The term amenorrhoea signifies the absence of menstruation. It occurs in two different forms: First, those cases in which menstruation has never occurred—emansio mensium; second, those in which it has disappeared after having been established—suppressio mensium.
The following pathological schedule may assist in the study of the subject. It need scarcely be said that it is not presented as correct in every particular, nor with the idea that the dividing-lines between physiological and pathological conditions can be always determined, but as a convenient guide to follow in the study of the subject:
| A. Amenorrhoea (absent menstruation) from | ||
| a, | anatomical conditions: want of development of organs, atresia of passages; | |
| b, | physiological influences: delayed puberty, idiopathic; | |
| c, | pathological causes: constitutional diseases, disease of the sexual organs, the cachexiæ. | |
| B. Amenorrhoea (secondary or suppressed menstruation): | ||
| a, | anatomo-pathological: atresia of passages, atrophy of organs; | |
| b, | physiological: pregnancy, nursing, premature change of life; | |
| c, | pathological: besides those given above—A-c—are psychical influences and exposure or taking cold during menstruation. | |
Absence or want of due development of some of the sexual organs is not of very infrequent occurrence. The ovaries are very rarely found wanting; they are more often checked in development and present the characteristics of early life. This condition may be the cause of delayed, irregular, or scanty menstruation, making a more or less near approach to amenorrhoea. Absence of the uterus is often combined with absence or with an undeveloped condition of the vagina, but this canal may be perfect and no change of the external organs be present to indicate that the uterus is wanting. It may also exist in a rudimentary form, and may be found corresponding in size and shape to the uterus of any period of early life.
Absence of the ovaries not only causes amenorrhoea, but checks the progress of the bodily development and prevents the sexual changes of puberty. When the ovaries are wanting there is almost always absence of the Fallopian tubes, uterus, and vagina. The symptomatology of absence of the uterus is not generally striking, the lack of menstruation being the principal sign; exceptionally, however, it is otherwise. In some cases where the ovaries are present and the uterus wanting, the most aggravated affections of the nervous system show themselves.
Congenital atresia of the genital canal may occur in any part of its course. Imperforate hymen is the most frequent as it is the least dangerous form, being more than twice as common as atresia of the vagina and three times as frequent as that of the cervix uteri. The vagina may be extremely small in calibre, closed in part or the whole of its course, or only a fibrous cord indicate where it should be. The uterus may be closed at the internal or external os; the latter is the more frequent. An occlusion at one point does not preclude the existence of other closures higher up. The effect of a closed canal with a recurring secretion above is evident, and gives rise to a well-marked class of cases. The organs above become distended, and the distension increases until an opening is made by art or the retained fluid bursts a passage for escape. This may occur outwardly with immediate relief and cure, or into the peritoneal cavity, causing speedy death. The time at which the uterus may be expected to give way under such distension cannot be stated, as the power of resistance of the organ differs and the amount of secretion each month may vary widely. Scanzoni in one case evacuated eight pounds of blood, the result of seven months' accumulation, and found the uterine wall as thin as paper. Bernutz states that the average time before interference is necessary is three or four years, and gives a case first operated upon in the tenth year of its course.
Menstrual retention is not at first indicated by pronounced symptoms. Suspicion of the nature of the case may be first excited by the severity of those symptoms which at every period announce the approach of menstruation and known as the menstrual molimen. As distension increases these become extreme, with rectal and vesical tenesmus and severe uterine colic. The nervous system sympathizes, as with all menstrual derangements, and there may be rigor, fainting, or even convulsions.
Whenever a patient presents such symptoms an examination should be insisted upon. It will generally reveal a smooth, soft, and fluctuating tumor, projecting externally if the case be one of imperforate hymen, or higher up if the vagina be occluded. If the uterus has become distended, there will be a round, smooth, elastic tumor above the pubes. Diagnosis will be more or less difficult according to the seat of the obstruction. Cases of imperforate hymen may be readily diagnosed by sight, if touch and the history are not sufficient. When the occlusion is deeper, the patient should be placed under the influence of an anæsthetic. By one finger in the rectum and the thumb in the vagina, and a sound in the bladder, the seat and extent of the obstruction may be determined. Should it be necessary, the urethra may be dilated and a finger passed into the bladder in order to make a diagnosis. Rectal exploration is of great assistance in discovering the uterine enlargement and its character. Scanzoni calls attention to the difference in the cervix when the atresia is at the internal or external os. In the latter case the cervix will be obliterated; in the former, it will be unchanged. With a perfect vagina and a cervix of this character retention may be taken for an early pregnancy, especially as it is not uncommon for sympathetic mammary symptoms and gastric troubles to be present. Time will demonstrate the nature of the case if a diagnosis cannot be made at once.
The age at which the menstrual flow is established varies greatly. The average age of puberty in this country, as appears from Emmet's tables made up of 2330 cases, is 14.23 years, and these are believed to be the only American statistics. A close correspondence may be noted between this and the statistics of the four largest cities of France, which give 14.26 as the average. But that it is not unusual for the appearance of menstruation to be delayed is shown by the fact that of the above 2330 cases, 288 only menstruated at sixteen years and 254 more between that age and twenty-three. The circumstances which may influence, within physiological limits, the appearance of menstruation should be considered in connection with cases of this kind. Climate and social position are the principal ones. The epoch of puberty descends in the scale of age in proportion to the average height of the temperature of various countries, and vice versâ. Social position and city life show a marked effect in hastening puberty as compared with the simpler manners and plainer life of rural populations. It amounts to an average of something over a year, and is explained by the influence of enervating and luxurious habits, of light reading and the drama, the chief subject of both being the grand passion, but especially of a freer intercourse between, and the co-education of, the sexes, and the greater extent to which music is cultivated and enjoyed.