Muzurirur, 10 (1988) 83-108 Elsevler Scientific Publishers Ireland Ltd.
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MAT 08473
Menopause and Menorrhagia: a historical exploration Joel Wilbush Research Associote, University of Alberta, Edmonton, Alberta, Cunada (Received 15 December 1987; revision received 4 February 1988; accepted 4 February 1988) Like a parallel article [l] this one also attempts to answer the question why complaints of excessive premenopausal bleeding have now virtually disappeared. Unlike the first, a review, this is a discussion paper. It explores widely, investigating the question from all aspects, even utilizing, if with caution, such unconventional sources as still unproven hypotheses or marginal theories. Presentational attitudes to, and handling of, climacteric complaints appear partially to obscure some symptoms associated with excessive menses. More importantly, however, the examination of the historical records in the light of present knowledge greatly increases our understanding of past soclo-clinical events. It is then that attention is concentrated on a significant omission in these data: the fall in numbers of biis per woman, fust among the French and European aristocracy, then the population of France and finally that of the rest of Europe. This parallels the spread of the menopausal syndrome and complaints of excessive menstrual loss. It is suggested that limitation of the family, by design or secondarily to lifestyle, has created a unique bio-endocrinology in the West. In the past this produced a number of complications, including climacteric menorrhagia. Never redressed by preventative measures - for these had repeatedly been rejected as militating against the lifestyle chosen by Western women - they were only solved with the advent of abdominal hysterectomy. Steroidal oral contraception and hormonal treatment have, however, made this operation often unnecessary. (Key words: Menorrhagia in climacteric, History Hysterectomy, Culture and endocrinea. History climacteric, Fibromyomata)
Menstruation
and contraception,
A disability disappears, a symptom gone Menopause among many Western European women [2] used to be almost always heralded by an irregular, occasionally excessive, catamenial loss, not infrequently progressing to menorrhagia of varying severity. Yet few climacteric women complain today of increased menstrual flow, let alone the “hemorragies depletives du temps critique” [3] of yesteryears. Menorrhagia, even the once almost universal heavy menses, are today no longer regarded as symptoms of either the climacteric or menopausal syndrome [4]. There is no doubt that uterine bleeding or excessive menstrual flow was, especially towards the end of the 18th century, a serious, often an extremely disabling, complication of the climacteric. Despite changes in medical management and other efforts at prevention and treatment the disability, albeit in Comqondence Canada. 0378~5122/88603.50
to: Joel Wilbush.
DPhil FRCOG,
36-11112-129 St., Edmonton,
0 Elsevier Scientific Publishers Ireland Ltd. Printed and Published in Ireland
AB TSM OYS,
84
a slightly milder form, spread during the 19th century from women of the upper classes, to whom it was previously largely confined, to women of other classes. Affecting first middle class women in France it became common towards the end of the century in England and elsewhere [5]. Having abandoned traditional therapy because of its proven iatrogenic effects, especially in provoking uterine haemorrhage, medical men increasingly attributed continuing excessive menstrual loss/menorrhagia to their patients’ lifestyle. These views were greatly supported by social, “anthropological”, observations, like comparisons between artistocratic French ladies and their sisters of the new British industrial upper classes, or, even more so, the peasant women of their own country. The latter’s complete freedom from climacteric complications, including menorrhagia, was regarded as proof of the health promoting qualities of an uncomplicated life close to nature, of moderation in food and drink and abstinence from the “pleasures of (promiscuous) love.” [l]. In harmony with popular Rousseauian advocacy of naturalistic simplicity and similar fashionable ideas, medical recommendations that women imitate this lifestyle were almost unquestionably accepted, if not enthusiastically embraced by patients. In fact, with the persistant belief in the wisdom of Mother Nature and the ecological good-sense of prescientific Man, many, it seems, still uncritically accept similar ideals today. Variations in identification of the causes of the different climacteric symptoms and complaints or recommendations for their avoidance or treatment, concern us here only in as far as they touch on the aetiology/management of excessive uterine bleeding. Though presented in unfamiliar terms, with physical, behavioural and social elements routinely intermingled, a fair number of these medical observations appear most perceptive [I]. Unfortunately contemporaneous lack of knowledge had, at times, prevented full appreciation of the significance of some of the factors thus singled out, while others, including probably the most important, were completely missed. Their evaluation is attempted in this present exploration. Yet, before examining the reasons for past prevalence of catamenial disturbances/menorrhagia or their present virtual disappearance, it may be profitable to take note, however briefly, of other factors which, though apparently only lessened the importance of these disturbances, have obviously contributed to their perceptual separation from the other events of the climacteric. Clinical/research considerations: technical and/or .attitudinal factors Catamenial events as markers The disappearance of complaints associated with catamenial disturbances from the lists of climacteric symptoms may, it can be argued, be, at least in part, an artificial product of current arrangement of clinical/research “material”. Women who are being investigated or are undergoing treatment are almost always
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divided, in accordance with their catamenial status, to those who are in the premenopausal, perimenopausal or postmenopausal climacteric phases. Such categorization transforms catamenial events from symptoms to mere classificatory markers. They are exteriorized, taken out of the climacteric experience and placed outside the context of its semeiology, in the field of taxonomical labels. In addition, when symptoms of women who are postmenopausal, i.e. having had no menses for over 12 mth, or even perimenopausal, a few months without a menstrual loss, are investigated they obviously do not include catamenial irregularities. Those of premenopausal “subjects” may do so but, since such complaints, unlike other symptoms, cannot be compared with those of the above groups they are, even when recorded, often ignored.
Equating climacteric and neurotic symptoms The last quarter of the 19th century witnessed a great increase in symptomatic climacteric patients in Britain and, later, in the USA. The menopausal, as opposed to the climacteric, syndrome [4] for many years known there largely from the French and French-influenced literature, consequently gained acceptance as a medical entity [6,7]. This was soon siezed upon by general practitioners to label [8] for the “female mergrims whom it offered a new, more “fashionable”, and miasms of difficult classification” [9] so common in their practice. Unwittingly it also encouraged women in the use of this pattern of illness presentation. This was especially so for those subject to behavioral disorders [lo] who, subconsciously, “discovered” yet another legitimate form which they could “utilize” in patterning their complaints [l 11. Climacteric symptoms therefore soon acquired a notoriety of not only “having only a subjective existance” [6] but being usually trivial. Nonetheless, while identification of climacteric disturbances as but “neurotic” disorders might not have been considered by many as misdiagnoses, failure to establish freedom from possible concurrent organic, at time ominous, disease had long been considered indefensible [12]. Yet this continued [13] encouraged by organicist prejudices, sustained by an often sexist bias. Improved clinical techniques had, concomitantly, succeeded in divesting the “traditional” menopausal syndrome of most of its agglomerated, contingent or incidental organic “manifestations”. Oedema, biliary colic or gastroenteritis often prevalent during the climacteric years, even cancer of the breast, were shown to be independent entities with no aetiological connection with it. The conceptual separation of uterine cancer (of cervix or body), or even more so genital bleeding, from a syndrome centred on uterine involution and cessation of the menses met, however, much greater resistance. Careful attention to clinicalhistorical details together with pathological and histological studies did not, nevertheless, take too long to demonstrate that, even if influenced by mid-life hormonal changes, uterine malignancy was not the result of the climacteric transition. The same was argued for disturbances of the catamenia, an integral part of the menopausal syndrome since its inception [l], specifically by denying,
a judgement still open to revision, any connection between oestrogen serum levels and emotional mood variations. These efforts eventually severely pruned the menopausal syndrome of its once “prodigiously multipled” [14] symptoms, especially those attributed to “sympathetic” [14], often organic, accretions. They left it, at least in as far as doctors were concerned, little more than a transparent expression of depression, anxiety and similar emotional disturbances. Medical men came, therefore, to regard it as a “neurotic” entity which could hardly be aetiologically associated with midlife menstrual irregularities or menorrhagia. The influence of psychology, psychiatry and the social sciences The intellectual revolution, wrought by objective studies of individual and group behaviour, in the understanding of human mental processes and conduct had inadvertently also stimulated a number of aberrant views. The new interpretations offered by psychology, and psychiatry, as increasingly guided by environmental, social and cultural considerations, have allowed a deeper more fundamental knowledge, based on extensive and much more searching research previously conspicuously lacking in medical and medicophilosophical theories. They have, however, almost imperceptively, also served to emphasize the duality of body and mind. Female ills have, inevitably, become “phychological” ills, their organic aspects forgotton. This has not been only, or even largely, the fault of these disciplines. The parallel, much greater, development of scientific medicine, of pathological anatomy, clinical physiology, human bacteriology and the multiple applications of the basic sciences sharpened the contrast between the two streams of medicine. Both have, the one as much as the other, each in its own way, combined in destroying all associations between the behavioural and organic aspects of the menopausal syndrome or any other “female complaints”. Concentrating attention on the emotional, social and behavioural facets of the climacteric has tended to divorce it from “the life events of the menopausal transition” [15]. The menopausal syndrome, in this its latest form, has become just “a disorder of middle life”, with catamenial irregularities, not surprisingly, seldom if ever mentioned. The pathogenicity of a misguided lifestyle: lW19th century views [ll Well aware of their patients’ self indulgent licentious ways, doctors, already in the 18th century, had long regarded many of the latters climacteric complaints as the results of their Sybaritic lifestyle. Indeed, blaming behaviour or external factors, like choice of food and drink, or changes in the weather, for consequent ills, for loose stools, headache or chest infection, is part of the Western cultural approach to and general view of illhealth. Unable, nonetheless, to compete with beliefs which incriminated failure of excretion of poisons, previously “purged” by the menses, in these maladies, accusations of “de mauvais emploi de la vie” [la] received but scant attention. The position, however, changed radically after
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the collapse of these traditional concepts. It altered even more with the realization that the opposite imputations that climacteric disorders were largely the iatrogenic effects of traditional medication [17] were somewhat exaggerated. There, indeed, remained little to blame but the old cultural standby: the misguided behaviour of patients. High living, “la profusion des mets” [18] “l’habitude de la bonne there. . . . (et) l’abus du vin” [19], is the most frequent, almost routine, object of medical disapproval and censure [20]. It would have certainly contributed to the frequency of biliary colic and other dyspeptic or colonic disorders, all among the more obvious agglomerated symptoms of the menopausal syndrome (vide supra), but hardly to menstrual disturbances. The latter might, however, have been aggravated by another, in some ways opposite, tendency, more fashionable early in the 18th century, when women “used very pernicious things to gain and appropriate” [21] a pale “delicate” complexion. These included both misconceived diets, frequently resulting in malnutrition, and exanguination by phlebotomy or leeches which, as Hall remarks [22], added to the symptoms of the climacteric. They might have also contributed to the premenopausal disturbances of the catamenia. On the other hand it is of interest that it has, though extremely tentatively, been suggested that the excitement generated by group sexual activity is inimical to conception [23]. Court life with its stimulation of “too lively passions” [24] culminating in “les plaisirs de l’amour” 1251 might possibly have been, in this respect, similar to that in other simpler societies [23]. The hormonal imbalance created by these group activities may not only have helped to prevent pregnancy. Having become quasi-permanent as more women opted for this lifestyle it may have possibly contributed to the excessive catamenial blood loss of the premenopause [26]. A very different, well documented, proven, consequence of frequent promiscuous sexual exposure, further magnified by a generally indifferent sexual hygiene, is a high incidence of cervical cancer. Often associated with vaginal bleeding, this cancer [27] is increasingly reported at the turn of the 18th century. Long known [28], the greater attention focussed upon it might have possibly been partly due to the novel utilization of the vaginal speculum as a diagnostic tool [29]. On the other hand it could represent a true increase in incidence, with the introduction, in 1801 or a few years previously [30], of this method of cervical visualization as an answer to the need for earlier and more accurate diagnosis of a spreading disease - and demands for its effective treatment [31]. Menorrhagia, inter-menstrual and postmenopausal bleeding may also be associated with cancer of the body of the uterus. Often unrecognized or not differentiated from that of the cervix [28] even today [32], it is only indirectly due to promiscuity. Cancer corpus uteri is more common among those who have borne but few or no children. Since the women considered here were often sterile as a result of venereal or postabortal infection, both associated with promiscuity, they would have been relatively frequently subject to it. A low pregnency rate, as well as a fat-rich diet are also among the factors predisposing to breast cancer [33]. Promiscuity has also, obviously, greatly facilitated the spread of “les maladies
