History of Medicine Questions

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  1. According to Lock and Kaufert, in their study, what are the variables taken into consideration when defining “menopause”? What do they mean by “local biologies”? What are the differences in understanding menopause between Japanese (Chinese, Thai) and North American (the US, Canada) societies?
  2. Do you consider Cobb’s article a primary or secondary source for understanding the Tuskegee syphilis study? Why? According to the author, what made the study possible and what terminated the study? What did the study add to the medical knowledge of syphilis?
  3. In “Materials on the Trial of Former Servicemen of the Japanese Army,” what were the crimes committed by these servicemen of the Japanese army? What are the similarities and differences of the implemented human experimentations between Japanese army and the Tuskegee syphilis study?

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AMERICAN JOURNAL OF HUMAN BIOLOGY 13:494–504 (2001) Menopause, Local Biologies, and Cultures of Aging MARGARET LOCK1* AND PATRICIA KAUFERT2 Department of Social Studies of Medicine, McGill University, Montreal, Quebec, Canada 2 Department of Community Medicine, University of Manitoba, Winnipeg, Manitoba, Canada 1 ABSTRACT Menopause marks the end of menstruation, once generally accepted as the closure of women’s reproductive lives. The current medical view of menopause, however, is as a pathological event with its own distinct set of symptoms and diseases. Researchers have described women as facing a dramatic increase in the risk of heart disease, osteoporosis, stroke, and Alzheimer’s, all as the result of the impact of changing hormone levels, particularly the decline in estrogen. The clinical literature has interpreted these findings in terms of the absolute necessity of replacing these lost hormones for all women who are menopausal regardless of any other physiological, social, or cultural characteristic they might possess. Using research done in Japan, Canada, and the United States, this paper challenges the notion of a universal menopause by showing that both the symptoms reported at menopause and the post-menopause disease profiles vary from one study population to the next. For most of the symptoms commonly associated with menopause in the medical literature, rates are much lower for Japanese women than for women in the United States and Canada, although they are comparable to rates reported from studies in Thailand and China. Mortality and morbidity data from these same societies are used to show that post-menopausal women are also not equally at risk for heart disease, breast cancer, or osteoporosis. Rather than universality, the paper suggests that it is important to think in terms of “local biologies”, which reflect the very different social and physical conditions of © 2001 Wiley-Liss, Inc. women’s lives from one society to another. Am. J. Hum. Biol. 13:494–504, 2001. The end of menstruation is a complex biosocial and biocultural process, but the majority of clinical researchers and physicians appear to assume that biological changes associated with this stage of the life course are essentially universal. Although researchers are becoming more aware of differences in the subjective experience of individual women, the changes are attributed to variations in psychological, social, and cultural factors, layered over an invariant biological base. Over the course of the past two decades, the end of menstruation has come to be understood by the majority of health care professionals and by many women as an event that signals an increased risk for heart disease, osteoporosis, Alzheimer’s disease, and stroke, just to name the most devastating of the vast array of disagreeable events that the medical world associates with female aging. The medical view of aging is often justified by the erroneous claim that at one time virtually no women lived much beyond the age of menopause. Based on a misinterpretation of demographic data showing that the mean life expectancy until the turn of the century in North America and Northern Europe was less than 50 years, this statement is particularly misleading when linked with a second claim, very frequently made in the © 2001 Wiley-Liss, Inc. PROD #M99102R2 medical literature: that a post-reproductive phase in humans goes “against nature” because virtually no mammals have a life span that extends much beyond reproductive senescence. These arguments assume that post-menopausal life in humans is the result of technological and cultural interventions which have influenced longevity favorably, and that women who survive past reproductive age are, in effect, biological anomalies. While such arguments are patently wrong, they lend support to the dominant medical view of menopause as a pathological condition. Based in part on the media and advertisements of drug companies, menopause has become a condition in need of medication. The tempering of this pathological account by anthropological perspectives, biological and cultural, is not only important but also rather urgent. This essay uses material on differences in symptom reporting taken from research in Japan and North America as the basis for a broader discussion of not only the difficulties and *Correspondence to: M. Lock, Department of Social Studies of Medicine, McGill University, 3655 Drummond Street, Montreal, Quebec H3G 1Y6, Canada. E-mail: cy61@musica.mcgill.ca Received 6 December 1999; Revision received 23 June 2000; Accepted 2 February 2001 MENOPAUSE, LOCAL BIOLOGIES, AND CULTURES OF