Encounters with Aging: Mythologies of Menopause in Japan and North America - Hardcover

Lock, Margaret M.

Hardcover

ISBN 10: 0520082214 ISBN 13: 9780520082212

Publisher: University of California Press, 1994

Synopsis

Margaret Lock explicitly compares Japanese and North American medical and political accounts of female middle age to challenge Western assumptions about menopause. She uses ethnography, interviews, statistics, historical and popular culture materials, and medical publications to produce a richly detailed account of Japanese women's lives. The result offers irrefutable evidence that the experience and meanings―even the endocrinological changes―associated with female midlife are far from universal. Rather, Lock argues, they are the product of an ongoing dialectic between culture and local biologies.

Japanese focus on middle-aged women as family members, and particularly as caretakers of elderly relatives. They attach relatively little importance to the end of menstruation, seeing it as a natural part of the aging process and not a diseaselike state heralding physical decline and emotional instability. Even the symptoms of midlife are different: Japanese women report few hot flashes, for example, but complain frequently of stiff shoulders.

Articulate, passionate, and carefully documented, Lock's study systematically undoes the many preconceptions about aging women in two distinct cultural settings. Because it is rooted in the everyday lives of Japanese women, it also provides an excellent entree to Japanese society as a whole.

Aging and menopause are subjects that have been closeted behind our myths, fears, and misconceptions. Margaret Lock's cross-cultural perspective gives us a critical new lens through which to examine our assumptions.

About this title

About the Author

Margaret Lock is Professor Emerita in the Departments of Social Studies of Medicine and Anthropology at McGill University. She is coeditor of Knowledge, Power, and Practice: The Anthropology of Medicine and Everyday Life (California, 1993) and author of East Asian Medicine in Urban Japan (California, 1980). In 2003, she was awarded the Robert B. Textor and Family Prize for Excellence in Anticipatory Anthropology, of the American Anthropology Association.

From the Back Cover

"A powerful intervention into one of the most important debates of our time. Meticulous in her methods and wise in her insight, Lock tames a sea of stormy argument to show how complex and consequential is the interplay of culture and biology. Her book will make great strides toward her ultimate goal: to dislodge the myth of the Menopausal Woman."―Jean Comaroff, University of Chicago

From the Inside Flap

"A powerful intervention into one of the most important debates of our time. Meticulous in her methods and wise in her insight, Lock tames a sea of stormy argument to show how complex and consequential is the interplay of culture and biology. Her book will make great strides toward her ultimate goal: to dislodge the myth of the Menopausal Woman."—Jean Comaroff, University of Chicago

Reviews

While the end of menstruation is a biological universal in women, the set of symptoms often reported to go along with it is not. Lock bases this conclusion on extensive interviews with Japanese women, who reported very few of the symptoms commonly reported in Europe and North America. Menopause is not necessarily a conglomerate of biochemical changes in mid-life but an ambiguous and ongoing state that is experienced differently in individual women. Like Robbie Davis-Floyd's book on childbirth, Birth as an American Rite of Passage ( LJ 8/92), this work looks at how culture, especially Western culture, seeks to control the natural physiological processes of the female body by medicalizing and pathologizing its normal functions. Lock's focus on menopause as a point of departure for discussing nature/culture dichotomies makes for a brilliant addition to the growing literature on the anthropology of the human body. A necessary purchase for anthropology collections and most academic libraries.
- Patricia Sarles, Midwood H.S. Lib., Brooklyn, N.Y.
Copyright 1994 Reed Business Information, Inc.

Excerpt. © Reprinted by permission. All rights reserved.

Encounters with Aging: Mythologies of Menopause in Japan and North America

By Margaret Lock

University of California Press

Copyright © 1994 Margaret Lock
All right reserved.
ISBN: 0520082214
1
The Turn of Life—Unstable Meanings

Konenki: the turn [change] of life; the critical age;
the menopause.
(Kenkyusha's New Japanese-English Dictionary)

In Osaka in 1984 the organizer of a public lecture about menopause started out the session by asking the entirely female audience, "What do you think of when you hear the word konenki ?"

"The end of one's prime as a woman."

"I think of things like migraines."

"The beginning of one's second life, when you can start to do what you like."

"My mother is in the middle of konenki and complains a lot of shoulder stiffness [katakori ], so that's what I think of."

"My mother had several very trying years suffering from rheumatism and she had a bad time with her autonomic nervous system too, so I feel quite frightened about what the future holds in store for me."

"I think right away of konenki shogai [menopausal disorders], but I don't know if they're psychological or physical, or both mixed up together. When I look at my mother, who's just reached that age group, I notice that she's becoming more timid. She worries about little things that don't matter and complains of insomnia and other things going wrong with her body. I came here today to hear about the physical changes, but I also want to learn about how to deal with konenki by approaching it with the right attitude."

"I'm already past that stage in life, but I never had any problems—I just laughed it off when people said I was having konenki , and I was fifty-five before I knew it, and now I'm having a great time."

"I'm forty-five and right in the middle of konenki , and I think of it as mother's time of rebellion [hahaoya no hankoki ]." A ripple of laughter

mixed with murmurs of agreement ran through the audience at this juncture.

