which have subsequently proved unavailing have really owed whatever

success they have had to the suggestion that went with them. Bumm, in

his text-book of obstetrics (Grundriss zum Studium der Geburtshuelfe

von Dr. Ernst Bumm, Wiesbaden, 1902), accepts Kaltenbach's and

Ahfeld's conclusions and thinks that the consideration of

_hyperemesis_ as an hysterical neurosis is well supported by the

success and failure of our therapeutics. All sorts of remedies, any

number of drugs, all manner of gynecological procedures short of

abortion, though also including abortion, have been reported as doing

good. All of them even including abortion have failed in a certain

number of cases. Evidently suggestion plays a large role. Hypnosis

often proves an excellent remedy.

Excessive Salivary Secretion.--Bumm considers that the excess of

secretion of saliva which is so often noticed in pregnancy is of the

same nature and should be treated rather by suggestion than by any

particular remedy, though remedies should be tried because of certain

helpful physical effects, and then the psychic element that goes with

them. The less importance given to the symptom, the less attention it

attracts, the more its passing trivial character is emphasized, the

sooner it will subside. Solicitude causes it to persist and even

increase.

LABOR

Suggestion in Labor.--When the subjects are normal, expectancy has

much to do with the severity of labor pains. In recent years so much

fuss has been made and so much said and written about woman's burden

and travail in the pains of childbirth, that preliminary dread and

anxious attention have wrought young women up to such a poignancy of

expectation as to make these pains worse than they really are. In the

old days child-bearing was as much a matter of course as the husband

going out to his daily work, and the taking of the dangers and

fatigues of it was a simple matter of duty. Labor was then {458}

comparatively easy and, while never pleasant, was also never an

over-uncomfortable process. The effect of unfortunate suggestion has

been to make it seem ever so much worse than it really is. Multiparae

furnish the best proof of this. A healthy woman who has already had

more than one child does not dread labor pains very much, or only to a

slight degree, because the previous maternities have lessened the

physical pain to be experienced, though a healthy woman's tissues are

so thoroughly resilient that nature is able to bring about a return to

normal conditions so complete that it is not always easy to decide

whether a woman has given birth to a child or not. Of course, there

are many cases in which tears reveal the former labor, but there are

others in which it is not so, and the renewal of the birth process

must, therefore, be nearly if not quite as painful as before,

especially if it is recalled that succeeding children are usually

larger. In spite of this in multiparae, labor has lost most of its

terrors because real knowledge of its comparative ease has replaced

the previous unfavorable suggestion, and instead there has come a

proper appreciation of what will have to be borne, and of the positive

pleasure of the relief when it has been borne successfully.

Healthy women of the lower classes have so little difficulty in labor

that they are quite frank to confess that it means scarcely more than

a few severe muscular pains during an hour or so. Some of them mind it

so little that up to within half an hour of the birth of the baby they

occupy themselves with other things and succeed effectually in

distracting their pains away.

In their article on "Hypnotism and Suggestion in Obstetrics" Drs.

Auvard and Secheron [Footnote 37] suggest that hypnotism can be

employed with advantage during labor, but it is more difficult to

produce it then than in the normal condition. Its only advantage is

anesthesia, and this can be obtained during the preliminary pains in

many cases. It is frequently impossible to produce complete

anesthesia, however. To replace hypnotism they advise that suggestion

in the waking state be used and they even suggest the employment of

pseudo-choloroform or other like means. This method they consider more

advisable than hypnotism, for there are no inconveniences and many

real advantages. The nervous condition of the patient after hypnotism

during labor is sometimes far from satisfactory.

[Footnote 37: "L'Hypnotisme et la Suggestion en Obstetrique,"

Paris, 1888.]

Nature's Methods.--In obstetrics and labor we have been finding in

recent years that we have not trusted nature enough, have not looked

sufficiently to the woman herself for assistance in its difficulties,

and have made her too much a passive rather than an active factor.

Practically all of the dangers that have accrued to the woman in

childbirth, certainly many times more than have come from any other

factor, have been due to well-meant but unfortunate attempts to help

her while preventing her from helping herself. Before the middle of

the nineteenth century most of the puerperal fever was due to

infection from over-zealous but unclean attendants. Now men are

proudly reporting hundreds of cases of delivery without even a vaginal

examination. Above all, we have failed to take advantage of the

occupation of mind that could be used to save women much of the

anxiety and suffering of labor. If the parturient woman were allowed

to change her position, as she does so naturally and frequently in a

state of unsophistication, and to help actively, as she can {459} in

many postures, in the delivery of her child, it would mean much in

diverting her mind from pain which is emphasized by inactivity. The

rule of having the woman lie on her back has been unfortunate in many

ways and has required much more external interference than if other

positions were adopted, while the pains have been more unbearable

because that is actually the position in which the woman suffers most

and in which she can do least to lessen them.

