Menorrhagia and menopause: a historical review

References

1. Clinical terminology here follows the guidelines set for articles in this journal many years ago (van Keep PA 1979 Editorial note, Maturitas 1:227). Though mentioning climacteric symptoms and climacteric complaints, these guidelines are silent regarding the term “the menopausal syndrome” nor do they specify a “climacteric syndrome”
   It is therefore here proposed to make use of the label “the menopausal syndrome” whenever referring to the culture-bound behavioral disorder [40], historically associated with “le temps critique” but continuing in one guise or another until lately [97]. The label “climacteric syndrome”, hardly utilized here, nonetheless appears to be an excellent one for the widespread sensations, semeions [47], even symptoms, to which so many women, most remaining silent, are subject at midlife.
2. • Blatt MH
   • Weisbader H
   • Kupperman HS
   Vitamin E and the climacteric syndrome.
   Arch Of Int Med. 1953; 91: 792-799
   • Scopus (128)
   • Crossref
   • Google Scholar
3. • Kupperman HS
   • Wetchler BB
   • Blatt MH
   Contemporary therapy of the menopausal syndrome.
   JAMA. 1959; 171 (BMI stands for Blatt Menopausal Index, see also): 1627-1637
   • Scopus (243)
   • PubMed
   • Crossref
   • Google Scholar
4. The first gynaecological book to devote space to “les accidens (sic) de la fin des menstrues” was: Astruc J 1761 Traité des maladies des femmes (vol 2, liv. I. chap. 11). PG Cavelier, Paris.
5. Menopause and Menorrhagia: a historical exploration. While this separation has become necessary on “logistic” grounds, it has allowed the historical evidence, as viewed by contemporaries, to be examined apart from its, necessarily more speculative, present day interpretation. It has, on the one hand, facilitated access to medical literature not readily available and on the other, with the advantages of modern clinical understanding and sociological perception, made possible the presentation of a comprehensive view of many of the problems faced by climacteric women during recent European history. The validity of the latter of course depends on the evidence here presented, but it could not be, in fact was not, formulated without present day knowledge. This article should appear in a future issue of Maturitas.
6. “Purgings” was commonly used in the 17–19th century medical literature as an alternative for courses or menses, to emphasize the excretory aspect of the monthly discharge. This aspect is forcibly expressed by Dionis when describing the female genitalia: “Tho the Womb is the most noble and necessary part in the production of Man, it nevertheless is a common-sewer, by which the terms are carry'd off every month”. (Dionis P 1719 A general treatise of midwifery, p. 61 (original French 1718) A. Bell, J. Darby, A. Bettesworth, J. Pemberton, C. Rivington, J. Hooke, R. Cruttenden, T. Cox, F. Clay, J. Battley and E. Symon, London.)
7. Translated: the discontinuation of female cleansing — a German popular name for the menopause up to the end of the 19th century. The same popular view is reported from France: “cette évacuation périodique est destinée a expulser un virus dont la matière acre et morbifique peut engendrer des effects délétères” — this periodic evacuation is intended for the expulsion of a venom the acrid and morbific matter of which may cause deletirious effects. (Gardanne 1816: 65[25]).
8. Pliny (Gaius Plinius Secundus 23–79AD) Historia naturalis. Tom 2, lib 7, Cap 15 art 13. While Pliny was only a chronicler of ideas,, his writing became later very influential. These beliefs were incorporated into medicine by Galen (129–199AD). Their wide, grass-roots, distribution not only in France, where it may be due to the settlement of Roman legionnaires, but in Germany and elsewhere point to general European traditions concerning the menstrual blood.
11. The full sentence (quote) reads on: “that it kills bees by its vapours, makes dogs mad if they taste it, destroys any plant that comes near it”. A fuller description of these noxious actions is given by Regner de Graaf (Graaf R de 1672 De mulierum organis generationi inservientibus tractus novus p 124 Officina Hackiana, Lugduni Batavorum) some 50 years earlier.
    La Motte does not “entirely agree” with either Hippocrates [13], because, in contrast to normal blood that of the menses does not clot, nor with Pliny since so “many women go everywhere and perform all their usual functions, when they have the menses on them… and cause no mischief”. Yet he is of the opinion that this sometimes happens, especially where “red-hair'd women” are concerned: indeed one, who was a servant in his house, caused his wine to go sour and pork to spoil. (1746: pp 57 et seq).
12. This is the heading of a chapter: “Cessation des règles et mort du sexe”, best translated as: cessation of the menses and disappearance (death) of the female sexual identity. (Moreau 1803:371[24]).
    It must, however, be mentioned that not only did Moreau not prescribe to the view that the menstrual blood was in any way malignant, but seemed “ashamed” cette erreur was propogated. He “appologizes” pointing out it is “une de celles (erreurs) que les grands hommes de tous les siècles sont en quelque sort forces de partager avec leur siecle” — one of the (errors) which great men in any era are somehow forced to share with their time (Moreau 1803:3:152 n [24]).
13. Most commonly as bleeding piles or epistaxes. All forms of periodic bleeding, even if not at monthly intervals were, from time to time, regarded as beneficial. Among these were many now known to be ominous signs of underlying serious disease — such as haemoptysis, haematuria or even bleeding from the nipple. (Tilt 1857:56[30]).
14. • Wilbush J
    La ménespausie — the birth of a syndrome.
    Maturitas. 1979; 1: 145-151
    • Scopus (24)
    • PubMed
    • Abstract
    • Full Text PDF
    • Google Scholar
15. • Wilbush J
    The climacteric syndrome: historical perspectives.
    in: Notelovitz M van Keep P The Climacteric in Perspective, Proc. of the 4th Int. Congress on the Menopause. MTP Press, Lancaster1986
    • Google Scholar
16. The Hippocratic school believed that the menstrual discharge was indistinguisable from ordinary body blood, tanquam cruor ex victima — like that which flows from the wounded (victim).