No mention of the symptoms most usually associated with menopause in North America: hot flashes, drenched sheets from night sweats, or even menstrual changes—but perhaps one doesn't talk about these things in public in Japan, even at a small informal meeting of women? These comments did not sound particularly unusual to Christina Honde and me, however; on the contrary, they had a remarkably familiar ring to them. The two of us had visited a total of 105 households in several different regions of Japan for over 150 hours in all, while women between forty-five and fifty-five years old had recounted their experiences, beliefs, and concerns about konenki .1 During the course of our conversations we asked everyone to explain the term to us and soon recognized that we would find no easy consensus about its meaning. On the contrary, it was surprisingly indeterminate, usually clustered with several other equally amorphous concepts that varied and nuanced the way women interpret konenki as both an idea and as experience. Konenki and terms such as the autonomic nervous system (apparently familiar, yet in this context paradoxically strange to Western ears), were not neatly packaged and separated out in the narratives of the women but spilled over into one another to form loose, relatively unstable associations.

I edit and frame the narratives, artificially separating out the concepts for the sake of clarity in this preliminary discussion. This strategy goes against my natural inclination as an anthropologist, which is to start with a broad sweep of the canvas—to situate the term konenki in a cultural context in order to understand it. But because in the West we tend to reduce the experience of female midlife to physical changes associated with the Menopausal Woman, I temporarily pare the Japanese narratives to relatively isolated units that focus on the body in middle age. This first set of comments does not, in the end, completely violate the Japanese understanding of konenki , because the concept includes sensitivity to biological change. Yet before we come close to the usual Japanese understanding of the term, we must recontextualize the subjective experience of konenki , and the physical signs and symptoms associated with it. Some of the same comments will reappear in later chapters as part of the longer narratives of which they originally formed a part. This strategy highlights from the outset important differences between the concepts and lived experiences of individuals as they go through the transitions of konenki and menopause, respectively, and the reader will soon see that, despite the dictionary definition cited above, they are not one and the same thing.

Aging and Konenki

Ito-san ,2 born in Korea of Japanese parents, lives in Kyoto in a Buddhist temple that she manages while her husband, the head priest, spends most of his time as a taxi driver. She says of konenki :

"It's something no one can avoid, but it's nothing to be afraid of or worry about—one should just accept it naturally. It's not simply the end of your periods, though. Things like high blood pressure, becoming farsighted, and going gray are all included. It isn't really that one's value as a woman is decreasing, it's just part of the aging process. I have high blood pressure now, which I never had when I was young, and I think it's part of konenki ."

"How old are you?"

"Let me see . . . Forty-six, nearly forty-seven."

"You said a lot of women become irritable at konenki ? Do you think this will happen to you?"

"Well, maybe, but given my personality, I think I'll get over it easily."

Matsuda-san lives in an isolated forestry village in central Japan where she works long hours in a tiny factory outlet making car upholstery with twelve other women, in addition to growing her own rice and vegetables and tending the family trees at the weekends. Unlike most of the women we interviewed who appeared to our eyes younger than their age, Matsuda-san looks a little older than her forty-nine years but gives the impression of boundless energy. "I almost never sit down, I'm always on the move," she says, so her comments come as a surprise:

"I'm in konenki , that's for sure. I get tired easily these days, and I have headaches and my periods are over—or irregular, anyway—I don't think I've had one for about a year. Anyway, I get really tired."

"When did you start to get tired?"

"Last year. I can't stick at things the way I used to. I get something like my sewing almost finished, and then I'll just let it go. Before, I'd have stayed up all night to finish it. It's because of my age . . . I hate it—I'm not young anymore. When I was young I used to try to take care of my complexion at night, but nowadays I'm so tired I don't even feel like washing properly, I just lie in the bath and soak . . . I'm just getting old."

"Were you expecting something like this to happen?"

"Yes. I used to go and work in the rice fields with obasan [mother-in-law] and she always told me, 'Things are fine for women while they have their periods, but once konenki starts, then you feel irritable and get weaker and can't do anything properly any more. You young people are lucky.'"

Transplanting rice seedlings. This backbreaking work, usually carried out
by women, is now mostly automated, but small plots and awkward corners
must still be planted by hand.

"Does konenki have some relation to when a woman stops menstruating?"

"Yes, I think so. While menstruation is regular her body is fine, but when it stops, various problems start to happen. For a lot of people their eyes get worse, and the first thing I noticed was losing dexterity, so I can't tie knots in thread easily or do up buttons smoothly any more."

"When do you think konenki starts?"

"About forty-five I think. Obasan told me that a few years before they stop menstruating most women start to get irritable, then five or six years after their last period, things settle down again. I'm forty-five now, so I have about another ten years to go I suppose."

Konenki apparently means something more encompassing than the end of menstruation for these two women, part of a general aging process in which graying hair, changing eyesight, and an aching and tired body appear to have more significance than does the end of the menstrual cycle. Some women believe that one can avoid konenki altogether, indicating that, in their minds at least, the end of menstruation is for all intents and purposes not involved. Kawamura-san lives in a fishing village on the island of Shikoku where, about twenty years ago, she was the first woman to get a driving license. She leaves the house at six o'clock in the morning six days a week and goes to the fish market together with her husband

where she buys fish, which she then spends the rest of the daylight hours selling from the back of her truck:

"I think maybe I won't have konenki . I'm forty-nine, so if I were to have it, it would start right about now. Some people don't have konenki , you know. It depends on how you let yourself feel about it [kimochi no mochiyo ]; it's just like morning sickness, which I never had."