AGING challenges of doing comparative research but also of the reasons why it is of critical importance. In addition, the many variations, not just in symptoms but in the experience of menopause, among populations of women as these variations are reflected in the long-term sequelae associated with aging, such as the incidence of heart disease and osteoporosis, are considered. Finally, the need for greater recognition of the inseparable relationship between culture and biology is argued, using as illustration the lives of the generation of Japanese women who are now menopausal. What is it that leads to the prediction that the majority of women would experience discomfort at menopause? One explanation lies in the use of small clinical samples, often drawn from women attending specialized clinics for menopausal women or referred for psychiatric care, as the basis for generalizations made about menopause, particularly in the 1960s and 1970s (Kaufert, 1988). It was not until large, community-based North American studies recruited women from the general population that the assumed connection between menopause and depression came into question (Whitehead, 1994). Another factor may have been the long-lasting impact of Freudian theories, particularly the work of Deutsch (1945) on menopausal women. The expectation that the loss of fertility would lead to depression was theoretically plausible, if empirically untested. The longitudinal research of both McKinlay and Kaufert (Avis and McKinlay, 1991; Kaufert et al., 1992) reveals that the association between menopause and depression does not hold for North American women. This paper uses research in Japan and from other crosscultural work to suggest that an association is not made between menopause and discomfort in these societies. Menopause as cultural construct Historical and cross-cultural research suggests that menopause is best understood, not as a fact, but as a construct. The very definition of menopause as a woman’s last menses does not “fit” with an experience which most women describe as a prolonged process rather than a singular event. The conflation of menopause with the end of menstruation is relatively recent in origin and was not always the case even within the medical literature. Writing in 1813, Halford 495 (1813:317) commented: “I should observe, that though this climacteric disease is sometimes equally remarkable in women as in men, yet most certainly I have not noticed it so frequently, nor so well characterized in females”. Halford was writing about that “period of life at which the vital forces begin to decline, commencing from about 45 until 60 years of age.” He described a general decay of strength, tiredness, loss of weight, and appetite and added: “The patient sometimes suspects he has a fever and might also experience head and chest pains, vertigo, rheumatic pains, swollen legs and sluggish bowels” but “above all, anxiety of mind and sorrow have laid the surest foundation for the malady.” Halford (1813) concluded by wondering if it was the prospect of death that “inflicted the wound in the patient’s peace of mind.” The term “ménopause” was invented in 1821 by the French physician Gardanne (Tilt, 1870). From the middle of the 19th century onward it gradually came into wide circulation in medical circles in Europe and North America to describe what was known in daily parlance in the English language as the “dodging time,” i.e., the years before and after the last menstruation (Tilt, 1870). The concept used from medieval times in educated circles to express the idea of a transition at mid-life—the climacteric—made no distinction between men and women. Gardanne, by creating the idea of ménopause, and linking it with menstruation, singled out female aging as something that should be managed by medicine just at a time when the professions of obstetrics and gynecology were being consolidated. It was over a century, however, before more than a few physicians paid serious attention to menopause. Tilt (1870) in England was a well-known exception for his clinical and theoretical work in the latter half of the last century, as was his colleague, Currier (1897), in the United States. Barnes (1873), another physician interested in menopause, represented the new approach to female aging when he noted: “[p]hysicians do, indeed, talk of the climacteric in man; but the analogy is more fanciful than real.” He went on: There is nothing to compare with the almost sudden decay of the organs of reproduction which marks the middle age of woman. 496 M. LOCK AND P. KAUFERT While those organs are in vigor, the whole economy of woman is subject to them. Ovulation and menstruation, gestation and lactation by turns absorb and govern almost all the energies of her system. The loss of these functions entails a complete revolution. (Barnes, 1873:263– 264) The assumption that menopause is a “revolutionary” transition appears to be shared by a good number of physicians today. There are, of course exceptions, including Novak et al. (1975), both father and son, at Johns Hopkins University who, together with a minority of physicians, have argued for many years in gynecological textbooks that menopause should be regarded as a physiological phenomenon that is protective for the aging body. The movement to impose a definition of menopause as a woman’s last menses was engineered largely by a research community anxious to find some way of categorizing women as either menopausal or not-yetmenopausal. Lacking any reliable or cheap equivalent for menopause to pregnancy testing, they had to rely on self-reporting, but