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1
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0023923907
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Menorrhagia and menopause: a historical review
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See parallel paper
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(1988)
Maturitas
, vol.10
, pp. 5-26
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Wilbush1
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2
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84915236106
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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 [1].
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3
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84915215356
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Brierre A de Boismont 1842 De la menstruation considerée dans ses rapports physiologiques et pathologiques p. 228 Bailliére, Paris. Freely translated: depleting haemorrhages of the critical time (=climacteric).
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4
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84915270739
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See Wilbush 1988 [1] note 1 for definitions of these terms.
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5
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0019266667
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Tilt EJ and the Change of Life (1857) “the only work on the subject in the English language”
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198b
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(1980)
Maturitas
, vol.2
, pp. 159-167
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Wilbush1
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6
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84915259635
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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 Women-p. 129. Williams & Norgate, London). (cf [1] note 127).
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-
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8
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84915262503
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(in press)
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Climacteric disorders: historical perspectives. In Studd JWW, Whitehead MI eds. The Menopause. Oxford, London etc:, Blackwell Scientific Publications
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Wilbush J (in press) Climacteric disorders: historical perspectives. In Studd JWW, Whitehead MI eds. The Menopause. Oxford, London etc: Blackwell Scientific Publications, 1–14.
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(in press)
, pp. 1-14
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Wilbush1
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10
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84915258184
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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].
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11
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84915249241
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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 [10], the subjective reaction to the latter. It is usually accommodated within a traditional form, familiar to the “audience”. Touched upon in Wilbush 1980a [47] as well as Wilbush J 1980c. Symptoms in middlelife and the menopause. Br Med J 1980; 2: 563–564, it is the subject of a paper in preparation.
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12
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84915245197
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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.)
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13
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84915269753
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eg. Crawford MP. What happens at the change. New Society 29 Oct 70.
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16
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0020357048
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Anthropology and the menopause: the development of a theoretical framework
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(1982)
Maturitas
, vol.4
, pp. 181-193
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Kaufert1
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19
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84915238242
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Conseils aux femmes de quarante ans
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Méquignon, Paris, (Ed. 1, 1781)
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(1787)
, pp. 7
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des Longrois1
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20
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84915247184
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Essai sur les maladies auxquelles les femmes sont plus fréquement exposées à l'époque de la cessation
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Ed 4, La Vve, Paris
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(1802)
, pp. 22
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Béclard1
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21
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84915218880
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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.
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22
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84915241246
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The female physician etc
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J Holland, London, (cf. [1] note 114)
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(1724)
Panckoucke
, pp. 42
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Maubray1
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24
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84915246326
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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, Samburu, 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 chimpanzees 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 [[Truncated]]
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26
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84915260435
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eg. Crawford MP. What happens at the change. New Society 29 Oct 70.
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27
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84915236406
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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.
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28
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84915274465
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“Considéré en general comme affection plus particulière aux femmes, on le voit (le cancer) se fixer plus souvent au seine qu'à d'autres parties, mais vu d'une manière restreinte, et comme affection correspondante à la cessation des règles, c'est l'uterus qui est son siege le plus ordinaire”. (Béclard 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.
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29
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84915280273
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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, François. 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. [1] note 69). Astruc who similarly suggests “an ulcer or cancer of the uterus” (Astruc 1762; 1:336 [24]) is brought on by climacteric [[Truncated]]
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-
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30
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0021703454
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Clinical information: Signs, semeions and symptoms, a discussion paper
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The visualization of the cervix uteri (and vagina), readily avilable after the introduction of the diagnostic vaginal speculum, (Récamier 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.
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(1984)
J R Soc Med
, vol.77
, pp. 766-773
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Wilbush1
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31
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84895715880
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J Johnson, London, 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 (not 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 Denman 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 Récamier became [[Truncated]]
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(1794)
An introduction to the practice of midwifery
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Dennam1
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32
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84915267538
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Denman, who regarded cancer of the uterine cervix as the most important, even only, complication of the climacteric, 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].
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33
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84915268835
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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.
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34
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84915242799
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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 chère” [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].
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-
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35
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84915245765
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Gardanne CPL de 1816 Avis aux femmes qui entrent dans l'âge 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 [1] note 58).
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-
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36
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84915256167
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Chambon N. Maladies des femmes Pt V. Maladies chroniques à la cessation des règles. 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.
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37
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84915227532
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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 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 60%) 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 [[Truncated]]
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38
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84915266308
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This may, in part, account for the European emphasis on virginity, especially among the upper classes.
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39
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84915232929
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Efforts to control natural increase vary greatly. The most prevalent contraceptive “technique” is probably lacation [cf. 57] often associated with prolonged postnatal ritual chastity, though avoiding deposition of the semen, commonly by withdrawal, is of equal if not greater importance.