17. Solidism or strictum et laxum (constriction and relaxation) can be traced to Asclepiades (2nd cent. BC) and the Methodist school which opposed Hippocratic humoralism (see Garrison FH 1929 An introduction to the history of medicine Ed. 4 p 106 and p 314. WB Saunders, Philadelphia, London & Toronto). Followers of this school, like those of Hippocrates, also believed the menstrual blood to share the same qualities as normal blood. They explained the menopause by the constriction of the uterine blood vessels, the hardening of this organ and the thickening of the blood [87], all ageing phenomena. One of the first to popularise these ideas in England was Culpeper (Culpeper N 1651 A directory for midwives or a guide for women. P. Cole, London), however, the first to combine these views with the then young science of mechanics, or more particularly “hydraulicks”, was a Scot, Simson. In his book (Simson T 1729 The system of the womb, with a particular account of the menses independent of plethora. R Fleming & Co., Edinburgh) he sets out to explain the monthly discharge of the menses and its cessation on purely mechanical principles, on the pattern established by Harvey's De motu cordis (1628). In this he was soon to be overshadowed by his contemporary, “l'immortel” (Chouffe 1802:11[43]) physiologist Haller who arrived at very much the same conclusions (Haller A von 1747 Primae lineae phisiologiae in usuu praelectionus academicarum. A. Vanderhoeck, Gottingen. Eng. trans. 1779 First lines of physiology. C. Elliott, Edinburgh). According to the latter, since the menses depend “hydraulickly” on the balance between “the quantity and momentum of the blood collected, and the resistance of the uterus … They cease entirely to flow when the uterus, like all other solid parts of the body, has acquired so great a degree of hardness, as cannot be overcome by the force of the heart propelling the arterial blood” (Haller 1779: 423).
18. An original thinker, Jean Astruc 1684–1766 was responsible for many seminal ideas in gynaecology as in other fields. He was the first formally to recommend bimanual vaginal examination in order to define the size of the uterus (Astruc 1762: 2: 115) and might have used the vaginal speculum not only as a surgical retractor but also, as later (1801) recommended by Récamier, as a diagnostic aid. His ideas concerning the aetiology of climacteric disturbances were somewhat complex [17] but not his treatment, which differed little from that recommended by Fothergill [18].
    Physician to Louis XV he was Catholic, though, judging from his name (recorded at Lunel, about 35 km from his birthplace of Sauvé, Languedoc, among the Jewish families of the 13th century, expelled from France 1306) of Jewish origin. He learned Hebrew from his father who was a Protestant preacher and was interested in Biblical studies. Treating the Book as sceptically as he did medical authoritative texts, he was the first to distinguish the Yahwist from the Elohist sources in the Tetrateuch (Astruc J 1753 Conjectures sur les memoires originaux dont il paroit que Moyse s'est servi pour composer le livre de la Genese. Chez Fricx, Bruxelles)
    Writing extensively on veneral disease he strongly supported, with wide historical research, the American origin of syphilis.
19. • Astruc J
    A treatise on the diseases of women in which it is attempted to join a just theory to the most safe and approved practice.
    in: Ed 2. Translated from the French [3]. vol 1. J. Nourse, London1762: 334
    • Google Scholar
21. This is followed [pp 323–331] by a complex explanation describing five states (4 simple and one combined) of the uterus, each with increasing severity of symptoms. While this system never attained popularity, possibly because of its complexity, it already emphasized most points made later by others, especially Fothergill [18].
22. • Fothergill J
    On the management proper at the cessation of the menses.
    Med. Obs Inquiries. 1776; 5: 160-186
    • Google Scholar
23. • Denman T
    An introduction to the practice of midwifery.
    in: J Johnson, London1794: 179
    • Google Scholar
24. • Power J
    Essays on the female economy.
    in: Burgess & Hall, London1821: 55-56
    • Google Scholar
25. • Saucerotte C
    Nouveaux conseils aux femmes sur l'âge prétendu critique.
    in: Ou conduite à tenir lors de la cessation des règles. Mme Auger Mequignon, Paris, Paris1828
    • Google Scholar
26. • Davis DD
    The principles and practice of obstetric medicine, a series of systematic dissertations on midwifery and the diseases of women and children.
    in: Taylor and Walton, London1836: 288
    • Google Scholar
27. • Ashwell S
    A practical treatise on the diseases peculiar to women.
    in: Samuel Highley, London1844: 196
    • Google Scholar
29. As suggested by the title, this book comprises two, very different accounts. The first is a mock-biological amusing review of woman as a “species”: the second a practical “guide”, recommending a lifestyle influenced as much by Fothergill as by Rousseau.
30. • Gardanne CPL
    Avis aux femmes qui entrent dans l'âge critique.
    (de)in: Gabon, Paris1816: 238
    • Google Scholar
31. • Menville
    De l'âge critique chez les femmes, des maladies qui peuvent survenir à cette époque de la vie, et des moyens de les combattre.