I was once told by an Irish grandmother the story of nearly one

hundred deliveries without accident of any kind, in which the only

rule had been not to touch the woman, but to allow her to change her

position and, above all, to facilitate her in getting on her knees in

a stooping bent-over posture so as to help herself. The upper mattress

was doubled over completely and the woman was encouraged to kneel on

the lower straw mattress, which was so arranged that it could be

changed completely, or destroyed immediately after labor. This seemed

old-fashioned and unscientific twenty years ago, when I heard the

story, but I have been interested recently in reading Professor King's

address on "The Significance of Posture in Obstetrics." [Footnote

38]

[Footnote 38: _Bulletin of the Lying-in Hospital_, Vol. V, No. IV.]

Professor King is sure that there are many advantages in following

certain natural inclinations of the mother to change her position and

that this helps her in many ways. Above all, as the psychotherapist

sees at once, it will occupy her mind, keep down anxiety and lessen

pain in many natural ways, besides encouraging concentration of

attention on muscular effort instead of on painful sensation. The

whole article is well worth reading, for in it he suggests that

certain obstetrical operations, even version, would not be so often

necessary, if the woman were sometimes allowed to assume the squatting

position in the course of birth. His illustrations make very clear the

help that changes of position are in the mechanics of many

difficulties of labor. The pressure of the patient's thigh on the

abdomen, when she was allowed to assume a squatting position, enabled

him, in a case in which the woman had been in labor twenty-eight

hours, in which ergot had been given by the midwife, in which the

waters had been discharged and the uterus was tetanically contracted

around its contents, to deliver the child without instrumentation and

without further delay. In five minutes the arm (for it was an arm

presentation) began to recede, and in twenty minutes the child was

delivered, head first, and mother and infant both did well. Other

cases with similar results have been reported by obstetricians quite

as distinguished as Professor King. Many other experienced obstetrical

teachers have expressed themselves to the same purpose in recent

years.

Postures after Labor.--Allowing changes of position after labor also

has its advantages. There is often retention of urine and this can be

relieved by allowing the woman to assume the usual position. It may be

impossible owing to the swelling and hyperemia in the neighborhood of

her urethra for the woman to pass water, and yet if she is allowed to

sit in the usual position upon a commode, she will in most cases pass

her water in a few minutes without difficulty and the risks attending

catheterization will be obviated. The power to urinate is due in these

cases partly to the pressure of the thighs upon the abdomen which

helps the bladder to contract and undoubtedly also to the suggestive

influence that the position has.

{460}

NURSING

The attitude of mind of a woman toward her milk supply is important,

as the flow of milk is closely subject to mental influence. The

presence of the child and the consequent exercise of maternal instinct

does more to bring about the prompt, healthy flow of milk than

anything else. Sometimes women in the later months of their first

pregnancy upon seeing a mother nursing her child have felt the flow of

milk to their breasts not rarely with such painful overdistention of

the milk ducts as to require artificial relief. On the other hand, a

fright may stop the flow of milk or make it scanty and a mother's

aversion to a child may prevent her being able to nurse it. The sight

of the father of the child in a state of intoxication may have a

similar result.

How much milk supply may be dependent on the state of mind, or at

least the state of the nervous system, can be realized from the

animals from which we obtain milk. Any serious disturbance is likely

to interfere with the milk supply. When a cow's calf is taken away the

animal will often refuse for a time to give milk. If a cow is scared,

as by the attack of a wild animal, or by being hit though only

slightly injured by an engine, it will often not have milk for several

days or even longer. There is an impression prevalent among farmers

that if a cow takes a dislike to a particular person they are not

likely to "give down" as much milk as would otherwise be the case.

This may be only a curious farmer tradition, that has no basis in

fact, although it is supported by so many observations reported from

many different countries that it is apparently to be taken as of

scientific value.

In modern times many fashionable women do not nurse their children

because they have not the proper supply of milk. It is easy to see how

this can be brought about through suggestion from many sources and the

sight of others neglecting their duty in this matter. Most fashionable

women would rather not nurse their children, and yet many of them feel

a bounden duty in the matter. Some of these, however, having heard

that many mothers of the better class are not capable of nursing their

children, easily persuade themselves that they come in this category,

and so their whole attitude of mind toward nursing is one of extreme

doubt. Knowing as we do how the mental state influences nursing we are

not surprised when these women prove not to have sufficient milk in

the early days of the nursing. If they are to have it they must look

forward with confidence to nursing their children and they must be

ready and willing to take such food and secure such fresh air as will

put them in the best possible condition for this function, always with

the thought that nothing can be better for a child than to be nursed

by its own mother. Nature has made exactly the form of food suited for

the particular child, and it matters not how healthy a wet nurse may

be, her milk is not likely to be so suitable. Much depends on the

nutrition of the child during this early susceptible period of its

life and there is more that passes over with the milk than merely the

food elements. It is well recognized now that the reason why nurslings

are protected from most of the so-called children's diseases and the

contagious diseases generally, is that, as a rule, their mothers {461}

have had these diseases, have acquired an immunity to them and this

immunity is transferred to the child so long as the nursing process is

continued. This has been shown to be true over and over again in

animals and holds good for human beings.

Professor Von Leyden, the distinguished professor of medicine at the

University of Berlin, points out that we are not quite sure as yet

just what may happen to the human race from the very general refusal

of mothers to nurse their children and the almost universal

substitution of the bovine mother; whether in times to come certain

bovine traits, at least as regards susceptibility to disease, may not

be stamped upon the human race, cannot be determined until this

experiment in ethnology, now being conducted on so large a scale, has

been carried to some definite conclusion.