veneriennes” [19]. Though an important factor in illhealth and menstrual disorders [ 1] these infections are, nonetheless, surprisingly seldom explicitly named. This may have been socially dictated by good manners, though they may have possibly been included in Chouffe’s “maladies anttrieurs” [14], also emphasized by Gardanne [34] and others. On. the other hand many of their manifestations, the connection with some of which, admittedly, may not have Liebaut (1582) already enumerates been realized, are freely mentioned. “inflammations, abscez, chancre . . . . verrues . . . . (et) condylomes” [28], so does Chambon [35] two centuries later. Most venereal or “socially transmitted” diseases (STD) have both local and general effects, some evident relatively soon after exposure, others remaining silent for many years. Many recurrent pelvic infections, later eliminated or contained by antibiotics, resulted in tubo-ovarian abscesses, which became a constant source of illhealth, impossible to control prior to the development of appropriate surgical excision. Similar conditions resulted from septic abortions or by intermittent, occasionally untreated postpartum infections. Complicated constant, pain, dysmenorrhoea and often dyspareunia, they were almost always accompanied by excessive menstrual loss. While also associated with sterility, the latter can often be due to mild, transient infections which regularly scar and block the fallopian tubes [36]. Sterility is, in turn, translated into fibromyomata and climacteric bleeding (vide infra). It may, indeed, be argued that tubal occlusion due to venereal, postabortal and postnatal infection, even without the general effects of syphilis have acted as a major limiting factor to the fertility and growth of some social groups in Western Europe. Yet, while it was a cause for concern to many [37], it was welcomed by others: indeed, it allowed promiscuous sexual relationships to continue without fear of conception and its social consequences. This unintended loss of fertility, associated with the hedonistic promiscuous lifestyle increasingly adopted by 17/19th century upper class women was complemented by an equally rising practice of intentional contraception. Such a reduction in the rate of conception may, as is now generally appreciated, result in a variety of gynaecological disorders usually most evident towards the end of the childbearing period. Upper class women had less babies; this must have influenced their endocrio-genital system, it affected their catamenia and helped shape the character of their climacteric. Circumscribed by cultural norms, no contemporaneous medical authority, trying to explain the increased incidence of menstrual disturbances, ever mentions this characteristic of Western upper class women, few, despite the knowledge available today, and in spite of the spread of this pattern of behaviour throughout society, have speculated on its still persisting effects, let alone its wider biological implications. Limitation
of the family
All societies have in one way or another [38] at one time or another [39], attempted to control their natural increase and so the numbers dependent on
their economic base [So]. Limitation of the family is, or was, however, seldom part of the ethos of any culture. Even its practice as a routine part of life is extremely limited, being embraced by only few societies the resources of which are visibly limited [41] by a harsh environment [42] or a small, island, area [43]. Western society has long been the only major exception [44]; following deep seated bents, formerly expressed only in mystical views of male-female idealized unions or fairytales, it has, alone among all cultures, shifted the focus of interaction between the sexes from reproduction to a companionship of independent men and women. Unlike women on the other shores of the Mediterranean, to the East and elsewhere, Western European aristocratic ladies [45] were, a few brief intervals notwithstanding, not expected to bear numerous sons. By the 16/17th century large families were no longer desired by most men of substance. The rule of primogeniture protected estates and property from being broken, scattered, or diminished in value and influence. Having too many sons presented unnecessary economic problems: indeed, the cost was at times enough to cause grave financial distress [46]. Female sexuality, almost everywhere closely interwoven with fertility, freed from the never ending obligations of motherhood, has become among the aristocracy, and more recently generally in Western culture, a sexuality of pleasure, sex for sex sake [47,48]. Renaissance redirection of intellectual endeavour, magnified by constant questioning in the enlightenment, had, by extension, eroded many traditional restrictions. Upper class women gained a degree of freedom, including sexual latitude, they had not enjoyed for over a millenium. Having assured succession to title, lands and property, a noblewoman, far from being her husband’s “preserve” was virtually free to follow her inclination in affairs of the heart [49]. Guarding against the penalty of conception, she ensured her lover did not rely merely on the control of karezza [50] but utilized a contraceptive device/condom [51]. As she became more experienced she learned of methods she could use herself [52] though often these were no longer necessary [36]. Neither she nor others wanted to, and seldom did, conceive again. The effects of limitation of the family, aided by contraceptive devices, are evident not only among the French nobility but, by the 17th century, also among some of the bourgeoisie. Yet the diffusion of birth-control methods down all classes of society did not occur till the end of the 18th century, undoubtedly greatly aided by the revolution. It took however 80 or more years before general contraception and the attendant fall in the birth rate became obvious in Britain and other European countries [53]. Slowly, despite setbacks, it spread, till today the trend pioneered by the women of the enlightenment, greatly broadened and amplified, has become an integral part of the relations between the sexes in modern Western life. A unique female bio-endocrinology The combination of factors which was in the past responsible for excessive premenopausal menstrual loss/menorrhagia was apparently also to blame for a
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variety of climacteric disorders affecting Western rather than women of other cultures. Similar circumstances are, indeed still associated with the unique bioendocrinology of this transition, and the catamenia generally, in the West. Though grossly familiar their exact numerical measurement, or the differences of values of their physiological markers from those of climacteric women of other cultures have not as yet been determined [54]. Indeed, the subject has not received much attention, for present tendencies are to blur distinctions, encompass divergencies within standard deviations and internationalize all processes as common to all mankind. This is not to dispute that the same processes are to be found in all human females: it is only to insist there are variations, in this as every other biological process. Rarely due in Man to genetic factors, most differences, once external agents are accounted for, can be traced to social and cultural influences. It is these which through action and feedback affect central control, modify neuropeptide secretion and alter endocrine levels. The hormonal balance thus achieved is, in turn, secondarily influenced, on the individual level, by emotional reactions which, however, are themselves also directed along cultural channels [47,48,54]. The external, visible, effects of the cultural and social attitudes to reproduction are only too obvious. A woman born in a non-Western society or, in the past, to one of the western “traditional” or “peasant” [55] subcultures, usually experiences only relatively few sequences of regular “menses” [56]: in fact some women only have an occasional “menstrual” [56] flow, others none at all. Married soon after the menarche, most women soon conceive: their menses suppressed during gestation and often lactation [57], they may have but one or two periods before they become pregnant again [57]. The process then repeats itself till a “menopause” is surreptitiously established during the last lactation [48]. Indeed, in these circumstances no fertile woman married to a fertile man has recurrent regular catamenia [58]. With late marriage [59], wide use of contraception, small families and avoidance of lactation, Western women’s life has, on the other hand, long become regularly punctuated with menstrual periods [60]. This phenomenon must, however, have been, even in the 18th century, relatively “new” - so much so as to raise the speculation that it was an “acquired” function [61]. Though the adjective “acquired” is scientifically inappropriate, cyclic menstruation cannot, strictly speaking, be called physiologically “normal” [62]. Commonly accepted as evidence of the failure of the endocrine-genital preparation for nidation of a fertilized ovum [63], the recurrent disruption of this biological process is in most cases due either to repetitive intentional avoidance, or a permanent, formerly always unintended, preclusion of conception - both closely associated with the Western way of life. Far from being a “natural” cyclic biological event [64], recurrent menstruation can only be regarded as the result of sociocultural choices, the product of interference with “nature” [65]. However justified, however much it furthered the cause of women’s equality, the choice for control of conception and reduction in the number of children
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borne has not been achieved without costs in female health [66]. Prior to the development of oral contraception the uninterrupted continued prevention of pregnancy exposed hormone receptors in many organs to long, repeated surges of ovarian and pituitary secretions, only seldom relieved by gestation/delivery/ lactation. This seems to have provoked a multitude of pathological changes ranging from disturbances of the hormone balance to distortions of growth, at time neoplastic, of hormone-sensitive tissues. While the latter, like breast cancer [33], are obviously of much greater general significance, attention here is directed more to those which promote menorrhagia: hormonal imbalance, benign fibromyata, some varieties of endometriosis or adenomyosis, and uterine cancer (cervix and corpus). The first two were not only the commonest, but, diagnosis being relatively easy [67] had been routinely noted. Interestingly such reports have historically been on the increase [68] until the growth in the hysterectomy rate and introduction of OC [69] seem to have reduced their incidence. Previously, however, the one or the other, often both, were the most frequent immediate cause of climacteric menorrhagia and so among the most important complications [70] of the unique, Western, female bio-endocrinology. Treatment versus prevention Medical and social, as much as ethical and religious logic or folk wisdom have always maintained that prevention is better than cure. Yet, in practice, Western men and women have always preferred to take the risk, follow their inclination and, if the worst comes, try and escape or minimise the consequences: seek remedies, make amends, buy absolution. Few Western women would, for instance, agree today to live the life of a Navajo or Orthodox Jewish woman, follow an exacting routine of genital cleanliness or equally strict code of behaviour, in order to escape cancer of the cervix. Few, indeed, as the doctors of the last century soon found out [l], would ever contemplate changing their lifestyle to avoid climacteric menorrhagia or other disorders. Like all members of the culture they take their chances and, if or when they get hurt, seek, often demand, help. Western doctors have always been trained to offer that [71]. Recent emphasis on patient eduction notwithstanding, they follow long established traditions [72]: they ask no awkward questions, remain ajudgemental and try and help, do everything in their power for people who, they know, will never listen or mend their ways. Health care systems operate on the same principles, and though most insurance companies weed out risky applicants or load the premiums of others, even they seldom ask questions of a sick person. Only too conscious of repeated failures to convince women to change their ways [73] many doctors endeavoured instead to control directly, even cure, climacteric disabilities. Long aware that once uterine bleeding, the menses, stopped, women often greatly improved in health [74], attempts were made to induce an early menopause by bilateral oophorectomy [I]. Abandoned because of unforeseen complications, greater efforts were concentrated on the more
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ambitious concurrent restore health.