    (CF de Ponsan)in: Baillière, Paris1840: 136
    • Google Scholar
32. • Brierre A de Boismont
    De la menstruation considérée dans ses rapports physiologiques et pathologiques.
    in: Ballière, Paris1842: 246
    • Google Scholar
33. • Whitehead J
    On the causes and treatment of abortion and sterility, being the result of an extended practical inquiry into the physiological and morbid conditions of the uterus with reference especially to leucorrhoeal affections and the diseases of menstruation.
    in: Churchill, London1847: 154
    • Google Scholar
34. • Tilt EJ
    On the preservation of the health of women at the critical periods of life.
    in: Churchill, London1851: 100
    • Google Scholar
35. • Tilt EJ
    The change of life in health and disease.
    in: A practical treatise on the nervous and other affections incidental to women at the decline of life. Ed 2. Churchill, London1857
    • Google Scholar
36. • West C
    Lectures on the diseases of Women.
    in: Ed 2. Churchill, London1858: 48
    • Google Scholar
37. • Clarke EH
    Sex in education or a fair chance for girls.
    in: JR Osgood & Co, Boston1873: 34
    • Google Scholar
38. • Tait R Lawson
    Diseases of women.
    in: Williams and Norgate, London1877: 147
    • Google Scholar
39. • Skene AJC
    Treatise on the diseases of women for the use of students and practitioners.
    in: D. Appleton & Co, New York1889: 422
    • Google Scholar
40. Though he must have been familiar with Astruc's work [3], translated into English [16] 14 years prior to the publishing of his article [18], Fothergill never mentions him. This is not unusual in the context of the time.
41. Although Astruc had, as already noted [17] taken a line very similar to that later pursued by Fothergill (see also [38] and [70]) and was, moreover, available in French, his work had little effect at the crucial time, only 40 years after its publication, when the whole approach to the manangement of the climacteric in France was so drastically changed (vide infra et [11,12]). It was Fothergill's criticism of traditional treatment, rather than Astruc's complex instructions how to use its various modalities which won the day. It is confusing, at least to the modern reader, to find the same emmenagogues and aperients condemned for the cessation but recommended for suppression of the menses [38], bleeding from the foot recommended prior to cessation [74] but not after it [70] — it may have also been confusing to his contemporaries. While this might have been the main reason for prefering Fothergill to Astruc others were probably also operative. Astruc was probably rejected very soon after publication, when the old traditional treatment was almost universally practised, and the reputation this gave him might have stuck, at least that is the impression one gets from the few references to him (e.g. Chouffe 1802:36[43]). His work was moreover only available as several library volumes while that of Fothergill easily procurable as a pamphlet.
42. These assertions, none of which, incidentally, relies on direct observation, are to forestall claims that the cessation of the menses results in either a general (by increase in blood volume) or local (by congestion of the uterine vessels) plethora. Fothergill takes it for granted everybody is “sensible that the menstrual discharge is not what it was too long and too generally believed … an evacuation of peccant matter and morbid humour, sometimes acrimonious and malignant, whose retention never fails to be extremely injurious, from its noxious qualities, to the constitution”, an “opinion the ancients entertained [7] concerning it”. There is, therefore, no reason to encourage the continuation of the catamenia on that account, nor devise a substitute for it. [11,12].
43. Compare: “Women in which aperitives (= aperients, laxatives) and emmenagogues have been improperly given to bring back the menses which have ceased naturally and of which the cessation has been mistaken for suppression” mostly suffer from the 4th state of the uterus [17] i.e. fluor albus. (Astruc 1762:330[16]).
45. The name of the translator did not appear on this first edition, but did on subsequent ones: Ibid 1800 (An VIII) ditto. Ed 2. Paris: Gabon, Ibid 1812 ditto. Ed 3. Paris: Méquignon.
46. • Wilbust J
    Climacteric expression and social context.
    Maturitas. 1982; 4: 195-205
    • Scopus (12)
    • PubMed
    • Abstract
    • Full Text PDF
47. Note 20 defines the term “behavioral disorders” (North American spelling), as used here, in a technical sense. These encompass all disorders, functional or somatic, the aetiology of which is largely associated with social stress. See also [67].
48. Petit Radel is described as a professor of medicine, clinique de l'ecole dite de perfectionnement, University of Paris, on the list of teachers attached to the thesis of Béclard [42] and Chouffe [43] who both qualified in 1802 [93]. The role ascribed to him here is pure guesswork, based on “reading between the lines”.
49. • Béclard
    Essai sur les maladies auxquelles les femmes sont plus fréquent exposées à l'époque de la cessation.
    La Vve Panckoucke, Paris1802
    • Google Scholar
50. • Chouffe JBP
    Des accidens et des maladies qui surviennent à la cessation de la menstruation.
    Croullebois et Gabon, Paris1802
    • Google Scholar
51. • Moreau JL
    (de la Sarthe)Ed 2. Histoire naturelle de la femme, suivie d'un traité d'hygiène appliquée à son regime physique et moral aux differentes époques de la vie. 2. L. Dupart, Paris1803: 376
    • Google Scholar
52. • Gardanne CPL
    Avis aux femmes qui entrent dans l'âge critique.
    (de)in: Gabon, Paris1816: 195
    • Google Scholar
53. This applies equally to the members of some other cultural subgroups such as “the wives of the emerging capitalist hard-working, God fearing, new industrialists” whom Fothergill attended in late 18th century England. [cf.103].
54. • Wilbush J
    Surveys of climacteric semeiology in non-Western populations: a critique.
    Maturitas. 1985; 7 (References regarding the effects of the climacteric among the peasantry of France in the 18–19th century are detailed in notes 2–6.): 289-296
    • Scopus (12)
    • PubMed
    • Abstract
    • Full Text PDF
    • Google Scholar

55. Jeannet JBC. Des Longrois 1787 Conseils aux femmes de quarante ans (Edl 1781) Paris: Méquignon .

    • Google Scholar
56. Freely translated: In an environment of free and pure air …. at the head of a family where, as wife and mother, they reign till the end of their days …. leading, as they have since infancy, a frugal and wholesome lifestyle (diet). (Jeanet 1787: 5–6[48]).
