160 DISEASES OF THE UTERUS. 



eases, as well as in chronic dyscrasia and venous congestions, has 

 nothing to do with menstruation. If, in our climate, menstruation 

 begins between the twelfth and fourteenth years, instead of the 

 fourteenth and sixteenth, it is only a morbid symptom if the girl be 

 undeveloped. Many girls at this age, who still go to school and 

 wear short clothes, have full breasts and hair on the pubes. We 

 may say that they have developed too early, but not that they have 

 any anomaly of menstruation ; in them the absence of the menses 

 would be pathological. But, besides these cases, we not unfre- 

 quently find apparently undeveloped girls, aged eleven or twelve 

 years, with regularly-recurring haemorrhages from the genitals, and 

 such characteristic symptoms of congestion in the pelvis that we 

 cannot doubt there is a case of early ovulation a true menstruatio 

 praecox. Experience shows that almost all such girls subsequently 

 suffer from obstinate chlorosis. Cases where menstruation has been 

 observed in small children are only partially reliable. 



It is very rare indeed for menstruation to cease several years 

 too late. Among us, women usually menstruate till forty-five or 

 forty-eight years old. If menstruation has begun early, it usually 

 ceases somewhat sooner ; if the reverse, it continues a few years 

 longer. Scanzoni has seen only one case, in his practice, where an 

 unmistakable menstrual haemorrhage continued to the age of fifty- 

 two years. Even very old women are inclined to regard all haemor- 

 rhage from their genitals as menstrual. 



Of course, we can only speak of amenorrhoea when the menses 

 are absent in a woman who has attained the age of puberty, and 

 has not passed the climacteric, and who is not pregnant or nursing. 

 [Above all, be it observed that the absence of menstrual flow does 

 not warrant the inference that ovulation has ceased. We know, in- 

 deed, that conception may take place during amenorrhcea. On the 

 other hand, the cessation of ovulation after destruction of the ova- 

 ries is not always followed by absence of the menses. In excep- 

 tional cases menstrual bleeding has been observed to continue for 

 some time after the sexual function has been destroyed.] 



Tardy menstruation is one form of amenorrhoea ; too early ces- 

 sation is another form. If a girl sixteen or eighteen years old be 

 no more developed than one of ten or twelve years, she can no 

 more be said to have retarded menses than a fully-developed girl of 

 twelve or thirteen who menstruates can be said to have menstru- 

 atio praecox. Except in cases of tardy menstruation or too early 

 cessation of the menses, amenorrhoea more frequently depends on 

 constitutional disease than on local affections of the genitals. It 

 is chiefly chlorosis, scrofula, and tuberculosis that retard the occur- 