operation
of hysterectomy,
to eliminate
bleeding
and
Hysterectomy for menorrhagia The first abdominal hysterectomy [75] was performed by accident. On 17th November 1843 Clay in Manchester [76], prepared for ovariotomy [77], found a grossly enlarged uterus: he removed it [78]. Not to be undone a rival surgeon “made the same diagnostic mistake” a few days later. These events were repeated in 1853 at Lowell, MA [79]. Mortality was appalling [80]. Despite this, and though cancer, an extenuating factor in the high mortality of vaginal hysterectomy [81], was not involved [82] demand for the abdominal operation grew [83]. It looked as if housebound women, constantly bleeding, rejected by husbands and lovers, saw in hysterectomy a new hope for recovery, a promise of a few years of sexual youth, of being noticed and loved. It was as if women, having nothing to look forward to but long years of waiting till a delayed menopause might allow them an equally colourless if healthier old age 131, grasped at the chance to live fully again. Undeterred by condemnation of the operation 1831 or its high cost [84], they were ready to gamble their lives for its benefits. This is not the place to enlarge on the history or development of the operative techniques of hysterectomy [76,77,79,85--881. We shall here ,only deal with those aspects relevant to this exploration: the role of this procedure in the control of menorrhagia in the climacteric and in conceptually separating it from this phase of life. Hysterectomy is a general term for several very different operations which only have the removal of the uterus in common [89]. Gynaecologically convenient, this terminology has quite often resulted in confusion or been utilized to conceal ambiguities [90]. Here we are only interested in operations designed to control excessive uterine bleeding and, to a lesser extent, bleeding from uterine malignant tumours [81,89]. While fears that the loss of the uterus might damage the very essence of womanhood had already been dispelled in Classical times [91], there was literally no one who could excise the normally situated organ. Surgeons were “externists” [92], traditionally limited to the removal of the prolapsed womb [93] and creating them “generalist” MDs [92] did not instill in them sufficient confidence to enter previously forbidden territory [94]. While “American audacity taught (them) not to be afraid of the peritoneum” 1951 surgeons felt extremely ill at ease invading the pars interna incognita. They did not know how to behave, how much they could safely do: their tactics were little more than a quick “raid”, “kidnapping” their “quarry”, exteriorizing it, closing the abdomen and proceeding as if it were an external organ, a limb to be amputated [77]. This applied as much to hysterectomy [96] as to the older ovariotomy [77]. It took 70 yr from the day Mrs. Crawford demanded her abdomen be opened [95] until doctors, realizing they could trust their sutures out of sight, in the abdominal cavity [97], became “internist” surgeons. It was only then that abdominal surgery, and abdominal hysterectomy, could
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really develop. Improvement followed improvement: better positioning [98], anaesthesia and infection control [99] greatly contributed to success, but it was the new suturing materials, instruments and, above all, refinements of operative techniques [lOO] which made the difference. Abdominal hysterectomy was, at last, becoming a relatively safe operation [loll. These technological improvements, however, obscure the less obvious social forces behind these developments, for no progress would have been possible but for the cooperation of women. It would have never happened had not gynaecologists been constantly pressured by ailing women, invalided by constant bleeding, who clamoured for relief: it would have not been accomplished had not women taken chances against all odds, demanding gynaecologists do the same and help them. The change from vaginal to abdominal hysterectomy [102], round about the first world war, is usually presented as a medical decision: yet, it probably would have not occurred/been greatly delayed, had it not been for the women’s movement. Remembered more for the fashions it inspired or its involvement in politics, wartime and post war, 192Os, feminism played an even greater role in promoting sexual equality including gross limitation of the family. Expressed in the ein-kind-system in Germany and not many more in France, England and elsewhere it culminated among some young women in choosing to have an early hysterectomy performed [103]. The vaginal operation which, with techniques then in vogue, led to difficulties in coitus [104], was understandably rejected by these avant garde women for subtotal hysterectomy [89] which, preserving vaginal and cervical integrity, putatively assured orgasmic coitus [ 1051. The 1920s brand of feminism has long disappeared but its popularization of hysterectomy as a method of birth control had not only survived but spread far and wide. Tolerated by both religious and medical authorities, it became one of the contraceptive methods [lOa] most favoured by the generation of women who, since the 194Os, had been made increasingly aware that the ovaries and their hormones, rather than the uterus [107], were responsible for their feminine image. By the late 1970s more than a million women a year in North America and Australia and more in Western Europe and elsewhere, were having hysterectomy performed for these indications. The changing climacteric Hysterectomy has also eliminated, to the delight of those who so regard it [103], “the curse” [108] of “acquired” [61] recurrent menstruation [62,64] as well as other uterine/cervical discharges. It has not only made excessive menstrual loss in the late childbearing years uncommon, or easily rectifiable, but has helped to dissociate such episodes from the climacteric. The reduction of the physical stress of childbearing through, on the one hand, limitation of the family and, on the other, better care during pregnancy, delivery and the post natal period, as well as medical support at all times, have ensured women reach the climacteric very much healthier than ever before [22]. Though liable to more gynaecological ills than women of other cultures, generally these, thanks to hormonal therapy or/and hysterectomy, cause but minimal damage
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[109]. Their climacteri is usually uneventful, or easily rendered asymptomatic. Secondary ametria [l 101, brought about by hysterectomy, has also resulted in a general reduction of uterine neoplasms. Early diagnosis by cervical cytosmears and diagnostic curettage has ensured those not previously operated are promptly treated, often long before the climacteric. This, in turn, has also disrupted the association of fear of cancer and fe temps critique [3]. Conclusion The social and cultural choices made by Western women had created a lifestyle which, its advantages and benefits notwithstanding, would have taken a high toll in gynaecological and general invalidism, complications, even life. The costs [66] would have been, as even a brief historical review [l] can show, far from negligible. Steroidal OC, endocrine medication/prophylactic replacement and, often more of help than all other measures, hysterectomy, have allowed women to escape these penalties [l 111; they enable them to live as they choose. Women cannot do so for long without these supports. Characterized as “interference”, even “assault” by a cohort of feminists who are ignorant of history [112], modes of treatment, largely introduced in the past at the behest of women, are being rejected. Reports of excessive climacteric menstrual loss are being heard afresh [113]. Do women really wish to prove again what history has already so adequately demonstrated?
Notes and References See parallel paper: Wilbush J (1988) Menorrhagia and menopause: a historical review. Maturitas 10: 5-26. The largest population of climacteric women prone to premenopausal bleeding was until late in the 19th century in France. These complications were, however, common among upper class women throughout Europe: indeed, they were first recorded in what the Germans call Mitteleuropa [ 11. Brierre A de Boismont 1842 De la menstruation conside& dans ses rapports physiologiques et pathologiques. p. 228 Baillibre, Paris. Freely translated: depleting haemorrhages of the critical time (= climacteric). See Wilbush 1988 [l] note 1 for definitions of these terms. Wilbush J. 198b. Tilt EJ and the Change of Life (1857) “the only work on the subject in the English language”. Maturitas 1980; 2: 159-167. eg. Lawson Tait’s acceptance of the disabilities of the change of life as “Severe enough to constitute a disease even though they may have only a subjective existance” (Tait RL 1877 Diseases of Womenp. 129. Williams & Norgate, London). (cf [l] note 127). Wilbush J. The climacteric syndrome: historical perspectives In: Notelovitz M, van Keep PA eds. The climacteric in perspective. Proceedings of the 4th Intl. Cong. on the Menopause Lancaster, Boston, the Hague & Dordrecht: MTP Press, 1986; 121-129. Wilbush J (in press) Climacteric disorders: historical perspectives. In Studd JWW, Whitehead MI eds. The Menopause. Oxford, London etc: Blackwell Scientific Publications, l-14. Rutherford RN, Rutherford JJ 1965 The climacteric years in the woman, man and family. In Klemer RH, ed. Counselling in marital and sex problems. A physician’s handbook Baltimore: Williams & Wilkins, 220-226.