"Do you think it has anything to do with the end of menstruation [seiri no owari ]?"

"Well, I wonder if that's about when it starts? . . I don't really know."

"Do you think there are specific disorders associated with konenki ?"

"No one really understands it, I think, but maybe konenki shogai [menopausal disorders] is something like a 'neurosis,' an illness caused by being nervous, perhaps. Like today, for example, I rushed around selling fifty kilograms of fish in just a couple of hours; then my hands started to shake—I'm wondering if that isn't konenki ? When I was young, even if I was rushed, I didn't have that happen to me; but now when I'm in a hurry, I can't even hold the calculator properly because my hands shake. This must be konenki —getting older [toshi no are ]."

Tanabe-san , who works on an assembly line in a cake factory, puts it this way:

"Some women start having problems when konenki begins, but others never really have konenki . My co-workers all talk about it, some of them have headaches and shoulder stiffness—the symptoms differ depending on the person, and so does the time when it starts and stops. I still get my periods every month, which is a nuisance since I'm fifty-one already, but I suppose I'll feel I'm in even more trouble when they stop!"

Forty-nine-year-old Yamada-san , a housewife who sews designer dresses in her home now that her children are grown, makes it clear that konenki is part of aging but nevertheless believes it is avoidable:

"It's a time when a woman's body is changing, when it's just on the verge of starting to get old—it usually starts about fifty, I think."

"Can men have it too?"

"I don't know . . . Yes, I suppose men go through konenki . With women, their periods start to get irregular, but actually I think men are particularly vulnerable and are likely to get sick in their fifties more often than women. I'm still menstruating regularly so I hope I can get by without noticing it when it's my turn."

"So the first sign of konenki in women is irregular periods?"

"I think so. Umm . . . Well I wonder if it's related to menstruation or not?"

"Which lasts longer, do you think?"

"Well, I don't really know. I suppose it depends on the person. My friends talk about their bodies . . . The hormones get unbalanced and they get irritable. One of my friends is getting shots from her gynecologist. But there're some people who stop menstruating without any sign of konenki . I know an older woman who goes swimming every day and plays mah-jongg—judging from her, you can reach the end of menstruation without having konenki ."

Many of the women who state that konenki can be avoided entirely apparently have uppermost in their minds unpleasant symptoms that they associate with this stage of the life cycle but that they believe not everybody necessarily experiences. In contrast, women who dwell less on specific symptoms and focus instead on the more general signs of aging assume that everybody goes through konenki . Urushima-san , married to a taxi driver who does the night shift, spends her afternoons giving her sister a hand in a bar that she owns. She focuses her explanation on the end of reproduction:

"It's the first step into old age. I feel sad when I hear the word—it's awful to think of not functioning as a woman any more [geneki no josei de naku naru ]."

"When do you think it starts?"

"About fifty-two or fifty-three, although my doctor said it's forty-two or forty-three, and according to him it's getting earlier these days."

"So it starts soon after menstruation has finished?"

"Well, I think so, but it seems my doctor doesn't think the same way!"

Eguchi-san , a full-time housewife and mother, paints a broader sweep than Urushima-san :

"I think konenki starts around thirty-five and goes on until about sixty. I think of it as part of roka gensho [the phenomenon of aging] . . . Don't Western women think this way?"

"Most North American women would say it's a short time, I think, right around when they stop menstruating."

"My sister is fourteen years older than me, and to hear her talk you'd think she's been in konenki all along, and she's turning sixty now."

"Do you think there's any connection between konenki and the end of menstruation?"

"No, I don't really. The time when your periods stop is related to when they first start, you know, and also to one's taishitsu [physical constitution]. I don't think you can necessarily say konenki is over when your periods stop . . . There really isn't much of a relation between the two."

Other women express similar sentiments but for different reasons. Some think, for example, that one can pass through konenki entirely and still be menstruating:

"I'm through konenki —it wasn't too bad."

"But you're still menstruating, aren't you?"

"Yes, but konenki is a hormone imbalance, and the body can adjust before a woman stops menstruating."

A few women make a very tight connection between the end of menstruation and konenki and state that they are in essence the same thing. For these women the meaning of konenki comes closest to the usual meaning given today in North America to the term menopause. Other women, like Honda-san , a full-time housewife, while agreeing that konenki and the end of menstruation are intimately connected, conclude nevertheless that they cover a different time span. Honda-san said during the interview that she was in the midst of konenki .

"Konenki is when your periods stop, and when your sacred function as a woman, the bearing of children, is over . . . After that you're just an ordinary person. I'm almost forty-nine, and for a while I couldn't decide whether I was in the midst of konenki or not. I was having so much physical trouble that I thought I was, but I also thought I still had a long way to go. But then I started skipping periods, so I must be in the midst of it."

"So you think konenki and the end of menstruation are identical?"

"No. I think the body takes time to adjust after one's periods stop, so it's usual to have some [physical] trouble [choshi ga warui ] for a while. Konenki extends before and after the end of menstruation. It starts when you're about forty-two and finishes at about fifty-five or so. Heikei [the end of menstruation] takes a year or so, not so long as konenki ."

"You said you're having a lot of symptoms right now. What are they?"

