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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 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.

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
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

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.

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