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The term “behavioral disorders” (North American spelling) is used here in a technical sense. It encompasses all disorders, functional or somatic, the aetiology of which is primarily associated with social stress. See: Wilbush J. 1981 climacteric symptom formation: Donovan’s contribution. Maturitas 1981; 3: 99-105 (n.23); also [47]. The presentation of illness is a complex subconscious process by which the individual communicates her or his distress to those surrounding her/him. Composed of many elements these include, besides, the often histrionic, exhibition of the visible changes or felt sensations of an underlying disease/behavioral disorder [lo], the subjective reaction to the latter. It is usually accommodated within a traditional form, familiar to the “audience”. Touched upon in Wilbush 198Oa [47] as well as Wilbush J 198Oc. Symptoms in middlelife and the menopause. Br Med J 1980; 2: 563-564. it is the subject of a paper in preparation. eg. “A physician has no moral right, by his opinion, to put to sleep the anxieties of his patient, and to save himself the trouble of thinking”, or examination, tell her all her complaints were just due to the change of life. (Meigs CD. Females and their diseases. Philadelphia: Lee & Blanchard, 1848; 446.) eg. Crawford MP. What happens at the change. New Society 29 Ott 70. Also Crawford MP and Hooper D 1973 Menopause, ageing and family. Sot Sci Med 1970; 7: 469-482. Chouffe JPB. Des a&dens et des maladies qui surviennent a la cessation de la menstruation. Paris: Croullebois et Gabon, 1802; 29 (cf. [1] note 95). Kaufert PA. Anthropology and the menopause: the development of a theoretical framework. Maturitas 1982; 4: 181-193. Moreau JL (de la Sarthe) Histoire naturelle de la femme etc. Vol 2. Paris: L. Dupart, 1803; 375. Loosely translated: the misguided (bad) way (utilization) of life. (cf. [1] note 56). Fothergill J. On the management proper at the cessation of the menses. Med Obs Inquires 1776; 5: 160-186 (cf. [l]). Jeannet JBC des Longrois, 1787 Conseils aux femmes de quarante ans, p. 7 (Ed. 1, 1781) MCquignon, Paris. Freely translated: the profusion of viands (cf. [1] note 51). B&lard. Essai sur les maladies auxquelles les femmes sont plus frequement expostes a l’tpoque de la cessation. Paris: La Vve. Panckoucke, 1802; 22. Translated: the tendency to eat (too) well. . . and the abuse of wine. (cf. [1] note 54). The disapproving tone of these inventories of “misdeeds” savours of a “puritanism” not usually associated with France. Obviously related to the naturalistic simplicity idealized at the period [1] it also shows a strong influence of bourgeois ethics mixed with bias against innovation [24], an almost monastic austerity and a parsimonious frugality. Maubray J. The female physician etc. London: J Holland, 1724, 42 (cf. [1] note 114). Hall M, Commentaries on some of the most important diseases of women. London: Rees, Orme, Brown and Green, 1827; 312. (cf. [1] note 115). While, as far as I am aware, no endocrinological or histological proof of such claims exists, the anthropological and ethological evidence is suggestive. Though they marry relatively late, few Masai, SambuN. or other girls who are allowed free group premarital sexual contacts, ever conceive. In fact conception is, among the Samburu, believed to be promoted by premarital clitoridectomy performed (for other reasons) as the young bride is separated from peers and lovers. (Spencer P. The Samburu. A study of gerontocracy in a nomadic tribe. Berkeley and Los Angeles: Univ of California Press, 1965). An analogous, if far from parallel, phenomenon is recorded in Man’s closest animal relatives. Female chimpanxees who routinely take part in group promiscuous coitus, seldom conceive. This, however, regularly takes place when a couple retire from the troop to live apart. (van Lawick-Goodall J. In the shadow of man. London: Collins, 1971). In baboons, these exclusive mutual relationships, because of a social system which emphasizes gregariousness and safety, must take place in public. The alpha male, however, establishes a social, rather than physical, private environment. (DeVore I. Male dominance and mating behavior in baboons In Beach FA, ed. Sex and behavior New York: John Wiley & Sons, 1%5). Astruc J. A treatise on the diseases of women etc. Vol 1, 1762; 339. translated from the 1761 French. London: J Nourse (cf. [l] notes 3, 16 and 53).
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Jeannett 1787; 78 [18] (cf. [l] note 52). The apparent reduction, though not complete inhibition, of fertility by group sexual activity, is probably due to the effects of the situational behavioural circumstances on the production of releasing-factor neuropeptides in the hypothalamus or elsewhere. This is presumably mediated by thalamus or cortex and would depend on the history and physiological status of the individual. (e.g. it may, for instance, not have the same effect when a woman, who is paired with an infertile man, takes part in periodic promiscuous sexual activity among the Australian aborigines or elsewhere). Conceivably the consequent “abnormal” catamenia may, if unduly prolonged, hypothetically, lead to excessive menstrual loss. “Consider& en general comme affection plus particuliere aux femmes, on le voit (le cancer) se fiier plus souvent au seine qu’a d’autres parties, mais vu d’une man&e restreinte, et comme affection correspondante B la cessation des regles, c’est l’uterus qui est son siege le plus ordinaire”. (B&clard 1802; 46 [19]). Freely translated: Generally considered as a particular affliction of women, cancer is most frequently seen attached to the breast, but viewed in a restricted context, as an affliction accompanying the cessation of the menses, the uterus is its most frequent site. When listed in the 16th century as a complication of “retention” of the menses, “carcinomes” sandwiched between “erysipeles, condylomes et hemorroydes”, are hardly accorded special attention (Liebaut J. Trois Livres appartenant aux infermitez et maladies des femmes. Pris du Latin de M. J Liebaut . . . . et faicts, Fran9ois. Paris: Jacques du Puys, 1582; 6-7. The Latin, Liebaut J 1577. De Sanitate fecunditate et morbis mulierum, was, in fact, largely an augmented translation of Marinelli G. 1563. Le medicine pertenente alle infermita delle donne . . , . divise in tre libri etc. Francesco de Franceschi Sense, Venetia). The putative toxic origin of cancer is still, if dimly, echoed two centuries later by Fothergill [17] who believes it is due to acrimony (cf. [l] note 69). Astruc who similarly suggests “an ulcer or cancer of the uterus” (Astruc 1762; 1: 336 [24]) is brought on by climacteric toxic menorrhagia (cf. [l] note 68), may, on the other hand, have been well aware of its grave prognosis. Indeed he warns that menses after the age of 50 must always be treated with suspicion for they often are a sign of “cancers or ulcers of the uterus” (Astruc 1762; 1: 340 [24]). Jeannet recognizes that a constant red ooze is often due to cancer (Jeannet 1787: 85 [18]) though he does not seem to be aware of cancer of the body of the uterus (see [l] notes 81 & 82). Astruc, however, point out that a simple scirrhus (fibromyoma) of the uterus may degenerate into a carcinomatous one (Astruc 1762; 2: 108 [24]) the tendency being more evident in large, long-standing scirrhus tumours (Astruc 1762; 2: 117 [24]). Chambon, remarking on the speed with which “obstructions” become scirrhus, discusses some of the predisposing factors which cause them to degenerate into “carcinomatous ulcers” (Chambon 1799 chap. 5 & 16 [34]). Wilbush J. Clinical information: Signs, semeions and symptoms, a discussion paper. J R Sot Med 1984; 77: 766-773. The visualization of the cervix uteri (and vagina), readily avilable after the introduction of the diagnostic vaginal speculum, (Rtcamier 1801), radically affected gynaecological practice. This was, understandably, more so in the diagnosis, and putative prevention, of cervical cancer and the treatment of cervical and vaginal discharges. Dennam T. An introduction to the practice of midwifery, London: J Johnson, 1794. Dennam (pp. 194 et seq) tells us that “empirics” claim to cure cancer by repeated “applications to the uterus”. Caustic and, later, the actual cautery, could have never been so used without the help of a vaginal speculum. Such application is. strictly speaking, a surgical (nor diagnostic) procedure, yet the preliminary visual inspection of the cervix, to determine whether it needed treatment (see Parrish J 1854 ‘The change of life’ in women; with remarks on the periods usually called ‘critical’. The New Jersey Medical Reporter and transactions of the New Jersey Medical Society 7: 209 quoted in Wilbush [8]) is a diagnostic act. If so, even if, as Demnan claims, they were treating “a disease which never existed”, they were the first to utilize the vaginal speculum as a diagnostic tool. It is, in fact, quite feasible that Recamier became acquainted with this practice and, realizing its importance, introduced it into “legitimate” medicine. (see Wilbush J. 1980a [47]).
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Denman, who regarded cancer of the uterine cervix as the most important, even only. complication of the cliiacteric. strenuously campaigned to improve its prognosis. Ready to check the claims of the medically derided “empirics” [30], he was instrumental in establishing a special hospital for cancer patients in London. Surgical Solutions, as detailed below, were also widely discussed in the late 18th/early 19th century with the first operations performed in the 1820s [81]. Because of low local incidence and other factors many countries do not statistically differentiate cancers of the uterine cervix and body. These are therefore, following the pragmatic international classification of diseases, often reported in WHO statistics under one label: uterine cancer. Cancer of the breast has, as already mentioned, been early separated from the menopausal syndrome. It may, nonetheless, be here noted that present evidence supports its association with a lifestyle which includes both “la bonne chtre” [19] and a fall in the conception rate (vide infra). These factors, among others, are still operative today, making this cancer the major remaining risk of the lifestyle persued by Western women [109]. Gardanne CPL de 1816 Avis aux femmes qui entrent dans l’&ge critique. Paris: Gabon. Gardanne alludes repeatedly to the influence of previous, particularly genital, disorders on climacteric ills: the subject is especially dealt with in pp. 239-241 (see [l] note 58). Chambon N. Maladies des femmes Pt V. Maladies chroniques a la cessation des regles. Ed. 2. Paris: Dugquir, 1799. Inflammation of the tubes, is covered in chap. 33, chap. 40 deals with l’hydropisie des trompes (hydrosalpinx), accent is more on the ovaries in chap. 34 while chap. 35 centres on ovarian abscesses (ovarian or tubo-ovarian subacute infection): in fact, the whole climacteric transition is likened to inflammation in chap. 8. Venereal warts are the subject of chap. 26 and condylomata of chap. 27. Modern figures, using “currently available diagnostic techniques”, capable of determining aetiology “for about 85% to 90% of couples”, suggest 30 to 40% of infertility in the USA, is the result of “pelvic disease interfering with normal tubal motility (adhesions, tubal blockage or endometriosis)” (Droegemueller W. Herbst AL, Mishell DR Jr & Stenchever MA 1987 Comprehensive gynecology p. 1039 CV Mosby Co. St. Louis Washington & Toronto). Considering that another 30-40% is associated with some “abnormality of semen production, over half (about 6Oqo) the infertility of women in the USA is due to the tubal factor. The dimension of this factor, or any other, as Droegemueller et al observe, varies in different populations. A study of 472 infertile couples in the Bristol & Weston area (of which, in contrast to the above, 28% were unexplained) showed only 20% due to this factor. However, taking into account a higher male infertility, higher unexplained etc. this translated into 568’0 of infertility in women due to the tubal factor - a close match. This study also contains an unexpected finding in an age of antibiotics - that “previous pregnancy appeared to contribute significantly to tubal damage causing infertility” (Hall MGR, Glazener CMA, Kelly NJ et al. Population study of causes, treatment and outcome of infertility. Br Med J 1985; 291: 1693-1697). Despite aseptic technique and antimicrobial therapy postabortal/postnatal infection is still causing infertility. This must have been much more extensive in an age when, because of inefficient contraception, the abortion rate was significantly higher. Though most tubal damage due to STD occurs today when infection, as is often the case with chlamydia, or even gonorrhoea. is subclinical or only mildly annoying, much damage is avoided by antibiotics in this as well as above infections. This extra protection was, of course unavailable, in both cases, only a few decades ago. The tubal factor therefore must have, only a short time ago, been responsible for probably 90-95% of infertility in women. (See position among American negroes prior to and during the 1930s: Witherspoon and Butler 1934 [69]). This may, in part, account for the European emphasis on virginity, especially among the upper classes.
