Читать книгу The sexual life of woman in its physiological, pathological and hygienic aspects - E. Heinrich Kisch - Страница 21

Not infrequently, though the catamenial flow has appeared at the usual age and has for a time been regular, pathological disturbances of this function ensue.

Amenorrhœa at the time of the menarche may depend on complete aplasia of the ovaries, associated with a rudimentary and imperfect development of the uterus. In such girls, the development of whose reproductive system is thus imperfect, the continually expected menstrual flow fails to appear, in spite of the fact that a recurrent menstrual discomfort, evoked by the congestion of the genital organs, recurs at intervals of four weeks; as, for instance, colicky pains in the abdomen, irritable, nervous states, and mental disturbances. Further, amenorrhœa may be due to one of the various forms of atresia of the genital organs, as for instance to vaginal or hymeneal atresia. In such individuals the first period passes by without anything to attract attention. But at the second period, distress will usually be manifested; and from this time forward, painful contractions of the uterus will continue to occur at four-weekly intervals, and to become more violent as period succeeds period, whilst the menstrual discharge is wanting, or, to speak strictly, fails to find an outlet. The blood collects behind the seat of atresia, and the accumulation gives rise to pressure symptoms affecting the bladder and the rectum, and ultimately also the sacral nerves.

Menstruation, after its first appearance in normal fashion, may be suppressed in young girls in consequence of mental impressions, such as sudden fright; such cases are observed after an escape from a fire, or after a railway accident. Mental stimuli of less intensity but longer duration have a similar effect; sometimes these take the form of auto-suggestion. A well-known instance of the latter phenomenon is furnished by the case of a girl who, in consequence either of actual intercourse or it may be merely of too intimate an embrace with a man, fears she has become pregnant, and actually suffers from amenorrhœa though pregnancy does not really exist. I saw a case in which amenorrhœa was thus produced in a girl seventeen years of age, whose ideas on the process of sexual intercourse were still far from clear. She had permitted a young man to kiss her repeatedly and fervently, and to clasp her in a close embrace. She was then afraid that she had become pregnant; the catamenial flow, which had been regular since she was fifteen years old, ceased to appear; and it was not until at length I was consulted, was able to assure myself that the girl was essentially virgin, and was, therefore, in a position to reassure her as to her own condition, that menstruation again became regular.

Functional amenorrhœa may also occur in young girls in consequence of a sudden change in the conditions of life, a removal from town to country, for instance, or the reverse, travel in regions where the climatic conditions differ widely from those hitherto experienced, or a change from an active to a sedentary kind of occupation. Of this nature is the following case observed by Winter: Miss Q., aged 20; menstruation began at the age of 13 and was regular thereafter; on three successive occasions amenorrhœa occurred during a visit to Berlin, in one case lasting 3 months, another 2 months, and a third 6 weeks, whereas when at home menstruation was regular though somewhat scanty. There were no molimina. Examination showed the wall of the uterus to be thin, length of this organ 7 centimetres (2¾″), both ovaries distinctly palpable. Such a form of amenorrhœa as this, commonly disappears when the girl removes from the conditions unfavorable to the fulfilment of her sexual functions to the conditions favorable to that function.

Not infrequently a chill is in young girls the cause of suppression of the menstrual flow that has hitherto been quite regular, especially effective in this respect being, standing in cold water, getting the feet wet, the influence of rain and wind at the menstrual period on the insufficiently clothed lower extremities, and vaginal injections with water at too low a temperature. Such cases are common among the working classes, especially in washerwomen; but they are also observed among the well-to-do. An example is given by Winter: Miss H., aged 19; menstruation began at the age of 13, regular, at intervals of 4 weeks, the flow lasting 2 to 3 days, and being normal in amount. Several years ago the patient caught a severe cold through paddling in cold water during the period. Suppression of the menses resulted, amenorrhœa being complete for a year and a half. Then menstruation recommenced, but was irregular, sometimes anticipating, sometimes postponing the proper period, the interval being occasionally as long as four months; when it occurred, the flow was represented by a drop or two of blood only, and dysmenorrhœa was severe. At each proper period, if the flow failed to appear, severe molimina occurred in the form of abdominal cramps and headache. Examination showed the uterus to be normal in shape, 4½ centimetres (1¾″) in length, with a very thin wall; both ovaries were palpable, but smaller than normal.