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40
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84915219943
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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).
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41
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84915272671
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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.
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42
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84915271142
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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.
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43
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84915244167
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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.
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44
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0007324881
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Abortion and depopulation on a Pacific Island
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e.g., B.D. Paul, Russell Sage Foundation, New York
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(1955)
Health and Culture
, pp. 211-235
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Schneider1
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45
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84915257324
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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.
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46
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84915260720
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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.
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47
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84915269091
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Jeannett 1787; 78 [18] (cf. [1] note 52).
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49
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0020215109
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Climacteric expression and social context
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(1982)
Maturitas
, vol.4
, pp. 195-205
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Wilbush1
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51
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84915272818
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Macfarlane 1986; 62–78 [45].
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52
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84915255833
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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 (1523–1563), they never, because they dulled sensation, became popular. Moreau, however, 250 years later, mentions “caleçons de taffetas ciré” (covers of waxed taffeta) utilized “pour … dérober 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.King Charles used condoms to escape his mistresses' claims-of-support [[Truncated]]
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53
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84915271080
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Vaginal contraceptive applications have a long history stretching back to the Petrie (1850 BC) and Ebers (1550 BC) papyri, Intravaginal 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 Malthusians the effect on the birthrate was similar, decline being pronounced by the last quarter of the 19th century. 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 [[Truncated]]
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54
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84915251933
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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 contraceptives the deeper reasons for these delayed “echoes” are not clear.
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55
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0022386273
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Surveys of climacteric setneiology in non Western populations, a critique
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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.
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(1985)
Maturitas
, vol.7
, pp. 289-296
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Wilbush1
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56
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84915227957
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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.
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57
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84915267133
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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, règles or periode/regel, it emphasizes “regular periodicity”, it does not, the seldom used “monthlies” or monatsblutung being exceptions, refer to a monthly regularity. Common usage expressons [[Truncated]]
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58
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84915226738
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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).
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59
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84915278158
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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.
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60
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85067504079
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European Marriage patterns in perspective
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D.V. Glass, Dec Everseley, E Arnold, London
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(1968)
Population in History
, pp. 101-143
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Hajnal1
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61
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84915229908
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The Western lifestyle has created “what has been termed ‘incessant ovulation’ … The occurrence of ovulatory menstrul cycles [cf. 58] 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. 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 bio-endocrinology has [[Truncated]]
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62
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12444306055
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Vincent, Paris, Le médecin philosophe, as Roussel became known (Moreau 1803; 1:412 [16]), conjectures that “le flux menstruel, bien loin d'être une institution naturelle est au contraire un besoin factice contracté dans l'état 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'espèce humaine, [[Truncated]]
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(1775)
Système physique et moral de la femme, etc
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Roussel1
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63
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84915233475
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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 flux and seldom, if ever, subject to recurrent menstruation. “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 [[Truncated]]
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64
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84915274134
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“Menstruation is the periodic discharge of blood and disintegrated endometium after a normal ovulatory 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.
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65
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84915262638
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Many infradian rhythms, some marked monthly and annual recurrent systems notwithstanding, are frequently not truly inherent but depend on suitable stimulation. Characterized as cyclic, they often change with circumstances, showing no persistance of an endogenous biorhythm, as, for instance, when monoestruous 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 [[Truncated]]
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66
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84915221386
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Indeed, viewed as a human activity/function in Lévi-Strauss's structural map, or classified within his binary oppositions of nature versus culture, it would be much closer to the latter than the former. (Lévi-Strauss C 1963 Structural anthropology, translated from the 1958 French) Basic Books, New York. Also see Lévi-Strauss C 1970. The raw and the cooked (translated from 1964 Le cru et le cuit) New York: Hippocrene Books).
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67
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84915222086
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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.
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68
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84915246542
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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]).
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69
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84915228960
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Menville records that “les femmes, alarmées par l'approche de l'âge critique, engagent leur médecin à leur toucher, … que celui-ci est tout supris de trouver des desorganisations si avancées de la matrice, qu'on est obligé d'en faire remonter l'origine à plusieurs années”. 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 l'âge critique chez les femmes etc. Baillière, Paris, 1840; 142 is almost certainly plagiarized from Saucerotte C Nouveaux conseils aux femmes sur l'âge prétendu critique etc. Paris: Mme Auger Méquignon, 1828; 9 (published semi anonymously). Unlike Menville who [[Truncated]]
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70
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84915284393
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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 fibromyomata, 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 [[Truncated]]
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71
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84915265975
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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 menstrual 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 climacteric in such sombre, depression-evoking colours and aggravated every organic complication [[Truncated]]
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72
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84915238777
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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 1986b WONCA 1986: a personal impression. Canad. Fam. Physician 32: 1413–1414 and 1520).