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Efforts to control natural increase vary greatly. The most prevalent contraceptive “technique” is probably lacation [cf. 571 often associated with prolonged postnatal ritual chastity, though avoiding deposition of the semen, commonly by withdrawal, is of equal if not greater importance. Avoidance of conception and the rate of abortion/infanticide always increase in times of economic hardship. Indeed it was the obvious poverty and overcrowding of the industrial working classes which prompted the establishment of many of the Malthusian leagues of England (Drysdale 1860) and other European countries. It was this which gave a sense of urgency to the efforts of pioneers in the mass propogation of contraceptive advice like Bradlaugh and Annie Besant in England (1876), Aletta Jacobs in the Netherlands (1882) and Margaret Sanger in the USA (1912). Limitation of numbers is not confined to the control of conception, indeed, usually this measure is taken too late after the often appalling, consequences of unfettered growth have been experienced. eg. The laws of Greek city states which in the unsettled times of war encouraged early marriage and high fecundity were often disregarded or changed when prolonged peace resulted in overpopulation. Population control in marginal, harsh environments, like the Kalahari desert or the Arctic, was, probably more often than elsewhere, generally achieved by the exposure of neonates. This allowed maximal utilization of the relative plenty of better years, unpredictable in such areas. e.g. Schneider DM. Abortion and depopulation on a Pacific Island In: Paul BD, ed. Health and Culture. New York: Russell Sage Foundation, 1955; 21 l-235. After the second world war, because of necessity, Japan, a “visibly limited . . . . island” society, adopted various measures designed to limit the number of children in the family. In tune with the capitalist ethos this is now widely and freely accepted. Whether coincidental or not, it may be noted that an apparently concomitant interest in climacteric research has also developed in that country. Family limitation in China is, on the other hand, only official policy which has little popular-cultural support. The latter is more evident among the overseas Chinese, especially in Singapore, which is not only a small island but has a highly developed capitalist economy. Family planning in India, Pakistan, Indonesia, Egypt and elsewhere has proved a failure. More agrarian than industrial capitalist, these countries all have long traditions of having as many sons as possible. The men and women of the Western, or more exactly North Western, European aristocratic elite have for many centuries had very different attitudes to having children (e.g. Macfarlane A. Marriage and Love in England, Modes of reproduction 1300-1800. Oxford: B. Blackwell, 1986) than their opposite numbers in other cultures, or, indeed, many of their own subjects. Spreading by internal cultural diffusion, these attitudes were first adopted by most property owners and, later, almost throughout the culture. Macfarlane 1986; 62-78 [45]. Wilbush J. The female climacteric, unpublished D. Phil thesis, Oxford, 1980a. Wilbush J. Climacteric expression and social context. Maturitas 1982; 4: 195-205. Lewinsohn R. History of sexual customs. Transl. Mayce A. New York: Longmans Green 1958. Original German 1956. Karexza, coitus reservatus, was already perfected by the troubadores (Il-13th century). Its practice, however, demands a degree of control not everyone can achieve. Named after Dr. Condom, physician to Charles II, (1660-1685). Male sheaths, manufactured of medicated linen, are, however, first recorded during the panic which accompanied the rapid spread of epidemic syphilis. Introduced as a “safe sex” method by Gabriello Fallopio (15231563), they never, because they dulled sensation, became popular. Moreau, however, 250 years later, mentions “calqons de taffetas tire” (covers of waxed taffeta) utilized “pour . . . dtrober des jouissance steriles” (in order to steal sterile joys) (Moreau 1803; 3: 19 [16]). Thin baudruche, goldbeater skin, “gloves”/condoms, often made of animal gut or fish-skin, had, however, become already by the 18th century freely available in the better shops of most European capitals. The first rubber condoms appeared in the early 1840s.
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Ring Charles used condoms to escape his mistresses’ claims-of-support for children. While blackmail or, for the young, a forced “shot-gun” marriage, remained an everpresent incentive, these threats have, since GC has shifted the responsibility to the female, lost much of their power. Not so the yet older reason for their employment as a precaution against STD. Still widely so employed during the 2nd world war, the use of condoms had greatly diminished with ease of cure by antibiotics. The rise of new resistant infections, especially when, like AIDS, they are invariably fatal, has, however, revived Fallopio’s sheath. Vaginal contraceptive applications have a long history stretching back to the Petrie (1850 BC) and Ebers (1550 BC) papyri, Intravaghtal appliances, usually used in conjunction with spermicides, have, however, proved much more effective. Sponges soaked in vinegar have been employed since Classical times: similar tampons were probably the contraceptive device most widely used in revolutionary France. Often employed, in defiance of official policy, to ensure families did not overgrow their financial resources, they collectively caused the birth rate to fall steeply. Imported into England and other European countries and extensively publicized by the Neo Malthuslans the effect on the birthrate was similar, decline being pronounced by the last quarter of the 19th ceptury. Incidentally this was also the time the menopausal syndrome began to be so noticeable in Britain and elsewhere (vide supra et [7]). Casanova (1725-1798) reports the contraceptive use of half a lemon to cover the cervix. The cervical cap was developed by Wilde (Germany 1823) and was popularized early this century by Marie Stopes in Britain (1921). The vaginal diaphragm, also invented in Germany (Mensinga 1880), was largely made known by Aletta Jacobs [39] through her Netherlands clinic (1882) - whence its popular name, Dutch cap. A variety of demographic trends have, after an interval of about 80 years, repeatedly duplicated in Britain the same secular changes previously recorded in France. While the immediate cause for the replication of decline in the birth-rate seems to be the use of contraceptive-s the deeper reasons for these delayed “echoes” are not clear. Wilbush J. Surveys of climacteric semeiology in non Western populations, a critique. Maturitas 1985; 7: 289-296. See especially the suggestion on p. 294. The serum levels of some endocrine secretions during the childbearing years. like those of FSH, are however known to vary in different areas. These terms have been enclosed in inverted commas because they are here broadened to include much wider classes of people. The first refers to the once very numerous intensely religious movements, especially strong among the middle and working classes of Britain and North America, but now only surviving as isolated religious groups. The disappearance of peasants from Western culture leaves today only soil-tillage-centred religious communities, like the Hutterites. in the second category. See Wilbush 1985 [54] for references to climacteric in European peasants. The literati, but much less so common-usage, terms denoting the periodic uterine blood loss in the nonpregnant state are, in most languages explored, derived from the same root as that for month. This is exemplified by the medical-Latin, terms here enclosed in inverted commas. The importance of medical-Latin has, moreover, made these general, at least in literati usage, in most European languages. The recent popularization of medicine has also increasingly disseminated their use in modern common or polite speech of many of them (e.g. German, Russian). It is interesting that non-literati. common usage polite terminology does not often, at least in English, French or German, follow this pattern. Though usually, as in words like periods, r&&s or periode/regd, it emphasizes “regular perlodicity”, it does not, the seldom used “monthlies” or monutiblutung being exceptions, refer to a monthly regularity. Common usage expressons also tend to vary with time: “courses” [108], first encountered in writing in 1563 was widely used during the last century but hardly today, “terms”, 1714, is obselete while “periods”. in print. though not frequently, since 1822, is dominant in present day speech, though not in writing. Fluor. derived from fluere, to flow (hence also fruxlls flowing and Jluvius, river) might have been the Latin common usage, and certainly an alternative, term for periods. The medical-Latin designations fluor albus, white discharge, now replaced by the Greek-derived leukorrhoea, and flux, discharge, directly associated with it, used to be common 18-19th century English medical usage. It might, in turn. have, probably by intentional
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mistranslation, confusing fro& flowers, with fluor, discharge, originated the euphemistic term “flowers”. used extensively during the last century, but, Victorian in character, long forgotton. The literati terms used in most Indo Aryan (e.g. Hindi, Gujarati, Punjabi) as well as some Dravidian languages I was able to explore are, also, allied to those for the month. Most, however, apparently also possess alternate/non-literati term which lack this association. Semitic languages, like Arabic or Hebrew, do not, however, connect the uterine sanguinous flow with either the month or even periodicity, though a non-literati term, used mostly by Christian Arabs, associates it with a monthly interval. Arab terminology is also, almost certainly because of Islamic religious influences, used in both literari (dictionary) Persian and Urdu, though the latter retains a term, equivalent to the Hindi, associated with that for month, and widely used by women. Maltese, on the other hand, free of Moslem influences, uses terms which include the word for month, identical with that in Arabic. The biblical term “custom of women” @en 31: 35) is the translation of a possibily popular (?male) term in use in the Hebrew spoken at the time the passage was written. Yiddish uses the Hebrew word for menstruation but old colloquial German as the verb. Sino-Tibetan languages (Chinese, Japanese, Vietnamese) apparently make little distinction between literati and colloquial usage, all have the month radical in the verb/substantive denoting menstruation. Lactation commonly suppresses ovulation and menstruation, though the former may rarely occur as early as ten weeks post partum, independently of a visible discharge (Cronin TJ. Influence of lactation upon ovulation. Lancet 1968; 2: 422-424) (cf. [64]). A menstrual flow is also not rare: 7.6% of 340 Egyptian women who relied entirely on breast feeding for prevention of pregnancy menstruated within a month of delivery the number gradually increasing to 60.5% after one year. A quarter (26.4%) conceived during a year from delivery (Hefnawi F and Bodraoui MHH. The benefits of lactation amenorrhoea as a contraceptive agent. Fertil. Steril 1977; 28: 320. Abstract of paper delivered at 9th Cong. Fertil and Steril). Anovular regular “menses” occur most frequently at puberty (20%) and the premenopause (50%). Regular fertile menses are experienced when a woman’s husband is away or coitus is avoided/infrequent, due to other circumstances. Hajnal J. European Marriage patterns in perspective. In: Glass DV, Everseley DEC, eds. Population in History. London: E Arnold, 1968; 101-143. The Western lifestyle has created “what has been termed ‘incessant ovulation’. . . . The occurrence of ovulatory menstrul cycles [cf. 581 throughout most of a woman’s reproductive years is relatively new. A few generations ago most of a woman’s reproductive years were anovulatory because she was either pregnant or lactating” (Mishell DR Jr. Noncontraceptive health benefits of oral steroidal contraception. Am J Obstet Gynecol 1982; 142: 809-816). Yet, such is the historical, and human-planetary, perspicacity of many gynaecologists and endocrinologists that they take it to be the norm, firmly declaring that “the menstrual cycle is the hallmark of reproductive function in the human female” (Mattox JH. Normal menstruation. In: Wilson JR et al., eds. Obstetics and Gynecology Ed 8 St. Louis Washington & Toronto: CV Mosby, 1987; 76). This may be true of North American/European women whose bioendocrinology has been rendered so unique by their mode of life, it is hardly so of the rest of womankind. “The hallmark of (their) reproductive function” is having babies. Roussel P. Systtme physique et moral de la femme, etc. Paris: Vincent, 1775. Le medecin philosophe, as Roussel became known (Moreau 1803; 1: 412 [16]), conjectures that “le flux menstruel, bien loin d’hre une institution naturelle est au contraire un besoin factice contract6 dans P&at social” (p. 197) (the menstrual flow, far from being a natural function, is on the contrary an artificial need, made necessary by the social environment). This suggestion would have, in fact, coincided with the one here attempted, had Roussel not blamed physical overindulgence and consequent plethora for this “need”. The same circumstances, he points out, make it necessary for the male to have repeated phlebotomy. Female animals, in the state of nature do not need such “evacuations” but the human female, having acquired vices, acquired menstruation. “Ainsi l’evacuation menstruelle une fois introduite dans l’espece humaine, se sera communiquee par une filiation non interromptue” (p. 202) (Thus the menstrual evacuation once introduced among human beings, passes from mother to daughter).