The commonest form of amenorrhœa at this period of life is, however, the constitutional amenorrhœa associated with chlorosis. In chlorotic subjects we have to do, not with a symptomatic absence of the menstrual discharge, but with a failure of the ovarian function, the graafian follicles failing to ripen. We generally find, according to Gebhard, that chlorotic girls begin to menstruate at the usual age, or even earlier. Menstruation recurs once or twice at irregular intervals, and then gives place to complete amenorrhœa, it may be suddenly, it may be gradually, the flow on each occasion being scantier than before. In chlorotic patients, the menstrual discharge, when present, is very thin and watery, and often contains a large admixture of mucus derived from the cervical canal and the cavity of the uterus. The amenorrhœa may be of short duration; or it may last for a long time; so that it is not until after the lapse of months or years, and as a rule in consequence of suitable treatment, that menstruation recurs, being henceforward either normal in frequency and strength, or on the other hand permanently scanty and of the postponing type. The associated disorders from which the patients suffer take the form of headache, dizziness, syncope, feelings of oppression, disinclination for mental and physical exertion, and so on. Since in such cases the ripening of the ovarian follicles also fails to occur, when the amenorrhœa is complete the menstrual molimina are generally wanting (Gebhard).

Stephenson also states that in girls who have been chlorotic for a longer or a shorter time, menstruation frequently begins very early, in any case earlier than in healthy girls.

Usually in these cases various other disorders are associated with the amenorrhœa, such as colicky pains in the abdomen, sensitiveness of the abdominal wall to contact or pressure, headaches, attacks of hemicrania, general mental depression, and hysterical manifestations.

In chlorotic girls, at the times when menstruation is due, a watery discharge often occurs, sometimes slightly tinged with blood. Dysmenorrhœa may also occur at such times.

Attacks of menorrhagia in young girls are usually dependent on disturbances of the nervous system. Sometimes such an attack occurs at the very first menstrual period. Occasionally also menorrhagia may occur in association with chlorosis, to be distinguished according to Virchow from a rare condition named by him “menorrhagic chlorosis,” characterized by excessive menstruation of an anticipating type. The bleeding is in such cases seldom very profuse, however, but the periods are very long, and the intervals exceedingly short. Castan regards such profuse menorrhagia and metrorrhagia occurring in young chlorotic girls, especially at the commencement of puberty, as of an endoïnfective nature dependent upon auto-intoxication. The toxins lead to inflammatory and degenerative changes in the muscular substance of the uterus. According to Frænkel in these cases the ovaries are usually enlarged, seldom smaller than normal.

Frœlich has discussed this subject exhaustively in his monograph on Menorrhagia of Young Girls and Hypertrophy of the Cervix Uteri.^[21] He states that the cases of menorrhagia in young girls at the time of the menarche may be arranged in two groups. In one of these the patients are chlorotic, and menstruation is normal neither in amount nor in duration, but it is the long continuance of the flow rather than its profuseness that gives rise to danger; in the cases belonging to the other group the patients are in excellent health at the commencement of puberty, but menstruation soon takes the form of long-continued and profuse menorrhagia. Cases of the latter kind are due to hypertrophy of the cervix uteri and fungous metritis. Such attacks of menorrhagia in young girls are seen also in cases of infectious disorders, as in smallpox, measles, scarlatina, and above all, influenza. The hæmorrhage often begins in the first days of the infection, and even during the period of incubation, one or two days before the appearance of the general symptoms. If the patient is attacked by influenza while menstruating, the menstrual flow may assume the character of a true menorrhagia. More often, however, in such cases, we have to do with an extra-menstrual hæmorrhage, such as may indeed be observed in girls who have not yet begun to menstruate.