57. Freely translated: A woman should live simply in the climacteric, imitating the style of life of country women, who seldom experience serious consequences at the cessation of their menses. (Gardanne 1816:153 [25]).
58. Freely translated: Seeing the multitude of dangers which menance … women who are always in a thick, humid atmosphere where the tumult of passions, profusion of viands, abuse of perfumes, fermented liquors and the experience (sensing or enjoyment) of a thousand pleasures constantly fire the blood, Jeannet is moved to warn that as youth loses its lustre, life its capacity for experiencing pleasure, age usually brings in its train more ills to fear, regrets to deplore, cares to take and privations to endure (Jeannet 1787: 6–8 [48]).
59. Freely translated: soft and sedentary life spent in the pleasures of love, in sleep in games of chance, the delights of the table and (big) spectacles. (Jeannet 1787: 78 [48]).
60. • Astruc J
    A treatise on the diseases of women in which it is attempted to join a just theory to the most safe and approved practice.
    in: Ed 2. Translated from the French [3]. vol 1. J. Nourse, London1762: 339-340
    • Google Scholar
61. Freely translated: Unrestrained frequent indulgence in the pleasures of love, (due) to passionate anger, to gluttony and the abuse of wine, and to venereal diseases. (Béclard 1802: 22 [42]).
62. Translated freely: an extreme susceptibility of the nervous system which magnifies the influence of the emotions (passions), an opulent, lazy life of luxury … late nights spent gambling, large crowds etc, the abuse of alcohol, immoderate drinking of tea or coffee etc … Excessive indulgence in the joys of love as well as the important previous diseases which had most influenced the menses. (Chouffe 1802: 30–31 [43]).
63. Translated: the misguided (bad) employment of one's life (Moreau 1803; 2: 375 [24]).
64. • Gardanne CPL
    Avis aux femmes qui entrent dans l'âge critique.
    (de)in: Gabon, Paris1816: 93-94
    • Google Scholar
65. • Gardanne CPL
    Avis aux femmes qui entrent dans l'âge critique.
    (de)in: Gabon, Paris1816: 239-241
    • Google Scholar
66. The various recommendations, prohibitions and exhortations commonly included in guides for women were often set under the headings of (1) Circumfusa — surroundings, air, smells, disinfection, pollution and dwellings. (2) Applicata — applied to the body from bathing and beds to clothes and cosmetics. (3) Ingesta — food and drink (4) Excreta — natural and artificial (including issues, cauterics, setons etc). (5) Gesta — bearing, movement, rest and sleep. (6) Percepta — sensations and passions.
67. Gardanne complains many women “ont plus de confiance dans les médicamens des vieilles commères…. que les secours de l'hygiène” (Gardanne 1816: 96 [25]). Contemptuously referred to as “old crones” these were the traditional folkhealers to whom women always turned in the climacteric before they started consulting doctors. (Wilbush 1981 [88]).
68. Freely translated: They consult their dressmaker (dress saleswoman) more often than their doctor (Gardanne 1816: 130 [25]).
69. • Tilt EJ
    The change of life in health and disease.
    in: A practical treatise on the nervous and other affections incidental to women at the decline of life. Ed 2. Churchill, London1857: 84-85
    • Google Scholar
70. • Tilt EJ
    The change of life in health and disease.
    in: A practical treatise on the nervous and other affections incidental to women at the decline of life. Ed 2. Churchill, London1857: 100
    • Google Scholar
71. Translated freely: (on reaching the climacteric as) their various conscious acts were no longer dominated by the, often tyrannical, influence of urges to experience pleasure, (women could) delighting in the purer happiness of family affections and the inhirent moral qualities of their sex. (Menville 1840: 157 [26]).
73. Translated freely: (renounce former ways) to the honour of our time and credit of all women, coveting only the glory of having enhanced the brilliance of the sweet names of mothers and wives … And when the time of life comes (in the climacteric) they listen to the voice of nature and submit with noble courage (pp 31–32).
74. Traditional treatment of the climacteric, as practised by female healers [60] and later by doctors, up to the end of the 18th century probably originated in Rome. It is probably there, possibly as early as the 2nd century BC, where the connection was made between the wilting of the secondary sexual characters and the increase in the blood level (to use a modern term) of toxins, once the latter were not excreted via the menses, and the various possibilities of inducing menstruation or, failing that, providing alternative outlets for body toxins. Surviving descriptions, written by Paulus Aeginata are only from the 7th century and Eastern empire (Aeginata Paulus, 7th cent., collected writings. Eng. trans. Adams F. 1844 Sydenham Society, London. Relevant items: Book 3 Sect. 30. esp 1:608). Aeginata's description refers to the treatment of menoschesis (= retention of the menses) which is not clearly defined. Though it appears to be more suitable for amenorrhoea associated with missed abortion, it has been indiscriminately utilized for all types of amenorrhoea, including that of the climacteric. In addition there are manoeuvres designed to provide an outlet for retained poisons: for details see [11,12,67].
75. • Wilbush J
    The female climacteric.
    Unpublished thesis, Oxford. 1980; (Relevant sections: 8-2-2)
    • Google Scholar
76. • Astruc J
    A treatise on the diseases of women in which it is attempted to join a just theory to the most safe and approved practice.
    in: Ed 2. Translated from the French [3]. vol 1. J. Nourse, London1762: 336
    • Google Scholar
77. Fothergill, however, suggests both the menorrhagia and cancer may be due to a common cause: “Sometimes these immoderate fluxes proceed from some irritating cause resident in the uterus or the parts contiguous to it. And among these none is more common than a deposition of acrimony which precedes a cancer of the parts” (Fothergill 1776 [18]).
