Should the patient give a history of periodical abdominal pains and malaise, although no menstrual flow has ever been noted, it is advisable that she should be examined as soon as possible, preferably under an anxsthetic, as there is a strong presumption that some form of genital atresia is present, which will require operative interference.
The most usual form of atresia found is occlusion of the hymen. The operation for the relief of this obstruction is simple of performance, but the results are likely to be so disastrous, owing to the liability to sepsis, that unless the practitioner is fully persuaded of his ability to perform the operation aseptically, and to keep the parts aseptic afterwards. he will be wise in calling in the assistance of a specialist. The vulva should be washed and shaved, and plentifully douched with an antiseptic lotion of i in 4,00o perchloride, or drachm to the pint lysol, cyllin, or other coal-tar antiseptic. A crucial incision should he made in the bulging hymeneal membrane. The freer the incision the better, as a small opening allows of the retained menstrual fluid becoming septic while it hinders it flowing away. The tarry fluid should be washed out of the vagina with an antiseptic fluid through a double current catheter (Bozemann's). When the vagina has been emptied, it should be packed lightly with iodoform gauze, wrung out of an antiseptic solution. The gauze may be left in place for three or four days, and after its removal an antiseptic vaginal douche should be administered twice a day for a Should atresia of the vagina or cervix be discovered on examination, the operation necessary to relieve the condition requires a more difficult and consequently more dangerous dissection, during which the same antiseptic precautions must he observed. In such cases the after-treat ment presents the difficulty that there is a great tendency for the artificial passage to contract, and the passage of suitable dilators is therefore almost a necessity.
In rare instances it will be found that the delay in the onset of men struation is due to a failure of development of the genital organs. Should the entire genital apparatus, including the ovaries, be rudimentary, nothing can of course he done. In the more common form, where the ovaries arc present hut the uterus, or uterus and vagina are rudimentary, dysmenorrlicea, or rather attacks of periodical pain without a menstrual discharge, is likely to ensue, and to become worse as time goes on; such cases often require ultimately the removal of the ovaries to relieve the pain.
When the young patient has menstruated a few times in the ordinary way, and the menses have then ceased to appear, the facies of the girl will in many cases lead the physician to the diagnosis and to the appropriate treatment. The vast majority of such patients suffer from chlorosis, and the main lines of treatment may be summed up as iron, rest, and Deeding. For such a condition Blaud's pill is of course an old favourite. It is perhaps best administered as a " Bipalatinoid," which insures the administration of a fresh iron salt to the patient. I have much faith in a combination of Iron and Arsenic, such as the following: Fcrri et Ammon. Cit. 5j.
Liq. Fozoleri 5ss.
Calumbee art 5vj. Misec.
Et. mistnra. CPt. 5ss. ter die Post cibos.
The combined citrates of Iron and Manganese may be given in 5-gr. doses, or the mixture of Decoct. Aloes and Mist. Ferri mentioned above may be prescribed. No treatment of chlorosis which does not take account of the constipation almost invariably present can be considered satisfactory. In my experience the best routine prescription is some form of saline. This may take the form of a wineglassful of Apenta or other aperient mineral in a tumbler of warm water half an hour before break fast, or of Kriischen or any other fashionable salt, or of what is equally efficacious and much cheaper, t or a teaspoonfuls of Epsom or Rochelle salts in a tumbler of warm water. Saline aperients should be prescribed
with due regard to the result, and the patient should he instructed to gauge her dose so as to obtain one free motion in the day, the amount taken being regulated to this end.
It is a mistake to prescribe much exercise for chlorotic girls. They should have plenty of open air and of sun whenever it can he got, but they should be encouraged not only to spend a ten-hours' night in bed, but to rest during the day as well. It is wiser to drop all active employment; if the patient is at school she should he given six months' or a year's holiday. Iler clothing should be warm, and she should have abundant plain, wholesome food. Fresh meat, ripe fruit, and green vegetables should be insisted on. Further suggestions as to treatment will be found in the section on A careful physical examination may disclose the presence of tuberculous disease, or cardiac or renal trouble, and the treatment appropriate to the affection should be instituted. Thyroid insufficiency is a cause of Amenor not at all uncommon in young and middle-aged women, and should be met by the administration of Thyroid gland in 5-gr. doses at bedtime. When a patient who appears otherwise healthy comes to a physician with a history of amenorrhoea after menstruation has once become established, the possibility of pregnancy should never be forgotten, no matter what her social position. It is not necessary to insist on a vaginal examination to determine this point, as after the third month the uterus can be made out as an abdominal tumour, and the breasts afford corroborative evidence. Unless the diagnosis is unequivocal, it is best to give a placebo, and ask for a re-examination in the course of a month, when the increased size of the uterus, if pregnant, will place the matter beyond a doubt.
It should not be forgotten that before the menstrual function has become fully established, a good deal of irregularity may occur without any abnormal condition being present. Thus it is very common to find a temporary amenorrhoea following on any considerable change in the patient's mode of life, such as the leaving of home to go to a boarding school or to enter business. Such cases, of course, require a minimum of treatment.
Later on in life the causes of amenorrhoea, and consequently the treat ment, vary. Most prominent is the amenorrhoea of pregnancy and lacta tion, and it should not be forgotten that even after the cessation of lacta tion menstruation may fail to become re-established for some months. Sometimes after labour the normal involution of the uterus goes too far. and the uterus becomes smaller than normal, with complete cessation of the menstrual flow (hyperinvolution). For this condition there is unfortunately no cure.
Any loss of blood profuse enough to cause a secondary anemia may be followed by amenorrhoea, which will be cured when appropriate measures are taken to restore the blood to the normal.
Sometimes the presence of an ovarian tumour or tumours leads to scanty menstruation, or even to amenorrhoea, but the absence of the menstrual flow is of small account compared to the more important disease present.
The menopause in rare cases comes on before the fortieth year. Nothing can be done to retard it, and the treatment appropriate for that time of life should be instituted.
I have entirely omitted to give a list of emmenagogues. Such drugs can find no place in the modern physician's armamentarium. Amenor rhoea is a symptom; its cause should be found and treated, and a drug which is professedly used merely to induce a menstrual flow should be regarded as at best superfluous, and at the worst as distinctly and possibly criminal when used indiscriminately.—R. J. J.