Endometriosis: A Hysterical History

Endometriosis: A Hysterical History

It's anything but funny.
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Leeches: so common a tool in medical history that for part of the 1800's, France was importing about 33 million leeches annually. With so many to keep track of, one journal advised doctors to count their leeches before and after a bloodletting for gynecological conditions — because a leech lost in a woman's uterus would cause not only extreme physical pain but also undue mental stress.

Yes, you read that correctly. Internal bloodletting. Leeches up the vagina. Aren't you glad to live in the 21st century?

By now, modern medicine understands that endometriosis is an extremely painful gynecological condition where cells from the endometrium — that is, the innermost layer of the uterus — show up elsewhere in the body. These growths of endometrial cells, also called ectopic lesions, cause infertility in affected women as well as inflammation and scar tissue wherever they grow. That scar tissue can turn into adhesions, sticking abdominal organs together (ow). This condition affects about one in ten women, which means a conservative estimate would be over 15 million people suffering from endometriosis in the United States alone. The only sure diagnosis is through laparoscopic surgery (inserting a camera to get a clear view of the lesions), and the only current treatment of the root cause (the lesions) is through surgery (deep tissue excision or total hysterectomy, which doesn't always help). Symptoms can be treated with painkillers and hormone therapy, but that's the same broad treatment for most gynecological conditions. Even with so many women affected, progress in understanding this disease has been slow.

A basic description of endometriosis was first given around the fifth century B.C.

The writers of the Hippocratic Corpus, of the fourth and fifth centuries B.C., narrowed down the symptoms of a gynecological disease to four main factors: pain, infertility, menstrual dysfunction and temporary relief with pregnancy. Although there was some suggestion that social class may influence the condition (that it was somehow only a condition of the upper class), these four symptoms would form a common thread connecting various seemingly distinct conditions with various names that wouldn't be connected in the medical field for thousands of years. Though we now refer to the condition as endometriosis, its most popular name for centuries was "suffocation of the womb" first coined by the Greek philosopher Plato (375 B.C.). According to him, this suffocation occurs because a uterus left too long without pregnancy starts to wander around the young woman's body, hungry for motherhood. If it wanders too far, the tubes get tangled and it is unable to breathe. Women so afflicted in ancient Greece would be treated with succession, the practice of tying the patient upside down on a ladder and shaking them until the womb returns to its proper location. The best prevention method they could come up with was to have girls get married and pregnant as soon as possible after puberty so as to satisfy this hungry and animalistic organ. This method of thinking about gynecological conditions likely contributed to the culture of early marriage for women throughout history and is actually still used in some parts of the world.

After about 500 years of descriptions of extreme pelvic pain causing convulsive fits, persistent infertility, organ adhesions and ligaments infiltrated with endometrial tissue, in the second century A.D., Galen of Pergamon concluded that on one hand, suffocation of the womb might be caused by menstrual blood flowing backwards and becoming anchored in the wrong organs (a theory still used today, called retrograde menstruation theory), and on the other hand, the condition is also likely psychological in nature because young widows simply must go mad after "their loss of sexual fulfillment."

Given centuries of medical research on this kind of pain... Meh, it's all in her head.

This was the first time that gynepathology was authoritatively linked with psychology (though the Hippocratic Corpus also vaguely suggested a link), and it was far from the last. From this seed of thought, the idea that women in chronic, invisible pain are just crazy would persist for millennia. Women would be labeled hysterical, blamed for their conditions, locked in madhouses that civilians visited for entertainment, and treated with shock therapy.

But that's up to the 19th century — let's not get ahead of ourselves. We wouldn't want to miss witchcraft and demonic possession, right?

She's a witch, and she's a witch, and she's a witch...