Perhaps this view is groundless, but there is no doubt that milk is

more than merely a food and that during the period after birth when

the child's nervous system is being formed, the perfectly adapted

mother's milk is more likely to be the proper food than anything that

human ingenuity can elaborate. We have heard much in recent years of

the tendency of education and civilization to lower the birth-rate and

to make women less fitted for maternity and for such maternal duties

as nursing, but stronger than any deterioration of the physical

constitution by the mental development is the unfortunate unfavorable

effect of mental suggestion upon such functions, by which the

preparation of the organism for their fulfillment is greatly

influenced. It is in this respect that the women of to-day differ from

the woman of the past much more than in mere physical development.

CHAPTER II

MATERNAL IMPRESSIONS

"Maternal impression" is accepted as a specific designation to signify

the real or supposed influence of emotion and especially serious

trouble, which may affect the mother's mind during pregnancy and be

transferred to the child _in utero_, with the production of

deformities or mother's marks. There used to be an almost

superstitious belief in the power of the maternal impressions to

influence unfavorably the child _in utero_. With the newer

developments as to the influence of the subconscious and subliminal

there might well occur in some minds an exaggeration of these ideas

with the production of much mental suffering at least, if not of more

serious results.

Maternal Impressions in Old Literature.--The belief in the influence

of maternal impression on the child _in utero_ is so strongly fixed

that to most people it will seem paradoxical to question the whole

subject. The evidence for it, however, is quite trivial, and none of

it rises above the grade of what may be explained by coincidence. But

there are many apparently insuperable difficulties, from the

standpoint of our modern scientific knowledge, with regard to the

whole subject. If we take up the medical books and the popular

science, or rather pseudo-science, and the folk stories of a century

ago we find overwhelming evidence for the belief in maternal

impressions. More recent {462} literature has but few examples, and

the more the details are studied the less is the evidence of any kind

that the mother's mind influences her unborn child. There is really no

more reason why a child should he marked within its mother's womb than

that it should be marked while nursing at the breast if something

should happen to the mother at that time. This latter effect strikes

one at once as absurd; the former, as we shall see, is exactly of the

same nature.

Many of the older stories of maternal impressions are reported on no

better grounds than the vomiting of snakes and the like, even live

mice, which used to be found in old-time medical literature. It is

true that there was usually no such morbidity about the stories of

maternal impressions, but men wanted to find some explanation for the

problem of the occurrence of deformities and markings and the maternal

impression idea seemed satisfactory and inviting by its very mystery.

The belief that animals could live for some time in human stomachs is

now relegated to the limbo of old-time credulous traditions. Maternal

impressions are on the same path and in twenty-five years they will be

as great curiosities in serious medical literature as the gastric

fauna of two generations ago. Under these circumstances prospective

mothers who are anxious over possibilities and who have dreads of all

kinds about their unborn children should be reassured and informed as

to the scientific status of this important question.

Mother and Child Distinct Beings.--There is no direct connection

between the mother and her unborn babe. No nerves run in the cord and

none pass from the uterine tissues to the placenta. It is easy to

understand the influence of mind on body under ordinary circumstances,

at least the mystery has a rational explanation. The central nervous

system rules the nutrition of the body. To cut off the nerve supply

has as serious an effect as to cut off the blood supply. Owing to the

existence of a chain of neurons, that is, a succession of nervous

elements, instead of one continuous nerve fiber from center to

periphery, it is possible for one of the neurons of the chain to be so

disturbed that the conducting apparatus is interrupted and impulses do

not flow. Hence, if a strong impression is produced on the mind with

regard to a particular part of the body the neurons leading to it may

be so disturbed that trophic nerve impulses do not flow down, the

blood supply of the part may be disturbed through the vaso-motor

system and consequent changes may take place.

_Absence of Circulatory Connection_.--Since no nerves pass, as we have

said, from mother to babe, disturbances acting on the mother's mind

can at most only influence the blood supply to the baby. Most people

think that there is a direct blood supply from mother to child and

that the mother's blood literally flows in the baby's veins. This is

not true. The baby's blood is an entirely independent structure,

originating in the child's own body, and always maintaining a distinct

and quite different composition from that of the mother. The baby's

blood has a higher specific gravity, and it has, in normal condition,

nearly double as many red corpuscles to the cubic millimeter as the

mother's blood. If the blood supply is disturbed by mental influences,

then it is not the baby's blood nor its circulation that is disturbed,

but only the circulation through the maternal part of the placenta

where an exchange of gases and nutrient elements between mother's and

baby's blood takes place. It is {463} impossible to conceive that

during this passage through a membrane of nutrient elements, soluble

proteids, gases, etc., mental influences should also pass over.

