AMENORRHOEA, or absent menstruation, may result from very different causes; and may occur, under one or the other of its various forms, at any period of the pubertal life of the female. These various forms of amenorrhoea may be arranged in three distinct classes. First, emansio mensium, in which the menses have never made their appearance. Second, suppression mensium, in which the menses, having made their appearance, have subsequently ceased. And third, partial amenorrhoea, in which the menses are wanting, perhaps for months in succession, but may appear occasionally and at irregular intervals.
Each of these classes of amenorrhoea will need to be more particularly considered, with reference to its nature, causes, symptoms, consequences and treatment.
The emansio mensium, or entire absence of the menses, in females who have so long passed the first age of puberty that the case cannot be regarded as one of simple delayed menstruation, depends upon a very great variety of conditions of the system, of which some are entirely beyond the control of art, some do not need to be interfered with, the remainder only being amenable to medication.
I. The first of these condition, is that which may be called congenital malformation; in which the ovaries are either entirely wanting,. or have remained imperfectly developed, or become atrophied. Similar to these are the cases in which these organs have been destroyed before puberty by accident or disease. The patients in whom this condition exists “may have the body generally well developed and healthy, the circulation active and regular, and the organic functions (save on) fully performed. But the breasts are not prominent; the genital characteristics and sexual propensities are not developed; the voice is deeper than usual; a slight beard appears on the upper lip; and there is a mixture of masculine with feminine peculiarities. Such cases are evidently beyond the reach of art.
There are other cases of amenorrhoea from malformation of less serious nature, which may be relieved by suitable treatment. These are instances in which the menstrual flow occurs internally, but cannot appear externally by reason of an imperforate hymen, absence of the vagina, adherence of its sides, or an impervious os uteri. The periodical efforts at menstruation enable us to determine in such cases that the ovaries are not wanting. And where the menstrual nisus appears without corresponding discharge, a careful examination should be made, till the nature of the difficulty is satisfactorily ascertained. The retention of the menses by an imperforate hymen is by no means dangerous; and admits of ready relief, by a slight operation, when the diagnosis is satisfactorily established. The retention which results from adhesion of the parietes of the vagina or occlusion of the os uteri, is far more serious; since, if not relieved by an operation of greater severity, it must lead to fatal results. Inspection alone, or the touch upon the vulva, will discover the tumor which indicated menses retained by imperforate hymen. But the introduction of the finger within the vagina, or even the exploration by the rectum, will be requisite to determine whether the uterus is wanting; its mouth seated up; or whether obliteration of the vagina be not the cause of the retention. Congenital atresia of the uterus, complicated by retention of the menstrual blood, may be suspected in those cases in which the hymen and vagina are pervious, but where at each menstrual epoch the sufferings increase in intensity, where the menstrual molimen is most violent, but no external discharge appears. There may be a gradually increasing tumefaction of the abdomen; and with the menstrual periods, real uterine colics, sometimes accompanied with chills, with frequent vomiting, colics, syncope, and convulsions. And if no artificial opening is made for the exit of the blood, the difficulty must, sooner or later, become fatal, either by the rupture of the walls of the uterus; by an inflammation of the peritoneum, which is being continually irritated and distended, or by an attack of general marasmus, exhausting the patient weakened by such severe and prolonged sufferings.
II. A second class of cases of amenorrhoea, consists of those which need no treatment. And it is important to discriminate these cases aright; since the female will perhaps suffer more from medication where none is required, than from want of it where it really may be needed. And these cases, now stated to be such as do not need treatment are the exact opposites of those already described as being beyond all treatment. For as those were cases of amenorrhoea from total absence of the ovaries and of ovulation; so these are cases of amenorrhoea in which the ovaries are present, but in which their functional action is so performed as to produce no menstrual flow. And to all appearance, and in fact, so far as the present light of science and of experience shows, these cases are perfectly healthy. Since many women have been known to conceive and bear healthy children and rear families, who never menstruated. And in all those cases in which young women have entered upon the age of puberty, without having experienced the menstrual flow, but still remain to all appearance in perfect health, whether we regard them as cases of amenorrhoea from incomplete development, that is retarded menstruation, or of ovulation without corresponding menstrual flow, all these need no medical treatment so long as they present no positive morbid symptoms.
As we have already shown, those whose sexual development, and consequent ovulation and menstruation, occur late, may prove to be endowed with a corresponding longevity, and power of bearing children long after the usual period of the change of life. This point should be well understood in order that the physician, planting himself on the ground of true physiology, may be able to allay the fears of anxious mothers, who are alarmed if their daughters fail to menstruate in their fourteenth year. it may be sufficient to state here, that there must be other morbid symptoms and conditions than mere non-appearance of the menstrual flow, to justify medical interference in the case of young women.
III. The third class of cases of amenorrhoea consists of those which are amenable to and which require medical treatment.
The first class was composed of those malformations in which ovulation,. and of course menstruation, was simply impossible, by reason of the absence of the requisite organs. These cases admit of no treatment. The second class, in which the amenorrhoea, is the result of some peculiarity of the system by which perfect ovulation may be unaccompanied with menstruation, or in which the amenorrhoea is simply the result of incomplete development without morbid symptoms (retarded menstruation), requires no medical treatment. But in the third class, the amenorrhoea, whether accompanying complete or incomplete sexual development, is a truly morbid condition, as shown by the attendant constitutional disturbances of the entire system. This class is not only amenable to medical treatment, but affords some of the most brilliant illustration of the truth of the Homoeopathic principles and of the action of the Homoeopathic remedies.
We have been thus particular in recapitulating, because it seems of the first importance to understand the difference between that form of late development which may be the result of constitutional strength and which is unaccompanied by morbid symptoms; and that which is the consequence of constitutional dyscrasia, and which is always evidenced by symptoms indicating the anaemic, or chlorotic condition, or by painful and ineffectual attempts at menstruation, or rather ovulation. For as we have shown that ovulation is the primary and menstruation the secondary function; so amenorrhoea is mostly to be considered to be the result of absence of ovulation, as in those cases in which the ovaries are entirely wanting; or identical with or the consequence of imperfect ovulation, where these organs are present.
Symptoms. Those cases of amenorrhoea in young persons, which are unaccompanied by any pain, or other morbid symptoms, and for which therefore we are not called upon to prescribe, are doubtless due to incomplete development of the ovaries. While those cases of amenorrhoea which are accompanied with periodical but futile and painful attempts at menstruation, and in which the general health evidently suffers, are in like manner to the attributed to failure of functional action on part of organs already sufficiently developed.
And this will appear the more evident from the consideration of the fact that the very late development of the ovaries and consequently late menstruation, is not only entirely painless, but may be an attendant of more than usual health and strength. And this will still further appear from the nature of the two entirely opposite classes of sufferers from amenorrhoea.
