A system of practical medicine. By American authors. Vol. 4

by Unknown

Among pathological conditions giving rise to amenorrhoea it would seem that disease of the ovaries should occupy the first rank in frequency and importance. The reverse is the truth. The ovaries are rarely inflamed, and when so amenorrhoea is not always the result. They are frequently the seat of cystic degeneration, producing tumors of large size, yet so long as but a small portion of one of the organs remains unaffected Graäfian vesicles may still be furnished and menstruation continue. It is by the influence of remote pathological conditions that the menstrual flow is most frequently restrained, and especially by those general affections known as cachexiæ, all of which exhibit marked depression and low grade of vital power and activity, if not more pronounced pathological processes. Chlorosis, the relations of which to menstruation are intimate, and which seems to be sometimes the offspring of amenorrhoea, exerts a marked retarding influence, amounting to an average of one year and a half. The scrofulous cachexia is still more potent: Scanzoni states that of 31 well-marked cases, in 19 menstruation did not occur until the twenty-first year.

Amenorrhoea which is the result of pulmonary tubercular disease comes frequently under observation. It may occur at a very early period of the disease, before there is any great amount of deposit in the lungs, when it is rather the expression of want of vital force than of the exhausting effect of the disease. Under these circumstances it is only to the laity a subject of serious consideration; to the physician it is but a symptom.

The suppression as well as the absence of menstruation may be caused by atresia of the passages, this form differing from the congenital only etiologically, and in the fact that the flow has been once established. The acquired atresiæ are mostly the result of violent inflammations or traumatic influences. The vulva and vagina, or either, may be closed from sloughing after difficult labors or gangrene following the septic fevers. Occlusion of the cervix uteri may follow labor or amputation of the part, but a far more frequent cause is the application of severe caustics, happily less frequent now than formerly. Lawson Tait says he has never met with atresia of this part from any other cause.

The mode of diagnosis has already been given, and in regard to symptomatology there is only to be noted the statement of Bernutz, that there is far greater intolerance of retention from acquired than from congenital atresia.

Atrophy of the uterus is a normal process after the menopause, but it sometimes occurs much earlier in life, and then causes scanty and irregular menstruation or amenorrhoea. Attention was first called to this condition by Simpson as a process sometimes following parturition under the name of super-involution. Several labors in rapid succession have been stated to be a cause, but Simpson and Courty both give a case after a single birth. Uterine atrophy may also result from the pressure of tumors, and it has been observed in paraplegias the result of defective innervation.

The deranged menstruation is the one prominent symptom of this condition, and a diagnosis is to be made by exploration. The cervix is found small and the body light when lifted on the finger. Bimanual examination and the introduction of the sound will reveal the true condition of the organ. The latter process should be cautiously conducted on account of a frequent change of texture in the uterine walls which allows the instrument to pass through them with the use of but very little force.

Amenorrhoea is physiological during nursing and pregnancy. The former needs no attention, the latter only in regard to diagnosis. A sudden cessation of menstruation, the patient presenting all the appearances of good health, should immediately excite suspicion as to the nature of the cause. It needs but little experience to distinguish and manage these cases in the lower social ranks. The case is different, however, in a family of good position, with an anxious mother urgent for active measures, where no suspicions will be tolerated and the imputation of possible pregnancy be warmly resented. Time is here the sure ally of the physician, and an examination should be deferred until such a period has been reached that pregnancy can be positively negatived or determined.

The influence of acute diseases in suppressing menstruation is not marked. During convalescence from them the flow frequently ceases from general debility. All chronic diseases depressing and exhausting in nature cause suppression, as albuminuria, cirrhosis, and cancer. Tuberculosis is as fruitful in interrupting the return as in preventing the appearance of the flow, and suppression from this cause is very frequent. Under impaired nutrition and depressed powers vital force is engaged wholly in maintaining existence; there is none for any function relating to the propagation of the species. In this class the disappearance is gradual; the flow becomes scanty and irregular in recurrence, and finally ceases. This form of amenorrhoea differs in no material point from the similar class already considered; it is but a symptom of disease of some vital organ or of some general abnormal condition.

Suppression from psychical influences is not at all uncommon. Fright, grief, bad news, sudden or prolonged anxiety, frequently cause this disturbance of function. The mental impression need not be very profound. Amenorrhoea is a common event with girls who go away from home to boarding-school. In these cases it is not probable that there is any pathological condition of the sexual organs; a change in their innervation is a phrase which will best serve to explain the origin of the derangement or to express our ignorance. The diagnosis of this form may be a matter of deep interest when it occurs directly after marriage, as it not infrequently does, and gives ground for the belief that pregnancy has occurred. Still more important is it when the suppression follows illicit intercourse, the fear of pregnancy then exerting a powerful emotional influence. Some cases are on record, and the writer has met with two: in both the function resumed its course after a time without remedies.

Exposure to storm, getting the feet wet, and the sudden application of cold to the genitals frequently cause suppression. All the conditions, however, are not well understood. The bathing- and fishing-women of Europe are said to ply their vocation without reference to menstruation, and to suffer no inconvenience. In these cases the increased flow of blood to the pelvic organs oversteps the narrow line which separates physiological from pathological congestion, and may even pass on to inflammation.