Supposed Examples of Maternal Impression.--The stories that are told

would lead us to believe that somehow definite changes in the mother

are reproduced in the babe. One case, which in a circle of friends

that I knew very well made many a convert to the idea of maternal

impressions, was that of a young woman at whom, during an early stage

of her first pregnancy, her husband playfully threw a tiny frog. He

did not know that she had a mortal dread of frogs. She was seriously

frightened and put up her hand to ward off the animal, and as the

clammy thing struck her palm she felt a shiver go through her. When

her baby was born a curious growth that had some pigment in it and

that, by a stretch of the imagination, might be considered to resemble

a frog was in the baby's hand--the same hand, by the way, as that

which the mother used to ward off the animal. The lack of any nervous

connection and of any direct blood connection between mother and child

makes the story simply absurd as an illustration of maternal

impression.

In recent years such stories have come from more and more distant

parts of the country. Kansas was the principal source of them until a

generation of great editors arose there. Texas was then their favorite

location, but Texas has in recent years become so progressive and so

closely connected with the rest of the world that, in spite of its

size, it does not produce so many of these wonders. A generation ago

the announcement of the birth of six children at once in Austria, or

somewhere else in Central Europe, would usually be followed by a

report from Texas announcing seven at a birth. Maternal impression

stories grew luxuriantly for the benefit of the news-gatherer in dull

seasons. A standing type of them is that of the farmer cutting hay on

his farm who puts his fingers too far into the hay cutter and has them

taken off. His wife binds up the bleeding stump. She is pregnant at

the time. When her baby is born--usually two or three months

later--just the same fingers are missing on the same hand of the

child. Now the mechanism by which such maternal impression could be

transferred to the child is incomprehensible. There is no connection

between the two, and the old metaphysical axiom (_actio in distans

repugnat_) that all action between bodies at a distance from one

another, that is without some connecting link between them, is absurd,

holds as good in modern times as it did in the Middle Ages. Surely a

tendency-to-amputation is not carried over from mother's blood to

baby's blood through the membrane in the placenta just as are the

gases for respiration and the nutrient elements for food. If it is, we

have a greater mystery than ever to solve.

Period of Occurrence.--The infant in the uterus is fully formed before

the tenth week of pregnancy and at a time when women are usually

almost unconscious of the fact that they are pregnant. Such

impressional changes as we have referred to, if produced after this,

must be in the nature of backward growth or an inversion of trophic

influences or a great perversion of embryonic life. They have nothing

to do with the formation of the child, since that is completed. They

are as much accidents as if the child should fall after it was born.

We know how fetal limbs are amputated through the formation of

amniotic bands, but that maternal impressions should influence the

formation of these bands is of itself ridiculously absurd. That it

should {464} influence them in a directive and selective way so that

certain limbs may be amputated at a certain point reaches a climax of

absurdity. A distinguished physician of our generation once said that

one might as well hope to absorb a pencil case in one's vest pocket by

medicine as to try to bring about absorption of fully formed

connective tissue by drugs. We cannot think of any mental influence

bringing about such absorption, yet to credit maternal impressions

with the production of fetal amputations not only supposes the

directive formation of connective tissue within the uterus, quite

beyond the domain of the influence of the mother's nervous system, but

also assumes the direction of the anomalous action of that connective

tissue in its mutilating procedures in a very exact and definite way.

Some curious things have been explained on the score of maternal

impressions and it is this very exaggeration that is perhaps the best

proof of how coincidence, imitation, and other factors play a role

that has exaggerated the idea of maternal impressions into a causative

factor. A typical illustration is the case cited years ago, half in

joke, perhaps, half in earnest, by a distinguished professor of

obstetrics. It occurred in the days when the elder Sothern was playing

Lord Dundreary to crowded houses and when Dundrearyisms were the

current witticisms and Dundreary ties and Dundreary clothes and

Dundreary whiskers were all the rage. A young woman who was recently

married became much taken with the actor and went to see him over and

over again, secured an introduction to him, and showed the liveliest

interest in him and the performance. Their acquaintance, however,

remained merely that of chance friends. Some months after it began,

not more than five or six at the most, a boy was born to her.

According to the story this boy, when he began to walk some years

later, developed that little skip in his gait which proved so taking

to those who crowded the theaters to see Sothern as Lord Dundreary.

By this time the play had lost something of its vogue and most people

did not recognize the curious halt in the gait, but it was very clear

to the mother and her friends. It was set down as due to a maternal

mental impression. Mental transfer seems ludicrous in this case. It is

much more likely that the mother was hysterical, and, wishing in a

morbid way to attract attention to herself and her child, taught the

boy the little skip, or perhaps some curious little skip once taken by

the child attracted the mother's attention because of her memory of

Sothern, and her surprise at the act impressed the peculiar action

upon the boy's mind, who proceeded to attract further attention by

repeating it. It is cases like this with their _reductio ad absurdum_

of the whole process that have quite discredited the belief in

maternal impressions.

Some Figures and Coincidences.--The occurrence of mothers' marks in

connection with various external incidents of pregnancy are only

coincidences. Most young mothers dread lest something should happen to

their children. About once in a thousand times an infant is marked in

some way. Nine hundred mothers rejoice over the fact that their baby

is not marked in spite of the fact that they feared it might be,

ninety-nine of them never gave the matter any thought and one of them

finds to her sorrow that her foreboding has come true. Occasionally a

mother who has not dreaded such a result finds that her offspring is

marked. Then she recalls all the happenings of her pregnancy and picks

out something to which she thinks she may attribute the accident.