78. • Astruc J
    A treatise on the diseases of women in which it is attempted to join a just theory to the most safe and approved practice.
    in: Ed 2. Translated from the French [3]. vol 1. J. Nourse, London1762: 339
    • Google Scholar
79. Recueil périodique d'observations de médicine, de chirurgie et de pharmacie. 1754; 1 (Annonymous): 187-192
80. This article emphasizes that haemorrhage is one “d'un grand nombre des maladies difficiles à guerir” which follows the termination of menstruation when “la malade est fort en danger”. It then illustrates its contention with two clinical cases, one 50 years old and the other, who also suffers from “hydropisie” (dropsy or oedema), “about 40” years old. Both also had a variety of other symptoms which, as in other writings, sound somewhat bizarre to modern ears.
    The following article, also annonymous, Observations sur une passion hystérique, ou plutôt sur une epilepsie survenue à la cessation des règles, in the same journal, 1: 193–198, though not directly relevant to our subject here, is of some interest as illustration of treatment at the time. When the patient, a 45 year old woman, convulsed it was observed she was “plethoric”, while questioning revealed her menses have greatly diminished. She was therefore bled copiously, the blood being reported as “inflammatory” in character. Despite all this “la malade guerit enfine”.
    The above journal was published monthly by J. Barbou in Paris for only four years (1754–1757) under the above title. 1758–1793 it was called Journal de médicine, de chirurgie et de pharmacie, further changes occurred later. It should be noted that up to 1788 this publication printed only 3 observations regarding la cessation des règles (the 3rd, in 1758, dealt with a spontaneous post menopausal “ponction”, possibly a cancerous fistula). At the same time about 18 observations/articles dealing with suppression des règles also appeared [cf. 88] (Le Roux MFF des Tillets 1788 Table indicative des matiéres, et table des auteurs pour les LXV premiers volumes du Journal de médicine. Paris).
81. “Evacuations” are the regular phlebotomias which were believed to be necessary for the maintenance of health. These were specially recommended in the premenopause. Astruc, for instance, advises women should “take care of their health with the greatest precaution”, having regular phlebotomies for 1–2 years “in order to diminish the volume of blood which regurgitates in the vessels” (Astruc 1762: 337 [16]). As long as women were not excessively bled there would have been no complications, the placebo effect outweighing any reduction in haemoglobin levels.
82. Aloes, “the basis of most medicines exhibited with a view to promote the menstrual discharge” [18], for instance, continued to be sold as emmenagogue (and abortifacient) throughout the 19th and first half of the 20th century. The most common preparation in England was Beecham's pills: it was used both by younger women or those in the premenopause, especially when anxious lest they were pregnant.
83. Compare: “The natural cessation of the menses scarcely requires any medicines: nothing more is necessary than to bleed sometimes in the foot and to give some stomachics” (Astruc 1762: 333 [16]).
    NB. While Astruc warns that “bleeding in the foot” after the menopause may cause menorrhagia [70] he does recommend it in the premenopause.
84. Freely translated: (Jeannet/the author) did not intend to write for the men of the Art (of medicine) but for the public. (Jeannet 1787: 28 [48]).
85. e.g. “les affections de l'âme ont …. une grande influence sur le mouvement progressive du sang, sur l'état de la matrice et le cours des règles” — the emotions greatly influence the progressive movement of blood, the state of the womb and the course of the menses. (Jeannet 1787: 73–74 [48]).
86. e.g. “Dans l'ordre social les femmes ont à souffir de mille dependences, comme dans l'universe physique, de mille infirmités” — socially women are subject to a thousand “inferiorities” (subjugation, insults) just as physically a thousand infirmities. (Jeannet 1787: 19 and frontispiece).
87. Freely translated: The softness (tenderness) of women's constitution. (Jeannet 1787: 12–13 [48]).
    It is this capacity, according to the doctrine of strictum et laxum, which, for instance allows pregnancy to stretch female bodies and genitalia, with their return to their former shape after delivery. Jeannet also extends this attribute to their character, to women's spiritual tenderness and other virtues.
89. Chouffe criticizes Jeannet, as well as Astruc, for having “confondu les accidens (sic) de …. cessation avec ceux resultans (sic) des suppressions.
90. A collection of largely 18th century German medical theses (in Latin, vol. 585, British Library) for instance, contains 36 dealing with maladies arising from menstrual irregularities. Only five, including Titius, 1710 [87], are concerned with cessatio menstruorum. The other four are dated 1776, 1779, 1789 [90] and 1800. The last one defended by Effler IHD 1800 De menstruatione vitiosa, Gottingen, mentions both suppressio mensium, or menostasia (pp 27–34) and menses cessantis (pp 34–36). Judging from their titles about ten more, dating 1673–1796, concentrate on the suppression or retention of the menses.
92. Jeannet speaks in this instance as if he was ignorant of the possibility of cancer. He describes some patients as extremely pale, emaciated even cachectic and at times subject to dropsy. The condition might have been cancer corpus uteri which, prior to availability of diagnostic tools such as a curette, or even a vaginal speculum, remained undiagnosed. Post mortem examinations were also not performed until their value was emphasized by Virchow.
94. Cancer in this context means cancer of the cervix uteri, [cf.81], which is visible, or else easily palpable.
96. This last, long, chapter (of four) in the booklet is entitled maladies causées par le refoulement des règles — disease caused by the forcing back (damming up) of the menses. Each complaint is dealt with separately, being given 2–10 pages.
98. The various parts of this work were originally published separately 1784–1785
99. Unlike Haller or Simson [14] Chambon sticks to orthodox solidist teaching and does not combine it with insights from hydrokinetics. The menopause is explained by the progressive hardening of the uterus and concomitant thickening of the blood. This process interferes with the pelvic circulation and often causes irregularities of the catamenia. The obstruction to the circulation and consequent reduction of quantity of the menses creates a general plethora, due to excess of blood, and a local one, due to interference with its free flow in the pelvis. This dammed up blood may occasionally burst out causing haemorrhage. [cf. 37].