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This is mother statement which, interpreted socially rather than genetically, agrees with what is being here said. Physiological function is determined by the biology of the species. Throughout the last million or so years of recent Homo errectus and sapiens development, during which infant mortality, as indeed the mortality of the young, had been extremely high, while the average length of reproductive years cut relatively short by earlier deaths, a woman had to bear at least eight, often more, children to ensure survival. Since every child was associated with a pregnancy of 9 months and those who did not die with lactation of 15-18 months it would be safe to surmise that women in this “state of nature” were only very occasionally disturbed by uterine fhtx and seldom, if ever, subject to recurrent menstruation. L‘Menstruation” had never been a natural biological function. it was not physiologically normal. The social changes, including limitation of the family, which have recently made recurrent menstruation part of human life, have only become biologically possible when constantly available food and security of community life have significantly lowered the infant and child death rate. Physiologically, however, women’s bodies have not as yet adapted to these new developments. As far as women’s tissues are concerned recurrent menstruation [63] is still anything but normal. “Menstruation is the periodic discharge of blood and disintegrated endometium after a normal ovulutoty cycle” (my italics. Mattox 1987; 76 [60]). Though anovular bleeding is grossly similar it is histologically different and not considered a true “menstrual flow”, a definition which also excludes OC, drug, surgical and other withdrawal bleeding. Many infradian rhythms, some marked monthly and annual recurrent systems notwithstanding. are frequently not truly inherent but depend on suitable stimulation. Characterixed as cyclic, they often change with circumstances, showing no persistance of an endogenous biorhythm, as, for instance, when monoe-struous ancestral wild animals become, once domesticated and protected, polyoestrous livestock. Not only is the putative cyclicity of human reproduction (Biorhythms and human reproduction 1974 Conference of the Intl. Inst. for the Study of Human Reproduction (Eds. Ferin M et al.). New York, London. Sydney & Toronto: John Wiley & sons) apparent only when the female is not pregnant but it can be adequately accounted for without recourse to hypothetical inherent biorhythms. Such explanation rests on two observations: (1) endocrine glands react each to the serum levels of the products of the other (2) Unless supported by secretions produced on implantation of the blastocyst in the uterine lining the luteinized granulosa cells of the corpus luteum can survive only a fiied number of days. The latter, 14 + 1 days, is the only constant among the many fluctuating variables of the “menstrual cycle”. Once the corpus luteum becomes inactive, the hypertrophied lining of the uterus disintegrates and appears as a sanguinous vaginal discharge lasting anythin from a few hours to 8 days or more (average 5 f 2 days). Occasionally, if rarely, the decidua menstrualis is resorbed and no discharge appears (This may occur during lactation [57]; it is the rule in animals when they do not conceive). The feedback of low ovarian endocrine serum levels, associated with the demise of the corpus luteum. also stirs the hypothalamus, the pituitory and eventually the ovary, stimulates ovulation and the formation of a new corpus luteum. The preovulatory phase in which this happens, far from being cyclically fixed, varies both in different women and the same woman in different times, and under different conditions. It may last only three or four, or stretch from 20 to 25 days. Speculation over lunar influences, correspondance to the synodic rather than four-weeks months, or other influences like electromagnetic fields or endogenous rhythm centres seem therefore meaningless. There is no intrinsic “cycle” to explain. On the other hand this, or any other attempt to deny inherent cyclicity can never detract from the awareness of r ecurrent change and the infleunce of the successive dominant hormones and alternating endocrine secretions on Western women’s emotional life and culture. (Asso D. T’he real menstrual cycle. Winchester, New York, Brisbane, Toronto & Singapore: John Wiley & Sons, 1983). Indeed, viewed as a human activity/function in Levi-Strauss’s structural map, or classified
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within his binary oppositions of nature versus culture, it would be much closer to the latter than the former. (Levi-Strauss C 1963 Structural anthropology (translated from the 1958 French) Basic Books, New York. Also see Levi-Strauss C 1970. The raw and the cooked (translated from 1964 Le cru et le cuit) New York: Hippocrene Books). It is not intended to embark here on a “calculation” of the costs and benefits of contraception. This is only to note the special organic complications of the methods of contraception which do not inactivate the hypothalmic-pituitory-ovarian axis of hormonal interactions. Mentioned early in Western medical books [28], scirrhous uterine tumours, fibromyomata, are relatively easy to distinguish once they are large enough to be palpated abdominally. The prognostic advantage, if not other considerations, of earlier diagnosis have, happily, led to the development of the most basic clinical investigatory method in gynaecology. Admitting he finds small tumours “difficult to distinguish”, Astruc tells us it is necessary to introduce “the finger through the vagine to the uterus . . . (and) to push the uterus up against the hand applyed on the hypogastrium” (Astruc 1762; 2: 115 [24]). Menville records that “les femmes, alarm&s par I’approche de l’age critique, engagent leur m&&in a leur toucher, . . . . que celui-ci est tout supris de trouver des desorganisations si ava&es de la matrice, qu’on est oblige d’en faire remonter l’origine 51plusieurs am&s”. Freely translated: the women, alarmed by the approach of the change of life (critical age) get their doctor to examine them vaginally, while the latter, suprised to find such advanced uterine derangements that it is obvious they have originated quite a few years previously. This passage in Menville (CF de Ponsan). De 1’8ge critique chez les femmes etc. Bailhere, Paris, 1840; 142 is almost certainly plagiarized from Saucerotte C Nouveaux conseils aux femmes sur 1’8ge prttendu critique etc. Paris: Mme Auger M&&non. 1828; 9 (published semi anonymously). Unlike Menville who asserted all complaints became worse in the climacteric, Saucerotte was interested in debunking contemporaneus sensational exaggeration of climacteric ills - by proving, in this case, that many of them antedated this phase of life by several years. Incidentally this quotation illustrates the initiative of women in establishing what amounts to a routine “climacteric checkup” (cf. Wilbush J. La Menespausie, the birth of a syndrome. Maturitas 1979; 1: 145-151; also Wilbush [8] where the term toucher, touch, is explained). The role of OC in preventing the formation of fibromyomata is, to say the least, still undetermined. Though the data collected by the OC study of the Royal College of General Practitioners (RCGP) “did not exclude the possibility of a true protective effect of the Pill” (Oral Contraceptives and health, interim report, OC study RCGP, London: Pitman & Sons, 1974; 26) neither did it prove it. Other studies have hardly been more conclusive. The difficulty may reside in that the aetiology of Bbromyomata, possibly because it is multifactorial, is still unknown, while, largely due to the high hysterectomy rate, there is also a scarcity of clinical populations suitable for investigation. Lack of space does not allow consideration of the various proposed hypotheses, the evidence, however points to (physical) avoidance of/barriers to conception as the most important aetiological factors. The nun’s chastity, the housewife’s diaphragm or the blocked tubes of the promiscuous all increase the risk of developing fibromyomata. This is strikingly corroborated by cross cultural data. White Europeans were, as late as the 193Os, thought to be genetically prone to this condition when it was pointed out that American negro women were nine times more likely to develop it (Witherspoon JT, Butler VW. The etiology of uterine fibroids with special reference to the frequency of their occurrence in the negro: an hypothesis. Surg. Gynecol Obstet 1934; 58: 57-61). This was, in turn, traced to the almost universal tubal infection/damage in this population which, prior to antibiotics, resulted in widespread early sterility. Fibromyomata grow from extremely small seedling tumours which, may not consist of more than a few aberrant cells. These cannot, however, increase in size unless subjected to oestrogenic, as opposed to progesterone influence. The latter, in fact, not only modifies growth stimulated by oestrogen, but reduces the number of tissue receptors sensitive to it (Wilson EA, Yang F. Rees ED. Estradiol and progesterone binding in uterine leiomyomata and in normal uterine tissues. Obstet Gynecol 1980; 55: 20-24). Prominent during the follicular phase,
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oestrogenic influence is greatly increased by incaant ovulation resulting in repeated follicularlikagrowth spurts and no pregnancy and/or progesterone modification/reduction of receptor density. OC does, however, radically change this hormonal confiiation. ~~pprauion of ovulation by OC does not. however, affect the rate of growth of fibromyomata if this is achieved by an oestrogen-rich “pill”. Early OC of this type, in fact, increased the growth of these tumours and other oestrogen sensitive tissues, just as, later, a sequential OC preparation, oestrogenic in influence, was found to increase the risk of endometrial adenocarcinoma (Weiss NS, Sayvetz TA. Incidence of endometrial cancer in relation to the use of oral contraceptives. N Engl J Med 1980; 302: 551-554). The latter, not being affected by as many factors as fibromyomata, responded quickly when the balance of oestrogen/progesterone was changed (Weiss & Sayvetz 1980, Kaufman DW, Shapiro S, Slone D et al. Decreased risk of endometrial cancer among oral contraceptive users. N Engl J Med 1980; 303: 1045-1047). The effect on fibromyomata (e.g. Meats 1966, RCGP 1974) bein slower and more complex is more difficult to assess. The effects of such a balance on benign tumours of the breast (Brinton LA, Vessey MP Have1 R, Yeates D. Risk factors for benign breast disease. Am J Epidemol 1981; 113: 203-214; Ory H, Cole P, MacMahon B, Hoover R. Oral contraceptives and reduced risk of benign breast disease. New Engl J Med 1976; 294: 41-22) nonetheless provides a suggestive support. Bearing in mind that “the differential effects of estrogen and progesterone on the level of receptor protein are likely to represent an important regulatory component of the human uterus” (Soules MR, McCarty KS Jr. Leiomyomas: Steroid receptors content, variation within normal menstnml cycles Am J Obstet Gynecol 1982; 143: 6-11) it is obviously important that OC contain the proper balance of progesterone to oestrogen. It may be further hoped that, even if other factors are at work, this ensures, as indeed it seems already to have ensured, that women free of uterine tumours, who depend on such preparation for control of fertility, have as low a rate of tibromyomata as those who bear children each two or three years. Western women’s approach to reproduction is also reflected in their attitudes to menstruation which, in turn, cannot but affect the emotional impact of the menopause and the catamenial disturbances which may herald it. While a menstmal flow is looked upon in most cultures as a setback, a sign that a desired pregancy has not been achieved, the monthly period brings to the average Western woman much more than relief she has not “been caught”. Considerably more prior to widespread hysterectomy though still very much so today, it is a monthly affirmation of a woman’s sexual desirability and her youth [48]. It might, in fact, have been this, rather than the theoretical toxicity of the retained menses [7) which so strongly prompted women in their middle years to attempt and induce the return of menstruation. It was to a large extent this which painted the clhnacteric in such sombre, depression-evoking colours and aggravated every organic complication of the Western aberrant b&endocrinology. Despite repeated exhortations, the last few from the World Health Organization and various associations representing general and family medical practitioners, all stressing the importance of prevention of illhealth few doctors feel they “are in the business of preventative medicine” (Wilbush J 19861, WONCA 1986: a personal impression. Canad. Fam. Physician 32: 14131414 and 1520). These can be traced to the laicization of medicine, the complete separation between the healer and the pmaching, demanding priest, as well as. more recently but by no means as completely, the physician and the policing, punishing state authorities. See Wilbush J. 1988 [l] especially quotations from Gardanne (341 and Tilt [94]. This is, obviously, only partially correct, as illustrated not only by historical [l] but many modem examples. Called une v&e vieil&ssc, a green old age, by 18th century writers (Jeannet 1787; 2 [18]). it was considered a time of vigour (Roussel 1775; 84 [61]) when the constitution of the female changed, when, without “obligation to the species”, she could live an individual life. (Moreau 1803; 1: 411 [la]). Cultivating her intellectual faculties she might even at this age acquire great attraction as attested by the medical philosopher Roussel [al] who in his later years much preferred climacteric to younger women (Moreau 1803; 1: 412 [la]).