{465} There must be some reason for it and she finds it. Sometimes she

begins by saying that it must be because she was frightened at such a

time, or fell down at such a place, or saw such a thing, and then a

week later she tells the story with circumstantial additions which

make it very clear to her friends that she knows exactly the reason

and that she had thought about it before and feared it might be so,

though the whole matter was hazy until it had been talked over a

number of times.

Coincidences have been the most serious detriment in drawing

scientific conclusions in every department of medicine. Most of our

diseases are self-limited and any medicine that was given being

followed by recovery seemed to be the cause of that recovery and the

more strictly self-limited a disease the greater the number of

remedies. When stories of maternal impressions are analyzed it is

found that a great many mothers have had forebodings as to their

children being marked and their dreads have not come true. A few have

feared and have realized their worst fears. Many women whose children

are marked can recall no event in the course of their pregnancy which

could have marked their child and they ask the doctor what he thinks

must have been the reason. But unintelligent mothers can always find

some cause by searching out unpleasant details of their experience

during pregnancy.

Intrauterine Nutrition and Nursing.--To explain the occurrence of a

frog-like appearance or a mousey patch on a baby as due to its mother

having been frightened by one of these little animals while nursing

would be the height of absurdity. But it is no more absurd than the

supposition that mental impressions in the late months of pregnancy

can have the effects that are popularly ascribed to them. If a mother

suffers from severe fright, or even if she has a fit of intense anger

or other profound mental disturbance, her milk may disagree with her

infant. Every physician has seen nursing infants made sick by the

change in the milk superinduced by strong mental emotions in the

mother. This, however, could have nothing to do with the production of

a special lasting physical mark on the outside of the body.

Maternal Solicitude and Superstition.--The wonderful stories that are

told are nearly all in the older literature and are much more

reasonably explained on the score of coincidence than on that of any

possible direct connection of cause and effect. Mothers, then, may be

reassured and made to understand that the better their own health, the

less they worry about their condition, the more likely is their

pregnancy to terminate favorably with a perfectly healthy offspring.

This is the source of so much concern in the little world of

child-bearing that it is worth while taking it seriously and making

mothers understand that the old notions in this matter are but

superstitions. Superstitions are not always nor exclusively religious,

they are survivals from a previous state of knowledge, the reasons for

which are now known to be false. Maternal impression, that is, the

belief in the power of the mother's mind over the unborn child, is a

superstition that we must now dismiss.

Favorable Maternal Influences.--Every now and then a sensational

newspaper has an article on how mothers will tend to make their

children physically handsomer by gazing at beautiful works of art,

beautiful scenes in nature, and seeing only handsome (one feels like

inserting well-dressed in the category, also) people during pregnancy.

The reading of good books {466} containing moral lessons of the

highest quality are supposed to have something of the same influence

on the child's character. There is no doubt at all that the more

carefully and simply and beautifully and healthily the mother lives,

and the more her mind possesses itself in peace and happiness, the

better will be her own nutrition and consequently that of her

offspring, and, all things considered, this will contribute to the

perfection of the infant's body and so give the best instrument for

the expression of its soul. That these supposed favorable influences

have any more direct power than this over the state of the infant that

is to be is doubtful. It is worth trying for, but if the indefinite

influence for good emphasizes, as it apparently does in many minds,

the presumed direct and definite influence for evil, then it is not

worth dwelling on.

Etiology of Deformities.--But if these curious deformities and

markings are not due to maternal impressions, what, then, is their

cause? To the question for many of the minor marks and slight

deformities--naevi vascular and pigmentary, extra fingers, slight

overgrowths, special peculiarities of bone and soft tissues--no

satisfactory answer can be given. We must simply say that as yet we do

not know. It is a good thing to say we do not know. Long ago Roger

Bacon declared that the principal reason why man did not advance in

knowledge more in spite of the amount of their work was that they were

afraid to say "I do not know," and accepted inadequate reasons and

insufficient authority in order to avoid this humiliating expression.

On the other hand, there are many deformities and markings, the

reasons for which have been found, and the more important they are the

more we know about them, as a rule. Besides, with the advance of our

knowledge of embryology we are getting to know more and more about

these difficult problems and many things that were mysteries before

are now clear. In addition to observation we have experiment and this

is making observation more thoroughly scientific.

The more we know of the intricacies of the development of animals and

human beings, the greater is our surprise that deformities do not

occur even more commonly than they do. All the openings of the human

as of the animal body gradually close in with the production of the

finished form. The slightest interference with growth in the

neighborhood of these openings, which involve nearly all of the front

of the body, leaves various deformities. Nature has surrounded the

developing embryo with fluid so that it is saved from jars of all

kinds and from contact with other tissues that would disturb growth.

Cell is laid on cell as brick is laid on brick in the building of a

house, and the predetermined plan in the immense majority of cases is

followed without accident to the minutest detail. That more mishaps do

not occur, considering the delicacy of the process and the perfection

of the finished structure, is hard to understand.