During the Middle Ages — or the Dark Ages of Europe — the supernatural found its way into the scientific scene. Whether a convulsive fit of pain was blamed on the woman herself being possessed, who was then exorcised, or was blamed on the neighbor across the street, who was then sent to the pillory or executed on charges of witchcraft, women got the worst of this new companionship between the mystic and the medical. Despite new observations on the anatomy of suffocation of the womb, such as an association with ulcers, treatments developed during the Middle Ages included those such as "shouting therapy" and other painful or torturous prescriptions with the idea that a malady like invisible pelvic pain is caused somehow by the woman's bad behavior, so the treatment must be karmic in response. We have to look elsewhere in the world for a bit of level-headedness. For example, it was Avicenna, the Persian polymath, who finally determined that pain was solely biologic and had zero medical benefits. Yet, with no cause of the chronic pelvic pain in sight, ideas of demons and magic as a cause of suffocation of the womb persisted through the Middle Ages and into the Renaissance. Occasionally, a physician would be called in as a witness during witchcraft trials, and it's known that Dutch physician Johannes Weyer and English physician Edward Jorden defended the women accused of witchcraft, insisting that the allegedly supernatural symptoms were in fact entirely natural conditions of the uterus.

The women were found guilty.

Women like them were found to be witches while, at the same time, physicians searched for a medically treatable cause of their ailment. There were two paths of research happening in parallel — some physicians, such as Thomas Sydenham, began to flesh out theories of a psychological cause of "hysteria," while others, like William Harvey and Johannes Vesling, looked to autopsies for a physical source of suffocation of the womb. Both of these paths would develop into the 20th century, and it appears that the treatment a woman got depended on whether she was recommended to a physician or a psychologist for her symptoms.

Physicians and psychologists gave wildly different treatments, but both would appear to have hundreds of years of research backing up their conclusions.

Women diagnosed with hysteria were held in the worst of mental institutions, including the infamous St. Bethlehem Hospital (commonly known as Bedlam), where they were physically restrained with chains and straitjackets. In France, many were held at Salpêtrière outside of Paris. The "hystero-epileptic" ward was entirely comprised of young women, the vast majority complaining of ovarian pain, yet even when the famous French psychiatrist Jean-Martin Charcot visited and made note of this common thread that should have pointed to a gynapathological condition, he concluded that the condition was psychiatric in nature. There was no reason, it seemed, to stop sending these "hysterical" women to the worst of prisons: mental institutions of the 19th century.

Meanwhile, physical signs of endometriosis were noticed most clearly in 1852 by Edward Tilt and in 1858 by Armand Trousseau, who identified the lesions on a macroscopic scale, and named the disease "catamenial hematoceles." It was finally in 1860 that Karl von Rokitansky discovered microscopic signs of endometriosis. Looking at strange tissue growths and uterine polyps, he noticed striking similarities between the growths and the characteristics of endometrial tissue, specifically the presence of glands that should only be present on the tissue inside of the uterus. These findings would be confirmed (or re-discovered) in 1921 by John Sampson, who would then coin the term "endometriosis" in 1927. Importantly, in 1887, Franz Wickel was the first to realize that it was women with very small endometriotic lesions who were most likely to be diagnosed with hysteria and sent to mental institutions, as the lesions were virtually undetectable.

20th century progress (mostly).

In the 1900's, a woman with pelvic pain but no clear cause could still be referred to psychiatrists, but progress in treatment and public awareness was rapidly increasing. Hysterectomy and specific nodule removal surgeries became more advanced with the introduction of non-video laparoscopy in the 1940's. In the 1950's, pelvic exams, previously considered a vulgar suggestion in the United States, became a common procedure with the rising awareness of cervical cancer and the introduction of the Pap smear. It was also in the 1950's that, with the vision of Margaret Sanger, the funding of Katharine McCormick, and the science of George Pinkus that the hormonal contraceptive pill was first introduced, and women with endometriosis were some of its earliest recipients. Unfortunately, the pill at that time used such high doses of estrogen that its side effects included cancers. Research didn't always move forward, though. In 1949, an investigator brought back theories from ancient Greece when he asked, "Is endometriosis principally a disease of the higher social and economic levels of society?"

Video-assisted laparoscopy was developed in the 1970's, and over time the cameras became smaller and the surgeries more precise. While surgical precision and awareness of rampant misdiagnosis have increased in the last few decades, there is still much confusion over the best treatment options for endometriosis. With only laparoscopy as a diagnostic, there is an average of seven years between the onset of symptoms and a diagnosis of the condition. Treatments now include full hysterectomy, deep tissue excision and hormone treatments — none of which tend to work on the first try. This leads women to get multiple surgeries in attempts to treat their chronic pain. Even as recently as 1995, reports have shown that over 50 percent of women complaining of chronic pelvic pain were told there was no "organic" basis for their complaints, thus leaving them forever untreated, or labeling them mentally unstable, or they're even recommended pregnancy as a treatment — the same archaic conclusion as thousands of years ago.