"Mostly dizziness and headaches. I heard from a friend that hormones might help, so I asked my doctor about it, but he said he would only prescribe them if the symptoms got really bad. He suggested that I just learn to live with it."

A primary-school teacher, fifty-four years of age, stated that she "failed" at getting through konenki .

"Konenki is a turning point in one's life [toshi no kawarime ], and everyone probably goes through it. I associate it with a loss of energy, needing spectacles, and getting what we call in Japanese 'fifty-year-old shoulders.'"

"Does it happen to men too?"

"Well, women seem to have more problems, although men have trouble too, but for them it's usually from overwork. For women it's linked to the end of menstruation, but you start to feel it much earlier than that. From about forty-two or forty-three on, you find you tire more easily, you start to feel your age. Somehow you don't feel as healthy as usual. Actually, I guess I really failed at getting through konenki . I was so tired that I had to take sick leave from work. After fifty, things usually settle down again though."

Many women stress that konenki is a turning point, a milestone (kugiri ) or an important change, and often the idea of a descent from the peak of one's physical well-being is implied: "It's the peak of life, just before you start getting old." One woman who farms in northern Honshu stated that the worst part about konenki was that people stopped calling her obasan (middle-aged woman) and started to call her obasan (old lady; grandmother; this term also indicates one's mother-in-law and occasionally one's mother).

Clearly, if accuracy is what we want, we should not translate konenki as "menopause" because the English term has come to be synonymous with the end of menstruation in the minds of the vast majority of people over the course of the last forty or fifty years in North America. Konenki , by contrast, sounds a little more like the now rather archaic "the change," or "change of life," terms still used in isolated parts of the English-speaking world such as Newfoundland (Davis 1986). What is most striking about the Japanese descriptions is the lack of agreement about the meaning of konenki . Almost everyone states that it has something to do with aging, but beyond that, there is little consensus as to what the term conveys.

Even in its timing and the relation of konenki to the end of menstruation, there is dispute. Some people believe it is a long gradual change from the midthirties to about sixty, while others state that it starts about forty or forty-five and goes on to fifty-five, and still others that it coincides with the end of menstruation and therefore lasts for only a span of one or two years at most. Those who opt for a longer transition usually think of the external markers of aging, among which they give the end of menstruation little or no importance. Less frequently, women focus on internal hormonal changes that they view as taking place gradually over several years. Some women believe that the end of menstruation depends on the time of its onset in adolescence and see both events as physiological milestones. But even these women usually give konenki a meaning that is much broader than simple physiological change.

While some believe that a woman can be menstruating after konenki is over, others state that after menstruation konenki is yet to come. Still

others assert that it can be avoided altogether—by which they apparently mean that not everyone has troubles or disorders at this time in the life cycle. In contrast, some women think of konenki as a difficult time for just about everyone in terms of physical symptoms, an unavoidable episode, after which full health returns. Others visualize it more as a turning point, so that konenki signals the beginning of old age and the inevitable approach of declining physical powers and eventual death. Several women stated emphatically that they have no knowledge about konenki , and that they don't really know what it is.

We might surmise that educational level or occupation account for some of the differences in responses, but such is not the case. A few rural residents, urban blue-collar workers, housewives, and professional women subscribe to a close link between konenki and the end of menstruation, but the majority of women from all walks of life would either equivocate on this point or actually dispute it.

Signs and Symptoms of Konenki

In common with the women who attended the public lecture in Osaka described above, most women when asked to describe the signs and symptoms associated with konenki report aches and pains of various kinds or else mention rather vague general complaints. Ogawa-san manages a farm in Nagano prefecture where she was born and grew up. Her comments about her friends and neighbors are very typical.

"I hear from other people that their heads felt so heavy that they couldn't get up. They didn't exactly have pain but just generally felt bad and didn't feel like working. Luckily I didn't have anything like that."

A woman of forty-seven, who works in a Kyoto factory where she makes underwear, comments about symptoms:

"It depends on the person. In my case my eyesight became weak and when I visited a doctor for my backache, he told me it was because of konenki . Some people tell me they have headaches and get irritable and that they become extremely nervous and sensitive. It depends a lot on one's physical constitution."

A rather well-to-do housewife of fifty-one focuses on changes associated with aging:

"All of a sudden I found I had lots of gray hair and my eyes became farsighted—that was when I started konenki . My eyes started to feel tired and painful in the evenings too. The optometrist explained to me that eyes start to get hard and lose their elasticity with age, and so they tire more easily. After hearing that I thought, Oh! All my muscles must be losing their elasticity just like my eyes. I have high blood pressure too, and when

I went to see my doctor about it last year he said I was just beginning konenki . Some women get irritable, but it doesn't seem to affect me that way."

A forty-seven-year-old housewife who is still menstruating says that she had a very brief konenki :

"I had this prickling feeling, like ants crawling over my skin. My husband said, 'Oh, that must be konenki shogai .' He'd read about it in some book. It didn't last long, although this one remains [Hosokawa-san pointed to her checkmark beside the question about 'lack of sexual desire']. My husband says it's because I'm too busy during the day—I'm not so sure about that though . . ."

Many women talk about a temporary physical unbalance:

"I think konenki means that the natural physical balance the body usually has is lost. The symptoms are headaches, tiredness, and irritation."

