"suppressed;" and, again, this suppression may be suddenly brought about and attended with acute symptoms, and hence properly be denominated acute suppression; or it may not be attended with acute symptoms, and may last long enough to be called chronic.

3d. I think it right to consider deficient menstruation as suppression, although but partial. This partial suppression assumes two forms, viz., infrequency, when the intervals are uncommonly long; and srantiness, the return being regular, but the quantity of the discharge much less than it should be. Or there may be both scantiness and infrequency.

4th. The menses may be retained in the cavities of the uterus or vagina, or both, after having been effused. This retention is very different in many respects from the suppression, giving rise to quite a different set of symptoms, and requiring a separate sort of treatment, agreeing with it only in the non-appearance of the blood externally.

Pathology and Morbid Anatomy.

The pathological states upon which the symptom amenorrhoea is based are very numerous, and sometimes inscrutable. The more obvious are the following: Congenital absence of the uterus or ovaries, or both; congenital or acquired atrophy of these organs; acute or chronic disease of the uterus aud ovaries. The general conditions causing it are anæmia, cachexia, pregnancy, and nursing, serious diseases of any of the vital organs or nervous system, and occlusion of some part of the genital passage.

Symptoms.

The local symptoms which attend the absence of the menses will differ according to the conditions which give rise to it. In acute suppression we shall have signs of great congestion, or inflammation of the uterus. The patient, after commencing to menstruate, being subjected to the causes necessary to suppression, such as the partial or general application of cold, is seized with pain in the back, hypogastric region, and hips, attended with a sense of chilliness more or less intense. These symptoms are usually succeeded by febrile reaction, headache, pain in the limbs, general languor, white tongue, and a persistent pain of varied severity in the region of the uterus. There is, in this state of things, as there seems to be, inflammation of the uterus and ovaries. The symptoms may subside, and generally do in a very few days, leaving more or less local discomfort in the pelvis and neighborhood. At the next menstrual period, if the uterus is not much diseased, and the system not greatly deranged, the blood is effused, but seldom with the same naturalness in quantity, quality, and painlessness as before; there is often more or less pain, which is manifested henceforth at each successive period.

At other times the discharge fails to show itself after having been thus suppressed, and the case becomes chronic, lasting an uncertain length of time. When this is the case, the non-appearance is likely to be attended by chronic inflammation of the uterus and ovaries, as the result of the acute attack, and the morbid effects brought about by uterine sympathies derange the stomach, bowels, liver, in fact all the chylopoetic organs, to such a degree as to render chymification or chylification imperfect. Sanguification will be thus vitiated, anæmia or cachexia results, and the patient becomes broken down and "miserable." We cannot but see in this catenation of circumstances the complicated effects resulting from inflammation of the uterus.

Should the suppression be primary,-by this I mean to say, should the menses never have made their appearance, the girl, if old enough and sufficiently developed, will suffer differently. And there is very nearly, if not quite, the same set of symptoms present in cases where they have made their appearance imperfectly in quantity and quality, or for a few times, and then ceased. The patient suffers under the symptoms of imperfect sanguification: inability to exercise, palpitation of the heart, shortness of breath, torpid liver and bowels, want of appetite, or an appetite for improper food at improper times, despondency, great apathy, and timidity. The surface is pale, and either white and translucent, or more commonly of a greenish hue. The sufferings are often very great and protracted, and not unfrequently merge into those of tuberculosis, insanity, or other serious organic diseases. It is not unusual, even in cases where menstruation has never been perfectly established, to find the patient afflicted, also, with symptoms of inflammation of the uterus.

The general symptoms accompanying scanty menstruation, when the scantiness is the result of imperfect establishment, are very much of the above character, viz., those connected with anæmia, etc. But the scantiness and infrequency, as also the entire suppression of menstruation, usually depend upon organic changes in the uterus grad ually brought about by chronic inflammation. What these are we cannot always determine. Sometimes, however, we find the fibrous structure condensed until the bulk of the organ is smaller and harder than natural; at other times it is greatly enlarged, as I have verified by examination. The most common alteration is condensation and atrophy. In such instances there will, of couse, be quite a different set of symptoms, in fact many if not all the symptoms found described in connection with chronic inflammation of the substance of the cervix and body of the uterus. I need not enumerate them here, but refer the reader to the article in which the general symptoms of these conditions are given. Chronic amenorrhoea, or scanty or infrequent menstruation, is in this way associated with the most miserable states of general health.

We are not to believe, however, that the absence of the menses is the cause of such nervous suffering as we often see associated with it, but that it is caused by the condition of the uterus and other organs upon which the irregularity depends. The non-appearance of the menses on account of the absence of the uterus is not usually attended with the chronic suffering I have here alluded to; ordinarily, and indeed in all the cases of this kind to which my attention has been called, the patients appeared to be perfectly well. One of these patients was thirty-three years of age, another twenty-seven, and a third twenty-two, and all of them were in perfectly good health. This is an argument, I think, in favor of the opinion just expressed, that the serious and annoying symptoms arise from the pathological condition of the uterus, or general conditions giving rise to it. The only symptoms these patients complained of at any time that seemed to be attributable to amenorrhoea were the backache, weight about the hips, etc., which denote the presence of the menstrual molimen. In the cases where amenorrhea exists before the organs are sufficiently developed to assume the function of menstruation, we often observe a good state of health, even after the person has attained to an age when the menses are expected. I have had occasion to see, examine, and watch for several years two cases of chronic amenorrhoea from deficient development of the uterus, and perhaps of the ovaries. They were both married. One of them is twenty-eight years of age, has been married nine years, has never menstruated, has no sexual desires, but lives happily with her husband, and desires to be like other women merely to have a child for him. There are no distressing symptoms in her case. Her breasts and uterus are developed to about the size in a girl of thirteen years of age. There is hair upon the pubes, the mons is well developed, as is also the clitoris. The other has been married three years, is twenty-five years old, and resembles the first completely.