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Gardanne, noting that, once over the menopause, many can. for Ahotter or longer time, enjoy good health, remarks that especially those who have been rendered ill, debilitated by heavy periods, take on a new life, for they acquire an embonpoint further accentuated by the animation and complexion of youth (Gardarme 1816; 64 [34]). In fact, they present “une couleur rose dans toute (leur) &endue, surtout au visage”, a generally pink colour, most noticeably in the face. (Menville. 1840; 149 [68]). Tilt agrees, suggesting that “the retained blood . . . . strengthens the inner tissues of the frame in the same way that it alters outward appearances”. Women acquire “an embonpoint” by the “unusual intensity of that force which presides over nutrition . . . (and) enables it to convert blood into fat” (Tilt 1857; 52 [95]). We are especially concerned with abdominal hysterectomy. Since many of the women who had intractable menorrhagia were afflicted with large fibromyomata. these could be only removed abdomhmlly. Ocassionally, however, a vaginal hysterectomy was performed with the uterus extracted by morcellement [ 1021. The best account is given by Flack IH (nom de plume: Harvey Graham) 1951 Eternal Eve. The history of gynaecology and obstetrics. Garden City, NY & London: Doubleday & Co., 431432. Incidentally this was the first total abdominal hysterectomy. Ovariotomy was an operation for the removal of large ovarian cysts. The technique has so changed that present day operations are no longer so designated. It consisted of opening the abdomen, draining, and delivering the collapsed cyst and securing its pedicle by a sturdy clamp (see Illustrations: Speert H Iconographia Gyniatrica: A pictorial history of gynecology and Obstetrics. Philadelphia: FA Davis & Co, 1973; 478). The excision of the tissue distal to the clamp was followed by closing the abdominal cavity. The clamp was then gradually relaxed .starting a few days after the operation and removed when no bleeding occurred. P&an and Urdy tracing in 1872 the history of abdominal hysterectomy for fibromyomata, take it for granted few up to their time ever deliberately set out to perform this operation. They divide the approach to hysterectomy into three periods: during the first, up to 1843, surgeons, on discovering their mistake, retreated and closed the abdomen: between 1843-1865 many carried on and removed the fibromyomatous uterus, often with fatal results; under the influence of Koeberle, after 1865, operators were ready to tackle whatever pathology they encountered. (Ricci 1945; 169-170 [79]). The main developments of abdominal hysterectomy are adequately covered in; Ricci JV. One hundred years of gy-naecology. Philadelphia: Blakiston, 1945; 166-177. 33 women, nearly 80010of the 42 who had abdominal hysterectomy, as reported in the literature 1843-1866, died. See also [83]. While an operation for the excision of the prolapsed uterus (see [91,93]) affected by cancer was widely discussed (Flack 1951; 524 [76]), the first one was done inadvertedly, the surgeon having intended to excise only the affected cervix (Ricci 1945; 228 [79]). The first vaginal excision for cancer of the cervix of a normally situated uterus, was successfully carried out by Sauter, the patient living for 4 months (Ricci 1945; 228-229 [79]). Though favourably reviewed in Edinburgh, the high mortality associated with attempts to duplicate Sauter’s success, roused Johnson in London to call it “one of the most cruel and unfeasible operations that ever was projected or executed by the head or hand of man”. (Johnson J. Extripation of the uterus. Editorial comment No. 6 quarterly periscope section. The Med. Chirurg. Rev. (London). New Series 1825 3: 264-267. These comments are widely quoted: e.g. Ricci 1945; 164 [78]; Cianfrani 1960; 342 [85]). The operation was, nontheless, undertaken by many surgeon-gynaecologists. Modified and improved, it was performed till the beginning of this century. While the diagnosis of gross cancer, especially of the cervix, was well within the capabilities of the early gynaecologists [27,28], that of microscopic cancer of the cervix, confusion with other cervical lesions apart [30], and fairly large lesions of the corpus uteri were beyond their technology. This is, however, unimportant in the present context, for we are here dealing with the perceptions of women, as influenced by medical judgement, when making their choice for or against hysterectomy.
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Hysterectomy was condemned by a great many doctors and surgeons, who like Johnson [81] were appalled by its high mortality [80]. In 1872, ironically just prior to the fall in this unbelievable death rate, it was also censured by the Paris academy of medicine. Walter Bumham, of Lowell MA, who, after his successful first hysterectomy, 1853, was in great demand but, somehow, could not repeat his initial success, declared he “would not easily be induced to make another attempt to extripate the uterus and ovaries or even to remove the uterus under almost any condition; and the operation should never be attempted without due consideration of the consequences of submitting a patient to such formidable risk” (Ricci 1945; 167 [79]). Still the procession of women demanding he operated was too much to resist: he continued, albeit unsuccessfully, till 1876 with a mortality of 12 out of 14 (85.7%). The table of fees of the Chicago gynaecological society for December 1879 quotes $1000.00 for hysterectomy, the equivalent of between 50 000 and 100 800.00 today. Other operations are also relatively expensive: e.g. D & C $25.00 and the application of a pessary $10.00 (Flack 1951; 528 1761). Cianfrani T. A short history of Obstetrics and Gynecology, Springfield Ill: CC Thomas, 1960. Garrison FH. An introduction to the history of medicine. Ed 4. Philadelphia, London & Toronto: WB Saunders, 1929. Green Armitage VB. The rise of surgical gynaecology. In: MunroKerr JM, Johnstone RW and Phillips MH. eds. Historical review of British obstetrics and gynaecology 1800-1950 Edinburgh & London: E & S Livingstone, 1954. Ricci JV. The genealogy of gynaecology. History of the development of gynaecology throughout the ages 2ooo BC-1800 AD. Philadelphia: The Blakiston Co., 1943. The various operations included. wholly or in part. under the designation “hysterectomy” or in which the uterus is removed, are usually grouped either in accordance with their main indications, or the operative techniques used in performing them. The main indications are malignant disease, menorrhagia (often associated with benign tumours), pelvic floor repair (PFR) and contraception. Operative techniques are distinguished by either the vaginal or abdominal approach. The latter was historically associated with preservation of the cervix in subtotal hysterectomy. Confusion regularly arises in conversation between patients and doctors/gynaecologists, most commonly this is due to misunderstanding regarding conservation/excision of the adnexae, for many interpret “total” hysterectomy as including the ovaries. The most frequent use of the term as an ambiguous label is the insinuation it stands for necessary management of uterine pathology when the real indication, or intent, is contraception [105]. Similar ambiguities are associated with the designation D & C. As Pare put it in 1573: “There are some women that have had almost all their womb cut out without danger to their life as Paulus testifieth” (Pare A. Of the generation of man (original French 1573 De la generation de l’homme etc.) London: T Co&, R Young, 1634). References to the excision of the uterus are, in fact, already found in the Hippocratic corpus (Cianfrani 1960; 342 [85], Green Armitage 1954 [87]) Soranus (2nd Cent. AD) is said to have amputated a gangrenous inverted uterus (Cianfrani 1% 342 [SS]) while Paulus Aeginata (7th cent.) records uncomplicated recovery after similar operations (Green Armitage 1954 [87], Ricci 1943; 318
w1). 92
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While the “internist” (a label still current in North America) Doctors of Medicine focussed their attention on the internal organs, surgeons were, by tradition, confined to the external surface of the body. The “new” MDs educated at Leiden and elsewhere under the influence of Boerhaave 1668-1738 and his pupils, and, even more so, the postrevolution French clinicians, however, combined the traditions of medicine, surgery and obstetrics. They were trained as “generalists”, both internist and “ externists”, to attend to the wounds of men, be “female physicians” and paediatricians, act as general “doctors”. The medical men who settled in North America were encouraged in the generalist approach by circumstances which forced them to answer any and every call for help. It is not surprising therefore that it was there that the first “internal” gynaecological operation was performed. In this position the womb was “external” to the body. Classical records no doubt emboldened
renaissance surgeons: Nicolo Falucci is reported to have excised the uterus in 1412 (Ricci 1943; 272 [88]). Ciiacomo Berengario da Carpi 1480-1550. the first accurately to describe the human uterus 1534, left accounts of two operations for the gangrenous inverted uterus. The central step in his technique was the use of a strong, ah inclusive, twine ligature which was tightened regularly till the organ was severed. Securing haemostasis, the site of the ligature was kept clean by a wine mixture. (Ricci 1943; 291-292 [88] Garrison 1929; 226: [86]) Ambrose Pare 15101590, Cristobal de Vega 1501-1580 and others performed similar operations (Ricci 1943; 322
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There are very good anatomical and physiological reasons which explain why the female internal genitalia especially when enlarged, the pregnant uterus, ovarian cyst or fibromyomatous uterus, were the targets of the first operations to invade the peritoneal cavity. Chief among these are: accessibility, just under the abdominal wall (when enlarged), relative ease of haemostasis - through the contractions of uterine muscle after caesarean section, or the compression of a not-too-bulky pedicle, and marginality to vital processes. Tilt EJ. The change of life in health and disease etc. Ed 2. London: John Churchill, 1857; 33. This, of course, refers to Ephraim McDowell’s feat, who, on 13 Dee 1809, was the first to invade the abdominal cavity and excise a tumour completely surrounded by peritoneum. His patient, Mrs. Crawford, moreover. completely recovered. Grossly enlarged fibromyomatous uteri are abdominal, not pelvic, organs, their bulk raising them out of the pelvis and causing the vagina to elongate. They can therefore be dealt with by the same technique used at ovariotomy, and their “pedicle” clamped in the same manner [77]. Large clamps, especially made for the purpose, were applied to the supravaginal portio cervicis, the body of the affected uterus was excised and the clamped cervix attached to the lower end of the abdominal incision (for illustrations see Speert 1973; 485: [77]). Alternatively a snare was applied to the same area and gradually tightened by means of a screw. much in the same way as used by da Carpi in 1521 [93], till the uterus withered and dropped off. KoeberIC replaced clamps and snares by a metallic pressure knot, serre noeud (Ricci 1945; 