Rather few people described symptoms that sound more familiar to Western ears. Midori-san , who has spend all her adult life in Ponto-cho, Kyoto, where she is a geisha, was one of them. At fifty-four she still has many working years in front of her:

"I'd heard that in konenki you feel suddenly hot and then cold, but that never happened to me. They told me that it happens at the age your periods stop. I was all prepared for it, but nothing happened."

"Where did you hear this?"

"Well, I live in a society of women, of course, and so you get to know what happens to everyone else. When you hear about someone saying that they're sweating a lot, then for sure someone else will say, 'that's konenki .'"

"Did you hear about people becoming irritable or anything else like that?"

"No, not really, but I was quite worried. In the end, though, nothing happened."

"Do you worry about getting older?"

"No, I'm not worried. My periods stopped and I was relieved that it was so easy. Now that's over I think of myself as a little older, but it doesn't bother me much. It all depends on how you let yourself feel [ki no mochiyo ]. It doesn't affect my work as long as I take care of my appearance properly and keep up with things. I read a lot and watch television and listen to what other people are talking about. I have to keep in touch—especially with what young people are saying—then I can talk with the customers."

Yamanaka-san , now forty-nine, recently quit her job with a bookbinding company. She talks about feeling suddenly hot at times but does not

give this symptom more significance than the others that she mentions:

"I'm in konenki now. I often have stiff shoulders—especially when I knit or sew and I sometimes suddenly feel hot [katto atsukunaru ]."

"When does this happen?"

"When I'm in a crowd my face becomes hot suddenly, and it feels as though it turns red."

"Do you perspire as well?"

"No, it only lasts a few seconds—less than a minute."

"Do you have any other symptoms?"

"I get a headache every two or three days, and I get irritated then and take it out on my children. But I don't have any problems that really affect my daily life. I'd heard that konenki is awful and people get really serious symptoms like dizziness or unsteady feet. My headaches must be konenki I suppose, but I don't say anything, especially not at home. If I complained to my husband he would just tell me to shut up; I can't expect any sympathy from him so I manage by myself."

Hattori-san runs a farm while her husband works in a nearby town in an insurance company. She says, "The most noticeable thing was that I would suddenly get hot—I'd seen older women have that problem—but then it happened to me, and I thought, Oh, so this is konenki . It's gone now, it just lasted for about six months or a year. It happened every day, three times or so."

"Did you feel embarrassed?"

"No, I just thought it was because of my age."

"Did you go and talk to anyone about it?"

"No, I didn't go to the doctor."

"Did you take any medicine?"

"No."

"Did you have any other symptoms?"

"My head throbbed, really badly sometimes—that was very unpleasant, but it's better now. I suppose it was something to do with the hormone imbalance, it's just aging really, isn't it?"

A total of 12 out of the 105 women interviewed reported symptoms that resembled hot flashes, but the descriptions were often rather vague, and the experience took on very little significance. Some women had heard other people talking about hot flashes, but an equal number had never heard of this symptom at all. Not one woman we talked to complained of major sleep disturbance, or of waking up with drenched sheets in the middle of the night. When talking about konenki they usually emphasized various aches and pains and feelings of lassitude, dizziness, irritability, and

Working on the assembly line in a cake factory.

so on, rather than what North Americans think of as the classical symptoms of menopause.

If we dissect the accounts to separate out myth and hearsay from what individual women recall as their actual lived experience, a rather large chasm appears. A good number of women say something to the effect that they heard that "Some women's heads are so heavy they cannot get out of bed," or "Obasan said that after konenki you get weak and can't do anything." And more often than not they go on to state, "but luckily I haven't had anything like that." Or they talk about changing eyesight, graying hair, aching joints, and other symptoms of aging that many men of the same age also experience. By far the majority of people gave the impression that, although there is plenty of gossip and banter about konenki , much of it negative, in general it is not a subject that generates a great deal of anxiety or concern; even so, as an augury for the future, as a sign of an aging and weakening physical body, it is not particularly welcome.

Among the women who were interviewed in their homes, the one person who confessed to a difficult time was fifty-two-year-old Tabata-san who lives with her husband and his father, together with her son and his wife, in a modernized farmhouse in Nagano prefecture.3 She spends her days tending the rice paddies and row upon row of chrysanthemums that

she sells commercially, and she also works for several hours in the middle of the day making tiny electrical circuits for a nearby factory.

"I've been having konenki for over seven years. Everyone said it would come early and that there would be lots of problems because I had a really difficult time with childbirth and got sick afterward. I worry about my health, but the doctor just laughs and won't listen to me. I have a heavy feeling around my throat and I feel as if I can't breathe, but the doctor can't find anything wrong with me. It feels like something is stuck there. I've had the problem for five or six years and I'm worried that I have cancer, but the doctor thinks I'm silly. I sweat around my face, even in winter, and when I wipe it off I feel cold. I get the same hot, sweaty feeling at night too. The doctor said that hormone shots would help prevent this, but that it's not good to have them unless it's absolutely necessary. He gave me some medicine, but I don't take it. I keep telling myself that I'm not really hot and that way I can control it. People say my face gets red when I feel hot and then, when I think how embarrassing it is to be sweating in front of other people, it gets worse. I don't care about the family, but it's embarrassing outside."

"Do you have any other symptoms?"

"Oh yes. I get headaches and shoulder stiffness. But the doctor doesn't listen to me when I talk about these problems. My husband's sister started having konenki about three years ago. She doesn't have my kind of physical problems at all, but she's started to think that people are talking about her and she gets weird feelings about people she never worried about before."