100. Excessive medicinal bleeding, like haemorrhage, causes “atony” and should be avoided. Chambon also points out that the use of a wrong vein, as one in the leg instead of the arm, draws blood to the uterus and may cause severe menorrhagia [cf. 70,74], a frequent objection which is still voiced at mid 19th century [12].
     Phlebotomy “in the foot” was popular because it was believed to relieve headaches. During the premenopause it was also traditionally used, as “directional phlebotomy”, to direct the blood down towards the uterus and bring on the menses. This is, of course, based on the old Galenic view of the ebbing and flowing of the blood within its vessels and makes little sense once the circular character of the circulation is appreciated. The continued arguments surrounding this procedure only prove most doctors, even articulate men at the head of their profession, did not appreciate the true nature of the circulation of the blood, Harvey's motu cordis notwithstanding.
101. • Titius SD
     De fine mensium initiis morborum variorum opportuno.
     Chris Henckel, Halae Magdeburg1710
     • Google Scholar
102. • Wilbush J
     What's in a name?.
     in: Some linguistic aspects of the climacteric. Ed 3. Maturitas. 3. 1981: 1-9 (See Note 15)
     • Google Scholar
103. Uterine involution in the climacteric was logically accepted as a sign of the waning of its power (e.g. Clarke 1814: 59 [109]; Tilt 1857: 5–6 [30]). This being so a woman could no longer, after the menopause, be subject to hysterical disorders, “depuis l'époque de la cessation des règles … la matrice s'etant sommis à sa nouvelle condition n'a plus … presque aucune influence sur les autres organes; la femme n'est plus exposée aux accidens (sic) hysteriques proprement dits, les maladies qui arrivent alors, et que l'on confond avec aux, sont plutôt du genre de l'hypocondrie” — after the cessation of the menses, the womb in its new position has almost no influence on other organs. A woman is no longer exposed to hysterical affections, properly so defined, her maladies, mistaken for these, being, in fact, hypochondrial (Béclard 1802: 65: [42]). “… et c'est alors qu'elles sont sujettes à l'affection hypocondriaque, parce qu'elles ont cessé d'être femmes, si je puis m'exprimer ainsi” — they are subject to hypochondriac affections for they have ceased to be women (females), if I am allowed thus to express myself (Vigarous 1801: 468 [99]). Both Vigarous and Béclard only echo long current ideas. Other difficulties arise in explaining, or attitude to, postmenopausal sexuality or even, as hinted in the last quotation, femininity. Medico-legal questions with the continued incarceration of women for crimes ostensibly committed under uterine influence, like post-partum infanticide or crimes of passion, also then demand review.
104. • Vanderlinde FJ
     Fata ac incommoda ex menstruis naturae lege tandum cessantibus oriunda.
     J. Wiesen, Heidelberg1789 (see also [80])
     • Google Scholar
105. Inter-organ sympathy or consensum, as it was called by the Classical writers, expresses the common observation that changes in one organ are often associated with those in another. This is observed both in health, as the “sympathy” between the uterus (especially in pregnancy) and the breasts, and in disease, like menorrhagia associated with diarrhoea or other disturbances of the lower gut. It was, in fact, concluded that “the uterus appears to be a very fertile source of sympathy, and many symptoms referred to other parts arise from it” (Clarke 1814: 53 [109]). It was especially generally believed that “the mind sympathizes with the uterus” (Clarke 1814: 57–59 [109]) as commonly seen in functional gynaecological complaints.
107. Translated: Enormous, stubborn, irregular and recurrent uterine haemorrhages not rarely supervene, causing cachexia, oedema or else uterine ulcers and cancer.
108. Each dissertation is preceded on its second page, by a list of the defender's teachers. These are identical in the two now under consideration: both contain not only the name of Pinel but also of Petit Radel [41].
110. Called professeur Pinel by Chouffe and le citoyen Pinel by Béclard, Phillipe Pinel (1745–1826) is much more famous for his humane treatment of the insane. Removing the chains from the inmates of the Bicêtre (male) and soon later the Salpêtriere (female patients) and stopping their harsh treatment, he is widely considered the real founder of the open-door school of psychiatry.
111. The original French text is: Chouffe divides “ainsi que le professeur Pinel dans son cours de nosographie, les accidens (sic) qui se developpent … en deux séries: les uns se manifestent dans l'uterus même; les autres, prodigieusement multipliés des troubles sympathetiques des diverses fonctions” (Chouffee 1802: 29 [43]).
113. While the present French spelling is hémorragie, both Béclard and Chouffe are nearer the Latin with hémorrhagie.
114. Classifications of climacteric events and disturbances are influenced by the differing views regarding the aetiology and nature of these changes and disorders. The difficulties experienced today are whether to classify the climactieric transition and even the menopausal syndrome [1] as but a hormonal “deficiency disease” (Rhoades FP 1965 The menopause, a deficiency disease. Michigan Med 64: 410–412), or functional phenomenon; or classify the first as a physiological change and the second, the menopause syndrome [1] as a behavioral disorder [40], even a culture-bound syndrome [47,40]. These choices did not even present themselves before the rise of psychiatry at the end of the last century and the social sciences in this one. The psyche, like the nervous system, was then generally believed to be in sympathy with, or affected by the womb.
115. Freely translated: the nosologists have taken little note of the derangements of the end of menstruation, most having excluded them from their systems (Chouffe 1802: 37 [43] — see also the next page, 38, where references to various nosologies are detailed).