After thousands of years of ambiguity and belittling, it's clear that more information is needed about endometriosis.

Frustratingly, some recent researchers purport to quantify the relative attractiveness of women with endometriosis, or characterize personality traits of women with pelvic pain.

However, many researchers are taking steps in useful, foundational research, working out the molecular markers of the condition, some of which might be treatable with prescription drugs or be useful as a diagnostic red flag as an alternative to laparoscopy.

Cover Image Credit: Medarus

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5 Things I Learned While Being A CNA

It's more than just $10 an hour. It is priceless.
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If I asked you to wipe someone's butt for $10 would you do it? If I asked you to give a shower to a blind, mentally confused person for $10 would you do it? If I asked you to simply wear a shirt stained with feces that was not your own for 12+ hours for $10 would you do it?

You probably wouldn't do it. I do it every day. During the course of one hour I change diapers, give showers to those who can no longer bathe themselves, feed mouths that sometimes can no longer speak and show love to some that do not even know I am there all for ten dollars.

I am a certified nursing assistant.

My experiences while working as a CNA have made me realize a few things that I believe every person should consider, especially those that are in the medical field.

1. The World Needs More People To Care

Working as a nursing assistant is not my only source of income. For the past year I have also worked as a waitress. There are nights that I make triple the amount while working as a waitress for 6 hours than I make while taking care of several lives during a 12 hour shift. Don't get me wrong, being a waitress is not a piece of cake. I do, however, find it upsetting that people care more about the quality of their food than the quality of care that human beings are receiving. I think the problem with the world is that we need to care more or more people need to start caring.

2. I Would Do This Job For Free

One of my teachers in high school said "I love my job so much, if I didn't have to pay bills, I would do it for free." I had no clue what this guy was talking about. He would work for free? He would teach drama filled, immature high school students for free? He's crazy.

I thought he was crazy until I became a CNA. Now I can honestly say that this is a job I would do for free. I would do it for free? I'd wipe butts for free? I must be crazy.

There is a very common misconception that I am just a butt-wiper, but I am more than that. I save lives!

Every night I walk into work with a smile on my face at 5:00 PM, and I leave with a grin plastered on my face from ear to ear every morning at 5:30 AM. These people are not just patients, they are my family. I am the last face they see at night and the first one they talk to in the morning.

3. Eat Dessert First

Eat your dessert first. My biggest pet peeve is when I hear another CNA yell at another human being as if they are being scolded. One day I witnessed a co-worker take away a resident's ice cream, because they insisted the resident needed to "get their protein."

Although that may be true, we are here to take care of the patients because they can't do it themselves. Residents do not pay thousands of dollars each month to be treated as if they are pests. Our ninety-year-old patients do not need to be treated as children. Our job is not to boss our patients around.

This might be their last damn meal and you stole their ice cream and forced them to eat a tasteless cafeteria puree.

Since that day I have chosen to eat desserts first when I go out to eat. The next second of my life is not promised. Yes, I would rather consume an entire dessert by myself and be too full to finish my main course, than to eat my pasta and say something along the lines of "No, I'll pass on cheesecake. I'll take the check."

A bowl of ice cream is not going to decrease the length of anyone's life any more than a ham sandwich is going to increase the length of anyone's life. Therefore, I give my patients their dessert first.

4. Life Goes On

This phrase is simply a phrase until life experience gives it a real meaning. If you and your boyfriend break up or you get a bad grade on a test life will still continue. Life goes on.

As a health care professional you make memories and bonds with patients and residents. This summer a resident that I was close to was slowly slipping away. I knew, the nurses knew and the family knew. Just because you know doesn't mean that you're ready. I tried my best to fit in a quick lunch break and even though I rushed to get back, I was too late. The nurse asked me to fulfill my duty to carry on with post-mortem care. My eyes were filled with tears as I gathered my supplies to perform the routine bed bath. I brushed their hair one last time, closed their eye lids and talked to them while cleansing their still lifeless body. Through the entire process I talked and explained what I was doing as I would if my patient were still living.