"How old were you when konenki began?"

"I was about forty-six. We had a big problem in our family then, and I was worrying all the time. I started getting konenki symptoms then with the big shock that I got."

"How awful for you. What happened?"

"I can't tell you about it, but it made me go mentally crazy, and my hormone balance was all upset.

"I think of myself as a nervous type, you know, because I always worry about people getting cancer. Also I worry that I can't manage to stretch the household money until payday, and then I panic. I'm very tidy about the house too. My daughter tells me that I worry about the tidiness too much, and she thinks that my daughter-in-law who lives with us will start disliking me. I never used to care about this kind of thing when I was young, but since I married into this household I've become very conscious about things like tidiness. It's partly due to my husband and my mother-

in-law (although she's dead now). I'm still scared of my husband—he gets mad just when last week's newspaper is hanging around. He's got me into the habit of feeling nervous, I think. I'm not really like this—it wasn't built into me from the start. It seems like even my basic physical nature [taishitsu ] has changed over the years since I've been married."

"Do you think some of your problems, like suddenly feeling hot, have anything to do with the end of menstruation?"

"I stopped menstruating last year. I wonder . . . What do you think?"

"Well . . . I think some people would think so, and I'm inclined to agree with them, about suddenly feeling hot at least."

Tabata-san , in contrast to the other women who were interviewed, is noticeably distressed by the symptoms she experiences, but she is reluctant to explain her physical discomfort solely in terms of physiological changes associated with the end of menstruation. Long before the interview (I feel sure), she created a narrative to account for her discomfort, composed of several plausible causes ranging from her husband's intransigence, to the bad shock she received that drove her temporarily "crazy," to her own personality. She distills, condenses, and telegraphs this narrative into the polysemic term konenki , which represents for her not simply aging and physical discomfort but distress of many kinds. Tabata-san was eager to tell her story to me and started out with the emphatic announcement that she had been having konenki for seven years. Unlike the majority of women we talked to, who dismiss konenki as hardly worth talking about or else interpret it simply as an inevitable sign of aging that may entail uncomfortable but temporary symptoms, Tabata-san loads this concept with an array of meanings and almost flaunts her troubles. In contrast to most women in the study, she freely admits that she is not happy and openly acknowledges that the anxiety she experiences is disabling; but she can find no way out, no responsive ear or helpful council. Her doctor laughs at her when she seeks to account for a large portion of her distress as caused by konenki , and her social problems remain undiscussed and unresolved. She is afraid of her husband; her own mother (to whom she might have turned) is dead, as is her autocratic mother-in-law. Her sister-in-law has her own troubles, and her daughter simply chides her. She is embarrassed to talk to her friends about the secret "family" problem that caused her so much distress and so remains isolated.

Tabata-san was expecting a bad time at konenki long before she reached this stage partly, she says, because she had a difficult time with childbirth. Both the end of menstruation and konenki are closely associated by many women with other concepts, one of which, chi no michi , posits a rather

close relation between difficulties at earlier stages of the reproductive cycle and a distressful konenki . When we consider the end of menstruation and konenki with chi no michi , the puzzle becomes yet more complex.

Chi no michi (path of blood) and Konenki

The end of menstruation has long been recognized in traditional Sino-Japanese medicine as the seventh stage in a woman's life when a quality known as tenki , intimately associated with the female reproductive cycle, goes into decline. One of the results of an abrupt decline in tenki can be the collection of "stale blood" in the body, associated with numerous non-specific symptoms, including dizziness, palpitations, headaches, chilliness, stiff shoulders, and a dry mouth. The phenomenon often lasts for a few years (Yasui and Hirauma 1991, 370) and is one part of a more embracing concept widely used in Japan until well into this century and commonly called the "path of blood."

The concept of the path of blood appeared as early as the tenth century in Japanese medical literature, and a priest writing in 1362 stated that chi no michi is related to the thirty-six symptoms that appear only in women (Muroga 1984). Its use was not limited to the medical world, however, and the path of blood crops up regularly in literary works from the fifteenth century onward. A 1986 movie entitled Yari no Gonza Kasane Katabira based on a classical bunraku drama by Chikamatsu Monzaemon makes much of this concept. In it the travails of an Edo-period love affair between a samurai and an "older" woman suffering from chi no michi -related distress are recounted in laborious detail.

Today the term path of blood is decidedly old-fashioned, and use of the concept of stale blood is virtually confined to those hundred or so physicians specializing in herbal medicine who posit a close relation between it and the symptoms of konenki (Fujihira 1982). The majority of women who were interviewed had heard about chi no michi , but most were rather vague on the subject. A Kobe woman says, for example,

"I guess it's some kind of women's disease, although I suppose it's something to do with menstruation, and so it's not really a disease—I don't really know. Old people used to talk about it with childbirth—they said you had to rest thoroughly so as to avoid chi no michi , but I don't know exactly what they were talking about."

A good number of women had heard about chi no michi from their mothers:

"My mother used to use the word chi no michi , and I suppose she was talking about what we call konenki shogai . People used to say herbal medicine worked well for it."

The clearest answers were given by women living in remote rural areas.