116. Vigarous offers a neat solution, in the context of the time, when he suggests the uterus should be studied in its four aspects as (1) a physiological, excretory organ (2) a pyschological one (organ vital) (3) an anatomical entity (4) a generative organ. Disorders can then be considered in whatever aspect of the uterus they affect (Vigarous JMJ 1801 Cours élémentaire de maladies des femmes, ou essai sur une novelle méthode pour etudier et pour classer les maladies de ce sexe. pp XIII–XIV. Déterville, Paris).
     A similar approach to the genitalia (both male and female) was taken by John H. Noyes (1811–1886) of the Oneida community, a community orientated fundamentalist Christian sect of the last century. Noyes differentiated between the excretory, reproductive and amative functions of the external genitalia allowing free exercise of first and last but not of reproductive functions which were highly regulated.
117. Translated freely: Most frequently haemorrhage is very severe and, though not fatal … leaves its sad victims only a languishing life, exposed to all manner of danger (Béclard 1802: 21 [42]). Indeed Béclard insists that diseases of the uterus merit special attention and every menorrhagia be looked at with suspicion (pp 31–32).
118. Two types (1) Recurrent uterine haemorrhages without a local cause and (2) Symptoms of cancerous affections of this viscus (Chouffe 1802: 31–32 [43]).
     Chouffe finds support for the first division in the writings of Bordeu and Hoffman, and for the second in those of Morgagni and, again, Hoffman.
119. By Récamier in 1801. Compare this with Astruc's position only 40 years previously as described above.
120. Denman (1794: 192 [19]) echoes him almost to a word, so do others early in the 19th century. This unanimity of opinion can only be explained by a uniformity of the clinical picture, dependent more on socioeconomic conditions than results of medical treatment. The 18th/ early 19th century doctors who wrote books generally attended the upper classes. Unlike the large court at Versailles and the aristocracy which kept French doctors busy, the reign of Farmer George was, despite the capers of his son, later the Prince Regent, extremely sedate. The industrial revolution has, moreover, created a new class with different mores, and the financial means to pay doctors — a class in which the climacteric transition was usually as smooth as that among French peasants. [cf. 46].
121. • Fothergill J
     On the management proper at the cessation of the menses.
     in: Churchill F Reprinted in Essays on the puerperal fever and other diseases peculiar to women, selected from the writings of British authors prior to the close of the 18th century. Sydenham Society, London1776: 503-515 (1849)
     • Google Scholar
122. • Wilbush J
     Tilt EJ and the Change of Life (1857) “the only work on the subject in the English language”.
     Maturitas. 1980; 2: 259-267
     • Scopus (7)
     • PubMed
     • Abstract
     • Full Text PDF
     • Google Scholar
124. It is of some interest that while Burns introduced many changes in the revised and enlarged 1843, Ed 10, this chapter was hardly touched.
125. Pseudocyesis was apparently not too rare, for “women are often mistaken in this matter at the leaving off of their menses” (La Motte 1746: 36 [8]). The emotional factors behind this subconsciously-motivated hysterical manifestation were, indeed, so transparent to contemporaries that doctors almost treated it as but another “foible of the sex” [112]. Burns quotes La Motte's observation that “many women have such a dislike to age that they would rather persuade themselves they are with child than suppose they are feeling any of the consequences of growing old” (Burns 1814: 123–124 [106]) (This is longer than the version of La Motte 1746: 36 [8] but may have been an independent translation of the French version 1722). Other authorities who mention this complication include: Astruc 1762 [16], Fothergill 1776 [18], Chambon 1799 [84], Gooch 1819 [110], Good 1822 [108], Ashwell S 1828 A practical treatise on parturition etc. T. Tegg, London, Brierre de Boismont 1842 [27], Whitehead 1847 [28] and Tilt 1857 [30]. Campbell and Campbell 1843; 151 [112] regard the condition as feigned.
126. • Good JM
     The Study of medicine.
     in: Ed 2. keeping with the ruling attitude Good recommends the attendant adopts “the character of an expectant physician”. 4. Baldwin, Cradock & Joy, London1822: 64
     • Google Scholar
127. • Clarke CM
     Observations on those diseases of females which are attended by discharges.
     Longman & Co, London1814
     • Google Scholar
128. • Gooch R
     An account of some of the more important diseases peculiar to women.
     John Murray, London1819
     • Google Scholar
129. • Blundell J
     Castle T Observations on some of the most important diseases of women. E. Cox, London1837
     • Google Scholar
131. The Campbells jokingly remark that an occasional post menopausal menstrual-like bleeding often raises disproportionate hopes of rejuvination, more so “in females who wish themselves to be younger than what they really are — a foible excusable in the sex, more especially those who have not relinquished the endearing hope of a matrimonial alliance” (p 50). Brièrre de Boismont cynically also relating such behaviour remarks that these women “dans leur joie rêvant déjà une seconde jeunesse” (Brierre 1842: 219 [27]). Whitehead, on the other hand, reports that such “return” of the menses was taken as “natural”. A woman of 55 whose menses stopped when she was 47 began to have regular periods: “She was not alarmed, however, by this event, believing it in reality to be a return of menstruation, a circumstance which she had heard was not uncommonly witnessed in life”. (Whitebread 1847: 173 [28]).
132. Reminiscing in 1975 over his first years in practice in the early 1930s, Ross Vant, emeritus professor of obstetrics and gynaecology, Alberta University, asserted malnutrition was very common among women. When I showed surprise, pointing out that the area was agriculturally rich and food plentiful, he retorted: “They were anaemic, anaemia was extremely common”.