they did not trust women to know their own menopausal status. Asking them whether they had menstruated within the last 12 months offered a seemingly more objective alternative. The peri-menopause— the period before menopause—was then defined by whether or not a woman had menstruated within the previous 12 months, but not the previous three (Van Keep et al., 1976). Although surviving in Europe, the term “climacteric” dropped out of the North American literature and menopause was equated with the last menses. Neither Japanese women nor Japanese doctors considered the end of menstruation to be a significant marker of female middle age in the early 1980s, when the research used in this paper was done. The Japanese word kônenki, usually translated into English as menopause, does not have its same narrow meaning. Understood as a long, gradual process to which the end of menstruation is just one contributing factor, the term kônenki is closer to the earlier European idea of the climacteric. Most Japanese respondents placed its timing at aged 45 or even earlier, lasting until nearly 60. Shea (1998) translates the Chinese term gengnianqi as “a stage in which one in- creases in years” or “a period of time in which one changes”, reading it as the equivalent of both kônenki and the European “climacteric”. She reports that many Chinese women used gengnianqi to identify their status in preference to describing themselves as no longer menstruating. By contrast, Thai women used the terms modlyad or sudlyad, translated by Chirawatkul and Manderson (1994), as “run out of menstrual blood”. While some Thai women expressed concern over no longer being able to discharge “bad blood,” the end of menses signaled not pathology but entry into a new, more spiritual phase of life. As one woman said: “Now I can go to the temple without anxiety of menstruation or spotting. I can go to other places very far from here to make merit as well”. Canadian women would sometimes define themselves as menopausal based on whether or not they were experiencing hot flashes or changes in their pattern of menstruation and not whether 12 months had elapsed since they last menstruated (Kaufert, 1988). A researcher would have labeled them as peri-menopausal, but they saw themselves as already menopausal women. The difference may seem slight, but their view of it transforms menopause from an event into a process, much closer in content to the idea of kônenki, gengnianqi, or the climacteric as a drawn-out, a transitional process. The same impetus that made researchers want a clear-cut method of defining the menopause influenced their search for a list of characteristic symptoms associated with menopause. The debate over which symptoms were menopausal emerged in the 1960s and 1970s, a period marked by numerous small-scale clinical trials of the effectiveness of different forms and strengths of hormone therapy in the alleviation of symptoms. Usually carried out in clinical settings and based on very small samples of women followed for relatively brief periods of time, the studies rarely discriminated between those who had undergone surgical rather than medical menopause. Researchers freely extrapolated to the general population of naturally menopausal women using findings based on women attending menopause clinics after having an oophorectomy (Kaufert, 1988). The assumptions underlying this research included the belief that differences between surgical and natural menopause 497 MENOPAUSE, LOCAL BIOLOGIES, AND CULTURES OF AGING TABLE 1. Comparison of the rates of core symptom reporting by studya Study Symptom Japan Canada USA (2 df) Diarrhea/constipation Persistent cough Upset stomach Shortness of breath Sore throat Backaches Headaches Aches/stiffness in joints Dizzy spells Lack of energy Irritability Feeling blue/depressed Trouble sleeping Lack of appetite Hot flushes Cold or night sweats Hot flushes/sweats (combd) Total (100%) 24.5 4.2 6.3 3.1 10.5 24.2 27.5 14.5 7.1 6.0 11.5 10.3 11.7 4.6 12.3 3.8 14.7 1,225 12.8 5.2 12.9 8.2 9.1 26.8 33.8 31.4 12.3 39.8 17.1 23.4 30.4 4.0 31.0 19.8 36.1 1,307 21.4 10.1 16.1 15.6 10.7 29.6 37.2 38.6 11.1 38.1 29.9 35.9 30.6 5.4 34.8 11.4 38.0 7,802 62.8* 68.4* 85.1* 177.6* 2.9 17.7* 45.2* 279.1* 21.4* 503.3* 246.6* 365.1* 189.8* 5.8 246.6* 158.2* 252.5* a From Avis et al. (1993). *Indicates P < 0.01. were irrelevant, that all menopausal women were the same and, therefore, representative of each other, and that the symptoms of menopause were universal. Although questioned by a few anthropologists, the first major test of these assumptions was undertaken by three surveys; the first and second in 1980–1981 in Massachusetts and Manitoba (Canada), and the third in Japan in 1983–1984 (Avis and McKinlay, 1991; Kaufert et al., 1992; Lock, 1993). Each study was independently conducted, but there was an agreement to match methods and design, particularly the selection of participants from the general, as distinct from a clinical, population. The Japanese data were collected from three parts of Japan: southern Nagano, a rural area, where most women either manage or work on farms; the southern part of the city of Kyoto, where women are employed in factories and in other blue collar jobs; and in a suburb of Kobe, where women are mostly what is termed in Japanese “professional housewives.” The United States study used the annually compiled census list for Massachusetts. A list of Manitoba residents registered with a government-funded health insurance plan (virtually the entire population of the province) was used in Canada. Both studies used random sampling techniques to