There are many factors likely to intrude in every pregnancy that may

lead to the production of unfortunate results. Literally millions of

cells are growing with apparent freedom from constraint in many

portions of the fetus, yet all are directed with definite purpose

corresponding to other cells and are destined to meet in due course of

time. Each one of them or at least each group seems to be independent

in its growth. Each growing cell doubles by dividing every few hours,

yet all are co-ordinated to a definite end. We admire the men who

begin at the two ends of a tunnel far distant from one another and

work without any communication except through the engineer's plans

{467} made long before, and yet make two bores that can be depended on

to meet with but a few inches of divergence. The bridges of tissue

that are built across the openings of the body jut out to meet one

another in this way and in more than ninety-nine out of every one

hundred cases there is not the slightest divergence. Many things may

occur to disturb conditions--not connected with mental influences, but

with distinctly physical factors--missteps, trips, jars on stairs or

getting off and on cars, on the sidewalk, etc. These, and not the

mythical factors that make up so-called maternal impressions, are the

causes of deformities and mothers' marks.

{468}

SECTION XII

_GENITO-URINARY DISEASES_

CHAPTER I

PROSTATISM

It may seem impossible to include prostatic hypertrophy, or the train

of symptoms connected with it, among those affections likely to be

benefited by mental treatment. The history of this affection, however,

and especially of its treatment in recent years since it has come to

be the subject of special study, has furnished many examples of the

value of suggestion in the relief of many of its symptoms. Many forms

of treatment have been exploited for a time, attracting attention

because of the cures attributed to them, and have then been relegated

to the limbo of unsuccessful remedial measures. A striking example of

the place of suggestion came with the development of organo-therapy

some fifteen years ago. The succession of events illustrated well how

much persuasion and a favorable attitude of mind might mean even in so

purely physical an affection as interference with urination by

enlargement of the prostate.

It was at a time when thyroid medication for myxedema having proved

successful the medical journals were full of reports of other

successful phases of organo-therapy. The spleen and the bone marrow

were being used in the anemias, the ductless glands in various

nutritional diseases and even extract of heart for heart disease. Just

on what general principle it was assumed by some German investigator

that possibly extract of prostate from animals might be of benefit in

the treatment of prostatic hypertrophy is hard to understand. The

German physician, however, gave an order to the butcher to send him

prostates and as furnished they were administered to the patients. A

number of patients began at once to improve on the treatment. They

were able to empty their bladders much better than before, the

residual urine was decreased, the tendency to fermentation was

diminished and, above all, the patients' general symptoms were much

improved.

The success was so marked that the German investigator published his

cases and, with the public mind interested in organotherapy, they

attracted wide-spread attention. He was asked how to obtain the

material and only then did he take the trouble to investigate just

what the butcher had been sending him. The description furnished the

butcher by the doctor was that he wanted an organ lying below and

somewhat in front of the bladder of the bull. It was found on careful

inquiry that the abattoir attendants following these directions had

supplied not prostates but seminal vesicles. As soon as this was found

out some of the therapeutic suggestions failed. A number of cases,

{469} however, continued to improve. German medical journals made fun

of the whole proceeding and most people will consider the ridicule

deserved.

Shortly before this time, however, we had had a very similar

experience with another pair of organs. In spite of the fact that

whatever we know about Graves' disease would seem to indicate that

that affection is due to an increased thyroid secretion in the system,

at the time of the organo-therapeutic fads, thyroid extract was

reported as having been used successfully in the treatment of this

affection. The name signed to the report was that of a trustworthy

English clinical observer. A few practitioners of medicine got similar

results, but most of them failed entirely to get his successes and

some of them were sure that their patients were rather harmed than

helped by the new medication. An investigation of just what material

was being employed in the English cases showed that the butcher was

supplying thymus and not thyroid glands. Suggestion did the rest, for

thymus has proved to be quite ineffective, and the treatment was

entirely expectant but acted on a favorable state of mind. Anyone who

has had much experience with Graves' disease knows how amenable to

suggestion the patients are. It would seem evident from the foregoing

story of organo-therapy for prostatic hypertrophy that sufferers from

prostatism are probably as prone to suggestion as patients with

Graves' disease. This is all the more surprising as the two affections

are so different in their etiology. Graves' disease being undoubtedly

a ductless gland disease, while prostatism is due entirely to

mechanical obstruction.

We have abundant additional evidence of the role of psychotherapy in

prostatism. Some years ago a well-known American surgeon suggested

that removal of the testicles would reduce the enlarged prostates. And

much improvement was seen after castration in those who previously

suffered from prostatism. The subject was carefully studied.

Experiments were made on animals and the results seemed to prove that

castration in them constantly produced prostatic atrophy. The fallacy

probably came from the fact that at the time so little was known about

the prostate in comparative anatomy and, above all, with regard to the

prostate in dogs, that it was impossible to come to any sure

conclusion as to reduction in weight and size after removal of the

testicles. A number of prostatic cases were treated by different

surgeons and with excellent results. Then after a time the number of

supposed successes dwindled or proved to be failures and now no one

does the operation. The only explanation that is at all satisfactory

in these cases, is that the rest in the hospital, the favorable

suggestion of reported cures and of an experimental demonstration on

animals led many patients, some of them even physicians, to secure a

better control over their bladders.