When tuberculosis or other serious diseases cause amenorrhoea they are usually well manifested before the suppression occurs, but sometimes this symptom shows itself so early in the case that it is regarded as the cause of the disease instead of the effect.

From what is said above, the reader will see that suppression is a symptom of the absence, imperfection, or disease of some of the organs of generation, or is due to some grave deterioration of the blood or nervous energies, and that we are to look into all the circumstances which attend upon it, with a view to learn the causing conditions. We shall not always be fortunate enough to ascertain this, and we must then content ourselves with conjecture, and a necessary uncertainty in the treatment we adopt.

Amenorrhea from Retention.

If the retention dates from puberty the patient at the proper time began to experience the symptoms of menstruation. In instances where the retaining condition is acquired, the symptoms will be found to have followed close upon a severe inflammatory or ulcerated state of the uterus or vagina. After the retention is thus established by accident, the symptoms do not differ materially from those manifested where the occlusion is congenital.

At first there are very moderate pains in the region of the uterus at each menstrual period. From month to month the pains increase in severity until they become excruciatingly severe. The pains at each menstrual epoch resemble those of labor, and cause the patient quite as much suffering. They are doubtless caused by the presence of the blood in the uterine cavity, and have for their object the expul sion of that fluid.

Soon after the establishment of this train of symptoms there ensues interparoxysmal suffering, much greater in some instances than others. There is a sense of weight in the pelvis and about the hips, weakness and pain in the back, dysuria, difficulty in evacuating the bowels on account of pressure upon the rectum, etc.

There is, after the first few months, enlargement of the abdomen, which increases more slowly than in pregnancy. The tumor is of the shape and in the position of the uterus, and fluctuates obversely upon percussion.

Diagnosis.

It is not usually difficult to determine positively when there is amenorrhoea, and yet there may be good reason to doubt in some instances. It is not necessary that there should be an effusion of blood to constitute menstruation, for there are periodical discharges from the genital organs which indicate the process of ovulation, and, under certain conditions of the system, are more appropriate than an effusion of blood. I allude to a periodical discharge of mucus or sero-mucus. The uterine congestion is not sufficient in quantity or force to give rise to hemorrhage, but causes effusion of the thinner portions of the blood.

We are often obliged to treat patients for a time without having more than their statements as a basis for our diagnosis, but fortunately, in most cases, this is sufficient. We are not justified, however, in continuing the care of an obstinate case for any length of time without making an effort to verify or ascertain the fallacy of the grounds for our opinion. And, if need be, we must resort to physical examination. The fact of our patient being a virgin should cause deference, but not forbid an examination indispensable to a

correct understanding of the cause of a condition that is destroying her life. I need only mention that suppression, attended with acute inflammation of the uterus and ovaries, will be attended with marked and almost invariably unmistakable symptoms. The pain, fever, tenderness, and sympathetic symptoms will leave no room for doubt. Anæmia, cachexia, nursing, etc., are obvious conditions, and will be easily made out by very little attention.

Correctness in diagnosis may be attained with great certainty when there is physical defect in the genital organs, by proper direct examinations of them, and they should be instituted when other means fail to satisfy us. The presence or absence of the uterus, in most instances, can be satisfactorily determined by introducing the finger into the rectum and a catheter into the bladder, and approximating them. If it is present, its thickness interposed between the two will prevent the finger from defining the shape of the instrument; if it is absent, they may be made to touch with the intervention of the walls of the rectum and bladder. The catheter, in this examination, should be introduced deep into the bladder, and the finger as far up the rectum as possible. With this precaution, there can hardly be a mistake. I have met with several instances of congenital absence of the uterus, and in all the vaginæ were absent, but each case presented all the external evidence of womanhood. The mons veneris was perfect and covered with hair, and the clitoris, labia majora, and breasts were well developed. The patients had the demeanor of women, and assured me that their desire for the society of men was as great as usual, and that they experienced strong sexual feeling. One of them had married, and was defending herself in a suit for divorce, upon the ground of her entire ignorance of any anatomical defect in organization; another was about twentytwo years of age, and submitted to an examination with the hope of having a correction of the physical defect, preparatory to entering matrimony. It is possible that the vagina may be absent while the uterus is perfect in formation-the same examination will furnish us with proof-or the vagina may be occluded from defect of formation. This can be determined in the manner I shall presently describe. Absence of the ovaries cannot always be determined by physical examination, but there is generally such a complete absence of the signs of womanhood in these cases that we cannot long hesitate. The mammæ are not prominent, the manners peculiar to the sex, desire for the society of males, and sexual propensity, are absent. There is no hair on the pudenda, and the whole external organs are not developed. The signs are the same at any age. The patient at mature age presents no more evidence of sexuality than the little girl.

I have very recently met with an instance of congenital atrophy of the uterus. The patient, although now twenty-eight years of age, has not menstruated, unless, as she doubtfully said, twice very scantily when