"They say if you overdo it after childbirth, then you could have trouble for many years after that. That's all part of the 'path of blood.' You should take it easy for seventy-five days after birth. You shouldn't even read the newspapers or sew."

"Do you think it has anything to do with konenki ?"

"Yes, I do, to a certain extent. If you overdo it the effects will show up after you get older and you may well get konenki disorders."

Another woman makes an explicit connection between chi no michi and what appeared to be hot flashes.

"I've heard about chi no michi . They say you get hot suddenly, or that your blood goes up to your head [nobose ], but I've never had anything like that."

In her 1984 study of an isolated village in northern Honshu, Nancy Rosenberger found that all the women she interviewed believed in chi no michi , and that middle-aged women regularly used the term to discuss physical problems at the end of menstruation. One woman she talked to referred to the idea of stale blood: in the old days "it wasn't like now when the nurses massage your uterus to get the blood out. After the baby was born, blood sometimes got left in there and got rotten like. It stays in there and causes problems later on in the menopausal years" (Rosenberger 1987, 164). Many women link the hardships of prewar days, extended families, and chi no michi , as does one woman who works in a textile factory in Kyoto.

"My mother and her friends used to say that if you got up and worked soon after childbirth, you'd have chi no michi when you got older. But of course, people used to have their babies at home, and if you had a mean mother-in-law, then she probably wouldn't let you rest but made you get up and start sewing clothes and so on right away."

Watanabe-san , who lives in a forestry village in Shiga prefecture, said she had wanted to be careful after childbirth, but that was impossible:

"I didn't get better after my son was born. I had to stay in bed for a hundred days, more than the usual seventy-five days of rest. Three days after he was born, I got a call saying that my mother had collapsed and was dying and that I should come right away, but I couldn't move. I couldn't even walk, and the blood rushed right to my head. So I felt terrible and I got really sick after that. When I went to see the doctor years later he said it was chi no michi ."

"The doctor said that?"

"Yes, he asked me if I'd had any emotional trouble right after childbirth, and I told him about the shock of my mother's death. It took about five

years to get over it. I had all kinds of medical tests and they told me that my liver was bad and that I had sugar in my urine."

"Do you think chi no michi has anything to do with konenki ?"

"No, I don't."

A few women think of chi no michi as more of an emotional than a physical problem.

"Chi no michi is a kind of hysteria, I think—with headaches, and irritability. In fact, I told my friends I might have it when I had a bad spell a few years ago."

Clearly chi no michi , like konenki , is a polysemic term to which a rather wide range of meanings can be attached. In the minds of some people these two concepts have an intimate connection, and frequently the old-fashioned term chi no michi is thought of as essentially the same thing as konenki disorders, the more modern concept that apparently superseded it. Books written for the general public by physicians often account for chi no michi this way (Matsumura et al. 1981, 56). Other people accept the idea of chi no michi as a broad concept that can be applied to the entire female reproductive cycle, and they usually assume that a difficult childbirth signals trouble at the end of the reproductive years. They visualize this trouble as stale blood remaining in the body from wear and tear during a stressed confinement or birth, later illnesses that affected the reproductive system, or an abrupt end to menstruation. In contrast, some women who believe in chi no michi make no connection between it and konenki . To the majority of people chi no michi is a physical phenomenon; to others it is primarily psychological.

Since most women, except those who live in rather remote rural areas, associate it with their mothers rather than themselves, we might be tempted to think that chi no michi will be relegated shortly to the category of superstition, but to date it remains as an entry in contemporary Japanese dictionaries: "Chi no michi : A general term for the special illnesses of women. At the time of birth, menstruation, konenki , and so on, irregularities in the blood circulation lead to various symptoms including headaches, dizziness, sudden feelings of heat, and an unstable nervous system. An illness of the blood [chi no yamai ]" (Gendai Yogo no Kisochishiki 1988).

The Autonomic Nervous System and Konenki

While talking about konenki many women made reference in their explanations to the autonomic nervous system—an allusion that lends to the discussion a tone of scientific authority (see also Rosenberger 1992). A

housewife who lives in the Nagano countryside stated, when asked, that references to people having trouble with their autonomic nervous systems are everywhere: in newspapers, on television, from friends, and so on. Kitayama-san , a Kyoto factory worker, suffers from jiritsu shinkei shitchosho (an imbalance of the autonomic nervous system).

"What's it like?"

"I get very upset and nervous, sometimes so badly that I can't read. Often people get this kind of upset at konenki , but in my case it's just an emotional thing—nothing to do with konenki . I went to see an internist about it because I was so nervous and I was having stomach trouble too."

A Kobe housewife who is an accomplished dyer comments on her many friends who received a diagnosis of imbalance of the autonomic nervous system.

"I don't know what it is exactly, but they seem to have a lot of vague symptoms, palpitations, dizziness, and other minor complaints. They always seem to have something wrong with them, and I'm tired of listening to them so I don't pay much attention. Quite a lot of them talk about losing their appetites."

"Is it connected in any way to konenki ?"

"Oh yes, for some people it's more or less the same thing I think, but for others it seems to be quite different."