That night changed my life.

How could they be gone just like that? I tried to collect my thoughts for a moment. I broke down for a second before *ding* my next call. I didn't have a moment to break down, because life goes on.

So, I walked into my next residents room and laughed and joked with them as I normally would. I put on a smile and I probably gave more hugs that night than I normally do.

That night I learned something. Life goes on, no matter how bad you want it to just slow down. Never take anything for granted.

5. My Patients Give My Life Meaning

My residents gave my life a new meaning. I will never forget the day I worked twelve hours and the person that was supposed to come in for me never showed up. I needed coffee, rest, breakfast or preferably all of the above. I recall feeling exasperated and now I regret slightly pondering to myself "Should I really be spending my summer like this?" Something happened that changed my view on life completely. I walked into a resident's room and said "Don't worry it's not Thursday yet", since I had told her on that Tuesday morning that she wouldn't see me until I worked again on Thursday. She laughed and exclaimed "I didn't think so, but I didn't want to say anything," she chuckled and then she smiled at me again before she said, "Well... I am glad you're still here." The look on her face did nothing less than prove her words to be true. That's when I realized that I was right where I needed to be.

Yes, I was exhausted. Yes, I needed caffeine or a sufficient amount of sleep. My job is not just a job. My work is not for a paycheck. My residents mean more to me than any amount of money.

I don't mind doing what I do for $10; because you can't put a price on love. The memories that I have with my patients are priceless.


Cover Image Credit: Mackenzie Rogers

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To The Undergrad Getting Grief For Choosing A 'Useless' Major, You'll Find Your Way

Yes, it is perfectly fine to not know what you want to do for a career while you're still in college.

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I am a sophomore double-majoring in communications studies and film media, and boy do I hate telling that to adults... or really anyone in the sciences or engineering fields.

The most common questions I get asked by family members, peers, friends, you name it, are:

"What can you even do with those majors?"

"What kinds of careers can you get with that?"

"Why'd you pick those majors?"

All of these questions come with a hint of concern from the speaker that I will be unemployed and broke as a thirty-year-old — not to mention the sly comments typically following these questions as well, stating how easy communications classes seem compared to those with nursing or biology majors.

Now, I'm not saying that my majors are necessarily difficult, but I won't let others make that judgment for me. Every field of study has its easy days and its hard days, and it's all relative to who you're talking to.

A few months ago, my cousin, a mechanical engineering major, told me he thought of me when he went on vacation to Virginia Beach. He and his girlfriend happened to pass a street performer doing magic on a sidewalk, so they stopped to watch the show. The magician turned out to be extremely talented and even said that he had been doing this as his main job for the past twenty years. However, the magician ended the show by saying, "This is why you don't major in communications, like I did."

My cousin got a chuckle out of the story, but it angered me.

Just because this singular man did not utilize his major does not mean that I will do the same. Most of those outside of the major are unaware of how big of an impact the communications field has on society. On top of this, there are so many job options available to people in this field straight out of college. Am I still worried about finding a job? Well, yes, people questioning my choice of major have made me more nervous about it. But regardless, I know it is not a dead-end.

Do I know what I want to do for a career? No... but I now know that that's OK! We don't have to know right now. Why rush the future and end up with a job that you absolutely hate? I'd much rather take my time now, sorting myself out and figuring out my strengths and interests so I can pursue the career that is right for me. I finally was able to find majors that I am happy with, so I will not settle for the judgments I get just because they aren't the most prestigious ones.

College is meant for learning, growing as an individual, and finding your right path in life. If we all came in freshman year with our lives planned out in full already, what would be the point of going to school? We have to take advantage of these two, four, five, or however many years of school it takes for us to get where we need to be and do as much learning as we can about class material and about ourselves.

So, for anyone that experiences judgment for majoring in art, theater, film, psychology, communications, or any other majors that may be looked down upon from time to time, don't let that discourage you. Take pride in your major, no matter what it is! As long as you work hard and work towards your goals you will make your own successes in life.

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