It took a good deal of persuasion as a rule to bring men, even men

well beyond seventy, to consent to the sacrifice of their testicles,

but once they did, the sacrifice brought a favorable suggestion to

work and so it was not long before they were able to make their

bladder act much more efficiently against the obstacles presented to

its contraction. Some could be persuaded more easily to sacrifice a

single testicle, but in these cases the mental influence was less and

the reported cures fewer. After a time the operation of vasectomy was

suggested as a substitute for the removal of the testicles. For a time

even this in the hands of certain operators gave excellent results.

Almost any other operation in the genito-urinary tract performed with

the definite persuasion {470} on the part of the patient that he would

be better after it would probably have acted just as favorably. The

whole story of these series of incidents in the surgery of the last

decade of the nineteenth century ought to be a clear demonstration of

how valuable for therapeutic purposes is mental influence oven in

prostatism, and how much we should try to secure its favorable

effects.

Unfavorable Suggestion.--Since enlargement of the prostate has become

a familiar subject of discussion and men know and hear much about it

every now and then, one has to reassure a man but little beyond fifty

that he is not suffering from this affection. Just as soon as a man

begins to urinate frequently during the day and to have to got up once

at night he begins to wonder how soon he will be likely to suffer from

further symptoms of enlarged prostate. If he is of the nervous kind

his worrying will soon give him additional symptoms that will confirm

his suspicions. Probably one of the most familiar of phenomena, even

to the non-medical man, is the ease with which worry and excitement

causes frequent urination. Probably no system of organs in the body is

so likely to be disturbed by the mind as the urinary system with the

exception, of course, of the allied tract, the genital system, but the

two are so one in union and sympathy that they cannot be separated in

practice. The prostate is rather a genital than a urinary organ.

_Urinary Worries_.--When a man begins to worry about the possibility

of bother from enlarged prostate and recalls that frequent urination

is one of the symptoms of it, it will not be long before this symptom

develops. Occasionally his first wakings to urinate at night or in the

early morning are only due to passing conditions, either he drank

freely shortly before bedtime or perhaps he did not drink enough. In

the one case the bladder is rather full; in the other a concentrated

urine, especially with the patient lying on his back, makes itself

felt over the sensitive area at the base of the bladder, waking him

up. The rest of the symptoms may develop as a consequence of

solicitude over a few such incidents.

Practically all men who reach sixty have some tendency to more

frequent urination than before. Their bladder does not hold as much

fluid with comfort and they are likely to have to get up in the early

morning. This does not necessarily mean any enlargement of the

prostate nor any pathological change. The physiological change that

takes place seems to be rather conservative than otherwise. Old

muscles are less capable of extension and thorough reaction than they

were earlier in life and in order that the bladder may not be

over-distended nature makes it more sensitive than before.

_Emptying the Bladder_.--In the study of these cases individual

peculiarities in the emptying of the bladder must be remembered. There

are some men who cannot urinate if anyone is near them, and who even

have to step into a closed toilet if they are to succeed in emptying

their bladders when others are in the room. Some who find no

difficulty in the presence of others in open urinals find it difficult

or impossible to urinate when it is expected of them. Under worry and

excitement urination may become urgent or imperative, but on the other

hand some men find it very difficult to empty their bladders under an

emotional strain. Now that much more is written publicly with regard

to symptoms from enlarged prostate and much more is heard of the

affection, many old men got worried and lose some of the power that

they had over their bladder before, not so much because of their

enlarged prostate as from the {471} psychic loss of control over their

bladder. The viscus consists of a series of muscles, the fibres of

which must be rather nicely coordinated and controlled in order to

secure that complete contraction necessary for thorough emptying. A

certain amount of residual urine occurs occasionally at least in many

other persons besides those who have prostatic obstruction.

_The Question of Operation_.--In recent years there has been a

tendency to suggest operation even on comparatively small prostates

when symptoms referable to them are noted. Operations on the prostate

have become much more easy and successful, and there has been the same

sort of feeling about them among surgeons as there was when operations

for affections, real or supposed, of the ovaries came into general

vogue twenty years ago. I have seen patients in whom an operation for

the removal of the prostate had been suggested, though the only

symptoms were somewhat increased frequency of urination during the day

and the necessity for rising two or three times at night. Such a

suggestion, by calling the patient's attention strongly to his

condition, emphasizes the irritability of the vesical tissues and is

almost sure to bring about a considerable increase in the symptoms.

The first principle of any treatment of irritability of the bladder

should be the setting of the patient's mind as free as possible from

solicitude. Any over-attention is sure to lead to reflexes and often

to what seems to be even imperative urination, though with a little

care and discipline much can be done for the relief of such symptoms.

The necessity for operation must be judged entirely from the symptoms

of the individual patient and not from any hard and fast rule with

regard to the size of the prostate. Prostates are eminently individual

organs, at least as individual as the human nose, and their projection

into the rectum is dependent on the relations of other tissues in the

neighborhood as well as on mere size. Men have been known to live with

comparatively few or no symptoms for many years, though at autopsy

they proved to have what would ordinarily be considered a

pathologically enlarged prostate.