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73
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84915218961
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These can be traced to the laicization of medicine, the complete separation between the healer and the preaching, demanding priest, as well as, more recently but by no means as completely, the physician and the policing, punishing state authorities.
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74
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84915230492
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See Wilbush J. 1988 [1] especially quotations from Gardanne [34] and Tilt [94]. This is, obviously, only partially correct, as illustrated not only by historical [1] but many modern examples.
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75
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84915251622
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Called une verte vieillesse, 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 [16]). Cultivating her intellectual faculties she might even at this age acquire great attraction as attested by the medical philosopher Roussel [61] who in his later years much preferred climacteric to younger women (Moreau 1803; 1:412 [16].Gardanne, noting that, once over the menopause, many can, for shorter 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, Gardanne 1816 64 [34]). In fact, they present “une couleur rose dans toute (leur) étendue, surtout [[Truncated]]
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76
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84915262608
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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 abdominally. Ocassionally, however, a vaginal hysterectomy was performed with the uterus extracted by morcellement [102].
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77
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84915265230
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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., 431–432.Incidentally this was the first total abdominal hysterectomy.
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78
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84915220669
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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.
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79
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84915228252
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Péan 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 Koeberlé, after 1865, operators were ready to tackle whatever pathology they encountered. (Ricci 1945; 169–170 [79]).
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81
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84915253806
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33 women, nearly 80% of the 42 who had abdominal hysterectomy, as reported in the literature 1843-1866, died. See also [83].
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82
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84915268223
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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 [[Truncated]]
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83
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84915271285
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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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84
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84915246927
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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 Burnham, 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%).
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85
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84915223249
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The table of fees of the Chicago gynaecological society for December 1879 quotes $1000.00 for hysterectomy, the equivalent of between 50 000 and 100 000.00 today.Other operations are also relatively expensive: e.g. D & C $25.00 and the application of a pessary $10.00 (Flack 1951; 528 [76]).
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90
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84915252121
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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.
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91
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84915244330
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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.
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92
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84915279243
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As Paré 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” (Paré A. Of the generation of man, original French 1573 De la géneration de l'homme etc.) London: T Cotes, 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 1960; 342 [85]) while Paulus Aeginata (7th cent.) records uncomplicated recovery after similar operations (Green Armitage 1954 [87], Ricci 1943; 318 [88]).
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93
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84915242626
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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 [[Truncated]]
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94
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84915262266
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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]). Giacomo 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, all 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 Part 1510–1590, Cristobal de Vega 1501-1580 and others performed similar operations (Ricci 1943; 322 [88]).
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95
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84915273117
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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.
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96
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84915242749
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Ed 2, John Churchill, London, This, of course, refers to Ephraim McDowell's feat, who, on 13 Dec 1809, was the first to invade the abdominal cavity and excise a tumour completely surrounded by peritoneum. His patient, Mrs. Crawford, moreover, completely recovered.
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(1857)
The change of life in health and disease etc
, pp. 33
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Tilt1
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97
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84915276084
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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. Koeberlé 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 [[Truncated]]
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98
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84915247121
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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]).
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99
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84915263567
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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 [87].
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100
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84915244100
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Though Semmelweis published his first paper in 1849 and his treatise in 1861 (Garrison 1929; 435–436 [86]) he was ignored, while Lister's well argued papers 1867 established surgical antisepsis, “Listerism”, as operation-room routine.
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101
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84915227504
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Separate ligation of the uterine vessles (Mikulicz 1880, Schroeder 1880, Stimson 1889). Preitonization of the cervical stump, rendering it “extraperitoneal” (Spencer Wells in 1880). Anterior and posterior peritoneal flaps (Emmet 1884, Eastman 1887) (Ricci 1945; 174–175 [79]).
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102
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84915269443
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Mortality during 1843–1866 was, as stated, around 80% [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 total 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%.
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103
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84915275972
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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. It was nonetheless generally favoured, in all cases, because of its lower rate of complications. Post operative haemorrhage was both less common and less troublesome 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].
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104
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84915282822
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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.
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105
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84915253355
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These techniques, surviving in some areas, notably in some parts of Britain, as late as the 1960s, 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 1980a [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, [[Truncated]]
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106
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84915281635
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“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” [104]. 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 [[Truncated]]
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107
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84915278952
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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 1960s–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 [[Truncated]]
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108
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84915260282
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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 MG, Bieber I. The [[Truncated]]
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109
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84915230486
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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.
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110
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84915231888
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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.
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111
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84915219421
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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.
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112
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84915229943
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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.
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113
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84915264643
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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 [[Truncated]]
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