     This is still now the position in many developing countries. Women infected with hookworm, schistosomiasis, or subject to recurrent bouts of malaria may, if suffering from uterine bleeding (much more common as an obstetric or postabortal complication than gynaecological disease) may become very anaemic. Haemoglobin levels of 3–5 grams/dcl in an active woman are not rare.
     In view of this the claims recently advanced that neglected excessive catamenial loss in the premenopause may be an important factor in climacteric illhealth among Western women seem grossly exaggerated. A mild anaemia thus generated would hardly be below the level of 10–11 grams haemoglobin/dcl and very unlikely to interfere with activity. Anemia much below this level only seldom goes unrecognized and is therefore suitably treated.
133. To illustrate this point Hall quotes Maubray on chlorosis or the “green sickness”: “However yet I have known many women in France, and Germany, who have been so far from thinking it an ugly colour, that they have esteem'ed it most beautiful; and have used very pernicious things to gain and appropriate the colour to themselves: esteeming flesh looking women, of fine sanguine complexion, mere RUSTICKS”. (Maubrey J 1724 The female physician, containing all the diseases incident to that sex in virgins, wives and widows together … both the mother and child. London: J. Holland, p 42.
134. • Hall M
     Commentaries on some of the most important diseases of females.
     in: Orme, Brown and Green, London1827: 312
     • Google Scholar
135. The explanation of functional uterine haemorrhage, as that of the aetiology of fibromyomata had to await the resolution of hormonal relationships and their effect on the uterus. This was not achieved till the 2nd and 3rd quarters of this century.
136. • Gardanne CPL
     De la ménopause, ou de l'âge critique des femmes.
     (de)Ed 2. Mequignon-Marvis, Paris1821
     • Google Scholar
137. • Colombat M de l'Isère
     Traité des maladies des femmes et de l'hygiène spéciale de leur sexe.
     in: Ancienne maison Gabon-Librairie Médicale de Labé, Paris. Eng. Trans: Meigs CD 1845 A treatise on the diseases and special hygiene of females. Lee & Blanchard, Philadelphia1838
     • Google Scholar
138. • Menville
     The clinical picture is that of severe anaemia secondary to menorrhagia with cardiac failure and gross oedema.
     (CF de Ponsan)in: Baillière, Paris1840: 140-147
     • Google Scholar
139. e.g. the physician must be wideawake to the patient's stage in life “car il ne fera jamais la faute de demander l'âge” — for one would never comit the blunder of asking (a woman's) age. (Brierre 1842: 221 [27]).
140. Brierre de Boismont admits examination for exclusion of cancer is often difficult and far from accurate. Many women recover after extreme weakness. This occurs mostly when haemorrhage is the only or principal sign, for haemorrhage is often but a “symptom” of this time of life. De Boismont's difficulties and confusion may have originated in the tendency at his time to regard fibromyomata as cancerous or precancerous.
141. Depleting haemorrhages of the critical time (= climacteric) (Brierre 1842: 228 [27]).
142. “Le traitment … nous tranquillisâmes le moral, la guérison, disions nous, etait certain; il falliat prendre quelques distractions, faire des promendes en voiture, et, si elles ne fatiguaient pas, en commencer quelques unes à pied” — The treatment … we soothe the patients spirits, cure, we say is certain. They should have some distractions, take the air in a carriage or, if they do not find it tiring even try walking (Brierre 1842: 229 [27]).
143. Representing 138 who complained of “flooding” out of 500 surveyed patients (Tilt 1857: 72 [30]).
144. Tilt, for instance states that “in the absence of all other signs, the change of life is to be suspected when, for the first time, towards the 45th year, the menstrual flow comes at intervals of a week or a fortnight” (Tilt 1857: 31 [30]). Indeed when these follow long periods of amenorrhoea he “looks upon cessation as probable whatever may be the age” (Tilt 1857: 31).
145. Tilt is called upon to lecture, he contributes a few articles to the medical press and publishes a new, fourth, edition of his book on the change of life [105].
147. As a surgeon Lawson Tait, like so many other doctors who regarded climacteric women as “hysterical”, found no Virchowian, objective, pathology to account for the clinical manifestations: as a gynaecologist he was, however, greatly touched with the real misery of the women who shought his help.
148. “The most terrible form of mental illness … a tendency to the abuse of alcohol” (Tait 1877: 129 [33].) This, according to colleagues was, in the early 1970s, a century after Tait, still very common among the more affluent families of the midlands, not far from where Tait used to work.
149. Tait put it in his usual flamboyant manner, advising “every woman … that as soon as she recognizes the fact that the change of life has set in, she should take twelve months' holiday: and (his) advice to every husband is to see that his wife has this.” (Tait RL 1833 Lecture to Women p 123, Birmingham Health Lectures 1st series pp 113–130).
150. • Priestly WO
     On over-operating in gynaecology.
     Br Med J. 1895; 2: 284-287
     • Crossref
151. In this address to the section of obstetric medicine and gynaecology of the British Medical association, Priestly speaks of “an epoch when oophorectomy or castration of women was … recommended and largely practised as a means of restraining haemorrhage in bleeding fibroids”. The operative technique was, as mentioned, pioneered by Lawson Tait. Concurrently, however, the mortality of subtotal hysterectomy fell to less than 10% (Ricci JV 1945 One hundred years of gynaecology. Philadelphia: Blakiston, p.177).
153. Graily Hewitt was one of the chief proponents of the theory of uterine displacements and their correction by pessaries. When he, therefore “concentrates on the uterus”, he attempts to correct its position — not remove it, as was done half a century later, by hysterectomy. Nonetheless, the therapeutic principle is very similar: No attempt is made to deal with the prime cause, efforts being concentrated on the target organ — in order to reduce, or eliminate, the disturbed expression of the underlying disorder.