Operations upon the prostate are valuable and indeed often afford the

only avenue of relief from an intolerable condition. The results are

not so encouraging in all cases, however, as to make recourse to

operation advisable until a thorough trial of palliative measures has

been made. It is surprising how often the confident suggestion of

assured relief when accompanied by the same amount of rest in bed and

the special care that is required for an operation, brings about a

disappearance of symptoms that seemed inevitably to demand surgical

intervention. There may be much residual urine, there may even be, as

a consequence of this, some fermentation with cystitis, and yet a

course of rather simple remedial measures may serve to bring about a

period of prolonged freedom from vesical symptoms. If these patients,

however, have heard much of the trials and sufferings of a catheter

life, the solicitude aroused with regard to their condition is

sufficient of itself to disturb their urination to a marked degree.

Unfavorable suggestion is particularly serious in its effects in these

cases, while favorable suggestion frequently repeated will enable the

patient very often to regain bladder control when the developments

present might seem to put that almost out of the question.

Position Suggestions.--An important suggestion for treatment in

prostatism with residual urine seems to be to teach the patient to

urinate lying down, {472} especially with the hips somewhat elevated.

This seems to be the element that proved capable of making many

different operations, castration, the removal of one testicle,

vasectomy, and other suggestions appear curative. My own experience is

too limited to make my opinion of much weight; but I have seen certain

patients greatly relieved of prostatic symptoms and their residual

urine much diminished by the advice to urinate leaning well out of

bed, lying prone with the head lower than the body. A small stool is

brought to the side of the bed, a pillow placed on it and the patient

leans over face down on this with the shoulders considerably lower

than the pelvis. This allows gravity to assist rather than hamper the

emptying of the bladder and after men have become a little used to it

they are quite satisfied to take the trouble. Personally I feel sure

that more generally applied this would put off the necessity for using

a catheter a good deal and even save some cases from operation that

now seem to need it. The principle is exactly the same as that by

which patients suffering from bronchiectasis avail themselves of the

help of gravity and get rid of the nocturnal accumulation of material

in their dilated bronchi. They can thus be saved much trouble and

exhausting effort.

So much, as we have said, is written in recent years with regard to

prostatic symptoms that a body of unfavorable suggestion has been

created. This must be neutralized as far as possible by calling the

attention of patients who have initial symptoms of vesical disturbance

to the ease with which mental influences act upon the urinary

functions. Solicitude and anxiety will add to symptoms and may even

bring about their continuance when the original, local and passing

condition which has caused them has ceased. Very often if the

patient's mind can be properly disposed a marked relief of symptoms

will follow, especially if, at the same time, remedial measures of

other kinds are employed to lessen the irritation that is being set

up. While prostatism seems to be due to such purely mechanical

difficulties that mental influences can mean very little, the history

of the therapeutics of the condition for the last twenty years shows

us clearly that if strong mental influences are aroused they bring so

much relief that many patients consider themselves cured. This

psychotherapy will not do away with the necessity for operation in

many cases, but it will cure many of the sufferers from milder

symptoms and will in not a few cases bring such relief as will prepare

the patients to undergo operation, if it should be necessary, with

more assurance of favorable results.

CHAPTER II

SEXUAL NEUROSES

Anything that disturbs the sexual sphere in either sex, no matter how

trivial it may be, becomes a source of worry and depression quite

beyond its real importance. It is not unusual for men and women to

become so worried over some trifling affection of their sexual organs

that they become convinced that serious pathological conditions are

developing and that there is little hope of anything like a complete

cure. This is particularly true of young patients, but holds also for

those of older years. Slight discomforts are exaggerated into nagging

aches and pains which produce extreme depression of spirits.

{473}

It is important, then, for the physician to recognize this and to

treat the patient's mind by reassurance while conducting whatever

other therapeutics may be required. There is danger always in these

cases of either making too little or too much of the affection. If too

much is made of it, an unfavorable influence is produced in the

patient's mind and the discouragement leads to so much inhibition or

even actual physical disturbance that the affection will not improve.

If too little is made of it, patients get discouraged and are prone to

think that the physician does not understand their cases. Then they go

to the advertising specialist in men's diseases who works upon their

fears and makes them feel much worse than before, though in the end he

may lift the cloud of anxiety from their minds and pretend to have

cured them. He always leaves them, however, with the impression that

something serious has been the matter, and this acts as a nightmare

and a source of dread in after time.

In men the unfavorable suggestions occur particularly as a consequence

of affections of the external organs. In women the same suggestions

are likely to make themselves felt with regard to the internal genital

organs. We all recognize the exaggeration of feeling and even physical

reaction that takes place with regard to slight sexual ailments in the

male, because it is easy to recognize just exactly what pathological

conditions are present and how trivial they may be and yet produce

serious depression and all kinds of symptoms, reflexly referred to

many other organs. There is a tendency to listen to the complaints

from women more seriously because the actual pathological condition

cannot be determined and there is always the fear that some serious

affection may be at work. It must not be forgotten, however, that the

complaints of pains and aches, the disturbance of sleep, of digestion

and of the intestinal function, the mental and physical lassitude and

the over-reaction to irritation which occur in both sexes as a

consequence of sexual affections may be due entirely to mental

solicitude and not to any real pathological change.