select women aged 45–55 years in Massachusetts and 40–59 years in Manitoba. Symptom reporting at menopause Symptom data were collected from 1,225 Japanese women, 7,802 Massachusetts women, and 1,307 Manitoban women who were 45–55 years. Table 1 indicates the 16 symptoms that were common across the surveys (Avis et al., 1993). These included the 11 symptoms that make up the menopausal symptom index developed by the International Health Foundation (1977). This index was embedded in a longer symptom checklist taken from a community-based survey of general health and placed in a section of the questionnaire focused on general health issues. This design was adopted to avoid cueing the response of women by labeling a list “menopausal symptoms” at the same time as asking them to define their menopausal status. Recall bias was limited by asking women only about symptoms experienced in the previous 2 weeks. The analysis shown in Table 1 used the chisquare goodness-of-fit test for equivalence of distributions from independent samples. The primary criterion value used for the chisquare tests is ! ! 0.01 and indicates the presence of a statistically significant difference across the three studies. There are significant differences on all but two of the 16 symptoms, sore throat and lack of appetite, neither of which comes from the International Health Foundation Index. Women in Massachusetts had the highest reporting rate for most symptoms, 498 M. LOCK AND P. KAUFERT TABLE 2. Percentage reporting hot flushes/sweats in each study by menopause statusa,b Hot flushes/sweats Menopause status Surgical menopause Natural menopause Perimenopause Premenopause a b Japan Canada USA 19.8 16.8 15.8 9.7 38.8 45.5 45.2 19.3 44.4 42.6 37.3 13.8 P < 0.01. From Avis et al. (1993). and women in Japan had the lowest; Canadian rates fell somewhere between the two, but usually closer to the Americans. Constipation is the only symptom which was more frequent in the Japanese study. Two symptoms usually described in the gynecological literature as the sine qua non of menopause—hot flashes and night sweats—are markedly lower among Japanese women than among American or Canadian women (Table 2). There was a significant association between these two symptoms and menopausal status in each study; however, the results of a three-way analysis that included hot flash and menopausal status suggest that this association varies across the three countries (P < 0.001). Even among the women of Massachusetts, hot flashes are only the fifth most frequently reported symptom, ranking below stiffness in the joints, irritability, depression, and headaches. Japanese women were less likely than Canadian or American women to report having felt “blue” or depressed, but there is relatively little difference within each study by menopausal status. Using the same set of 16 symptoms, Shea (1998) interviewed 400 women in China and reported that overall symptom reporting was higher among Chinese than Japanese women except for hot flashes. Their frequency was almost the same and much lower than that reported by women from Manitoba or Massachusetts. Chinese women were about as likely as American women to report headaches, backaches, and feelings of irritability. Thai women associated headache and irritability with the end of menstruation, but not hot flushes (Chirawatkul and Manderson, 1994). (Unfortunately, differences in the method of collecting symptom data prevent a direct comparison among Chinese, Japanese, and Thai women.) On the basis of the differences between Japanese and Chinese women, Shea (1998) suggests that sweeping generalizations about women and menopause in East Asia are to be avoided. Differences and similarities in these symptom patterns argue strongly against any simple causal link between declining endogenous estrogen levels and hot flashes ...
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Question 1

What are the variables taken into consideration when defining “menopause”?
According to Lock and Kaufert (2001), the cross-cultural inquiry on menopause carries
its basis on the anthropological study in the work of menopause in women. Menopause marks the
conclusion of menstruation for women. Lock and Kaufert (2001) feel that the view of menopause
is a neurotic occasion with its own different series of diseases and symptoms. The variables that
are used in defining menopause are seen in terms of the complete requirement of replacing the
lost hormones for every female who has reached despite the social, cultural, and physical traits
that they might have. Socio/cultural and biological variables are presumed to relate in
complicated means that are poorly comprehended. The work by Lock and Kaufert (2001)
challenged the universal idea on menopause by proving that there is a variation between the
symptoms at post-menopause and menopause illness reports from a study population to the other.
What do they mean by “local biologies”?
Lock and Kaufert (2001) use the term local biologies to show the manner in which the
embodied experiences of the physical ambiences, including those of health, well-being, and
illness, are partly informed by the material body, individual, social and environmental variables.
The authors posit the idea of situated biologies as an ideological contribution to the mostlypolarised debate over the material human body as being either universal or local. Both Lock and
Kaufert recapitulate the medical anthropological idea of local biologies prior to highlighting the
biological research at hand. The local biologies concept is u...

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