169: [79], Green Armitage 1954 [87]). He is also. incidentally credited with the invention of the haemostatic forceps (Garrison 1929; 603: [86]). None, for a long time, dared trust sutures controlling cut blood vessels out of sight, inside the closed abdomen. The first to do so was apparently Vincenz Czerny of Bohemia in 1879 (Ricci 1945; 75 [79]), while Tait was not far behind (Flack 1951; 515: [76]). An inclined position, the head much lower than the feet, had been utilized in surgery, such as repair of inguinal hernia, for many centuries, but apparently fell into disuse. Modified, Trendelenburg utilized it in gynaecological surgery already in 1880, though he did not formally describe it till 5 years later. (Speert H. Obstetric and gynecologic milestones: essays in eponymy New York: Macmillan, 1958; 421-430. Green Armitage 1954 187)). Though Semmelweis published his first paper in 1849 and his treatise in 1861 (Garrison 1929; 435436 [86]) he was ignored, while Lister’s well argued papers 1867 established surgical antisepsis, “Listerism”, as operation-room routine. Separate ligation of the uterine vessles (Mikulicz 1880, Schroeder 1880, Stimson 1889). (Spencer Wells in 1880). Preitonixation of the cervical stump, rendering it “extraperitoneal” Anterior and posterior peritoneal flaps (Emmet 1884, Eastman 1887) (Ricci 1945; 374-175 ]791). Mortality during 1843-1866 was, as stated, around 80@/0[80]. Despite all advances the death rate 1881-1885 was still 50% (Ricci 1945; 171 [79]). yet by the 1890s it fell to less than 10% for subtotal hysterectomy. In 1891 Polk presented a series of 17 totul hysterectomy with only 2 deaths, 11.75% (Ricci 1945; 177 [79]). By 1910 the death rate for subtotal hysterectomy, where previous pelvic infection was not present, was below that of vaginal hysterectomy and by the early 1920s it fell below 2%. The turning point was, according to Green Armitage [87] around 1910. Vaginal hysterectomy, for long the standard procedure, is clearly an advantage when laxity of the supporting tissues also requires attention. & was nonetheless generally favoured, in all cases, because of its lower rate of complications. Post operative haemorrhage was both less common and less troublesome
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to control, while infection was always less serious and much easier to drain. Difficulties, however, arose when the uterus was adherent to other structures and, more so. when too large to be extracted, necessitating bisection or piecemeal removal [75]. Limited to young. middle class women and much more widespread on the continent than in Britain, little has been recorded of this aspect of the early 1920s. My information is largely based on the recollections of women and men who lived through that period, supported by a few oblique references in novels. Ein-kind-system = German for a “system of one child”, a drastic form of family planning often supported by subtotal hysterectomy, widespread in Germany among the middle classes after the first world war. These techniques, surviving in some areas, notably in some parts of Britain, as late as the 196Os, frequently resulted in “tenting”, conical constriction of the vault, which, when combined with some of the concomitant methods for PFR, produced a rigid, narrow, tapering shortened vagina. Often precluding coitus, these results were actually welcomed by a number of climacteric women who, after being subjected to years of sexual bungling, welcomed the opportunity of “expressing (their) hostility by withholding . . . . pleasure” (Huneycutt HC and Davis JL. All about hysterectomy. New York: Readers’ Digest Press, YT Crowell Co, 1977; 260) and shutting the gates. (See discussion in Wilbush 198Oa [47]). The attitudes of the young, middle class women of the 1920s were, of course, diametrically opposed to such behaviour. These persisted to late middle life so that when offered PFR in the 1950s and 1960s they often questioned, even refused, vaginal surgery in case it interfered with coitus. “There is an old-fashioned European idea that if the cervix is left in sexual expressions and feelings will be enhanced” (Nugent N. Hysterectomy: a complete up-to-date guide to everything about it and why it may be needed. Garden City NY: Doubleday and Co., 1976, 135). This is mentioned in many older gynaecological textbooks (e.g. Shaw W. Textbook of gynaecology, Ed 1 to Ed 7, London: J & A Churchill, 1936-1956. Young J. A textbook of gynaecology, Ed 3 to Ed 10, London: A & C Black, 1933-1956. Jeffcoate TNA Principles of gynaecology London: Butterworth & Co. 1957; 664-665). The preservation of the (modified) cervix in the Manchester operation for PFR might also have improved matters, mainly through the prevention of “tenting” [RN]. It is probably not a fortuitous coincidence that WE Fothergill’s more important papers, describing this operation, span the years 1913-1921, the very same period in which subtotal hysterectomy [102] became so popular (see Speert 1958; 108-115 [98]). The necessity of living with restrictions had early adjusted attitudes in many Roman Catholic countries, notably in France and Southern Germany [103]. In North America where medical practice, long influenced by rigid puritanical moral views, was further burdened with Catholic injunctions, an unspoken alliance was forged, during the 196Os--1970s between women and their gynaecologists. The former soon discovered they could get round both religious interdictions and medical regulations by pleading uterine illhealth. They exaggerated symptoms and told “a lot of little white lies . . . . and their doctors sometimes manufactured a few additional ones in order to pass the inspection” (Huneycutt, Davis 1977; 112 [104]). Sympathizing with their plight doctors were more than ready to recommend that “patients to whom tubal sterilization is unacceptable (be) sterilized by hysterectomy” (D’Esopo DA. Hysterectomy when the uterus is grossly normal. Am J Obstet Gynecol 1%2; 83: 113-122). Put differently “in some cases where a religious principle conflicts, (the woman’s) only salvation (from emotional turmoil) may be to have a physician teU her that her uterus must come out, thereby relieving her of the fear of pregnancy or guilt from using birth control” (Huneycutt, Davis 1977; 112 [104]). Despite conservative criticism this attitude was finally endorsed by most USA gynaecologists and spelt out in a position paper (The determination of the necessity of gynecological surgery 1977 Am. COIL of Obstet 6t Gynecol, Chicago) to remain official policy till lately. “The use of hysterectomy on relatively trivial gynecological grounds is (therefore) considered for sterilization in environments where primary sterilizing procedures have a religious or cultural stigma” (Hawkins DF, Elder NO. Human fertility control, theory and practice. London & Boston: Butterworth. 1979; 354).
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Writing in 1850, Tilt was only expressing growing scientific views that “though the uterus has been regarded”, since Classical times if not long before, “as the fundamental portion of the female generative system (this) distinction. . . in reality belongs to the ovaries”. (Tilt EJ. On diseases of menstruation and ovarian inflammation in connection with sterility, pelvic tumours and affections of the womb. London: John Churchill, 1850). This was amply proved during his lifetime both clinically, by bilateral oophorectomy, and histologically by examination of the tissues of the ovary and uterine mucosa and their correlation. Though the physiological, hormonal, aspects of ovarian influence were not worked out till the 1920s and 1930s many women well appreciated the position quite early. Though already understood by the young women of the 1920s [103], folkloric beliefs persisted to such an extent (Drellich MO, Bieber I. The psychologic importance of the uterus and its functions: Some psychoanalytic implications of hysterectomy. J Nerv. Mental Dis. 1958; 126: 322-336) that gynaecologists had, and some still often have, to make completely sure what a woman’s perceptions of the uterus are before advising hysterectomy. In fact, some women even today, and many more only in the recent past, still “equate(d) hysterectomy with complete loss of feminine function” (Nugent 1976; 67 [105]). Reflecting the annoyance some women feel, this label, first encountered in writing in 1930 in a North American novel, may be a barbed mispronounciation of the term “courses” [56]. Much more common in North America than in other English speaking countries, it reflects, at best, only the sentiments of a minority of women. This unfortunately applies only to gynaecological conditions. Breast cancer, also largely associated with women’s present lifestyle, and due, in part, to the limitation of the family [33], is still far from being under control. The term “ametria” refers to the congenital absence of the uterus. “Secondary ametria” is here used in preference to the “ugly” adjective “hysterectomized”, to describe the condition of women who have had their uterus surgically removed. Medicine has, in this case, allowed inclinations to be followed: it has, moreover ensured few if any pay the price of indiscretion. This is probably one of the most striking examples of persistance in a chosen lifestyle, regardless of danger or discomfort - and doing it by the utilization of medical technology, research and therapy. Women did not give up, “mend their ways”, as doctors wanted them to do. Instead they made the doctors find the means to protect them - while they continued to do whatever they wanted to, however bad for their health it was considered to be. Many of the arguments voiced by feminists emphasize the “natural” aspect of the climacteric and the desire of women to undergo this transition, as indeed other events in life, such as childbirth, “naturally” without “interference” by doctors or any other “medicalization” of life’s events. The advocates of a return to nature (vide supra, first section, and [1]) however forget that in that state, be it reflected in pre-industrial Europe, in other cultures or among those who use but simple technology and are therefore “close to nature”, women have but one life breeding. None is, to be sure, ready to return to a life of alternating pregnancy and lactation, Western women have wrought not only a great cultural achievement but also a true biological developmental step in limiting their fertility and finding the time and energy to participate in the public and cultural life of the community. They have done so at the cost of changing their bio-endocrinology. This makes it impossible for the majority to regard many female functions, including the climacteric transition as “natural”. There are exceptions - but these only highlight the fate of the majority. The position is simple - but is emotionally extremely difficult to grasp. Though we tend to regard the social system to which we have been born as “natural” - this is not necessarily so - knowledge of others and of our own history can easily demonstrate it is a cultural milieu an environment which has its own “interfering ” rules. Oldenhave A. Can the mean increase in psychological symptoms in premenopausal women observed in huge-scald studies be explained by the increased prevalence of excessive menstrual bleeding? Abstracts, 5th International Congress on the Menopause. Sorrento. 1987; Abstract 35: 51.