Everyone is in agreement that imbalance of the autonomic nervous system is a technical medical term, in tone nothing like the anachronistic chi no michi and also unlike konenki , used simply to describe part of the life cycle. Men and women can suffer from this problem, but women are thought to be much more susceptible. Reasons given for female vulnerability vary, but many people pointed out that hormonal changes influence the autonomic nervous system, and hence women are particularly at risk at the onset of adolescence, at each menstrual cycle, and at menopause. Physicians who specialize in herbal medicine believe that stale blood (oketsu ) can have a negative effect on the functioning of the autonomic nervous system. A further reason commonly given is that women are "by nature" more nervous than men; an explicit link is made between an imbalance of the autonomic nervous system and "mental" problems. Oda-san , who works in a factory that makes underwear, talks about her experience.

"I once had it [jiritsu shinkei shitchosho ]—when I had a thyroid problem. I got very impatient and irritated. It seems to be a state that is just one step before madness. The doctor gave me a tranquilizer and then my ki 4 settled down gradually. It lasted about a month."

"So it doesn't have anything to do with konenki ?"

"Well, I'm still menstruating, but I've heard that serious problems happen at konenki . I'm haunted by this thought, and maybe because I'm a bit physically unstable it might be bad."

Adachi-san works in an internist's office as a receptionist, and she reports that many patients come to see the doctor with problems related to their autonomic nervous system. Unlike Oda-san she does not link them closely to konenki .

"I've never had it myself. Some people say their hair starts to fall out, and some are very irritable and others just seem to feel bad. I don't think it has much to do with konenki ."

Another forty-six-year-old woman who works in an electrical appliance factory stated that both she and her friend have regularly experienced dizziness and nausea for over five years. Her doctor diagnosed a problem of the autonomic nervous system but assured her, when she asked, that it was nothing to do with konenki . Eguchi-san , who works in a cake factory, states that she too was given a diagnosis of jiritsu shinkei shitchosho .

"It was something like a serious depression. It happened right after we moved to Osaka. I couldn't stay quiet, I kept jumping up and down all day. It took me more than a year to get over it. I was aware that something was wrong, but I just couldn't control it, and I knew it was connected with our living conditions. Anyway, I went back to my old home to see the family doctor near my parents' house, and he was very understanding and gave me some medicine."

It gradually emerged from our talks with Japanese women that for many the concepts of konenki , chi no michi , and jiritsu shinkei shitchosho are not clearly separable entities. Other people make a sharp distinction between one or more of them, and the majority no longer really believe in chi no michi . Perhaps a discussion of all these apparently rather obscure ideas is an unnecessary semantic exercise, since surely, if we specified ahead of time that we wanted to talk about the end of menstruation, all this confusion could be swept aside?

It is possible, of course, to ask about the end of menstruation, for which the word heikei (the end, or shutting off of the menses) is used in scientifically oriented texts. This term is probably closest to the current meaning of menopause in English, but it is a technical term that many women do not readily understand, and they sometimes have to see the written Japanese characters before they fully appreciate what is meant.5 Women, when they talk among themselves, and patients and doctors use konenki and not heikei when conversing; several doctors stated that they explicitly

avoid the use of heikei with patients because it is too "hard" and technical a term.

Alternatively, we could simply talk in everyday language about the end of menstruation (seiri no owari ). If women are encouraged to explain further, they will usually elaborate in scientific terms how the menstrual cycle works, or else they will say they don't have much education and can't explain these things or, alternatively, exclaim: "I was hoping you'd explain that to me!" If the interviewer persists and asks, for example, what symptoms if any are associated with the end of menstruation, the conversation quickly slides into an exchange about konenki . In other words, we are forced to talk about konenki and its linked concepts, because physical changes or difficulties that occur at this time are attributed by most women to larger, more encompassing events, internal and external to the body, not simply to observable changes in the menstrual cycle or to declining estrogen levels. Many women have a good scientific grasp of the menstrual cycle and are well versed in simple endocrinology. When talking about the end of menstruation, however, the majority take a broad approach to what it represents, which often encompasses ten or more years, and they move easily back and forth between social meanings associated with midlife changes, personal experience, and physical changes over this time.

Limiting a conversation about konenki to the end of menstruation (even a conversation with the typical physician) is, therefore, an entirely artificial exercise in Japan and imposes an alien framework around the exchange that soon brings it to an awkward halt. If, in the interests of an accurate conversation, we reject the use of the term konenki because of its lack of precision, there is no language left with which to talk about the experience of konenki or the social meanings attributed to it.6 It would be like asking women to explain how it felt to give birth to a baby, while insisting that they confine their language to the intensity of the contractions, the number of centimeters of dilation, and the pain. Although the English term menopause has systematically been stripped of meaning in most quarters, save that of the end of menstruation, konenki , in contrast, remains as a rich, condensed, and polysemic concept around which people can weave narratives about aging in which mind and body, self and other, past and future, can be reflected on and partially reconciled.

The Medical World and Konenki

We might expect that Japanese doctors when discussing menopause, in their professional writing at least, would summarily dismiss the word konenki from their vocabulary, and confine themselves to the use of a more precise term. Until very recently, such has not been the case at all. In

discussing this part of the life cycle, both informally and in writing, the majority of physicians, although they have an image of declining estrogen production in their minds, tend not to isolate this knowledge or focus their narratives on one particular hormone but rather emphasize a complex of interdependent changes. Dr. Shimada, a Tokyo gynecologist, explains.

"The English word 'menopause' should be translated as heikei since this means the end of menstruation. Konenki is a much larger event, it's the time when the physical symptoms that mark this part of the life cycle appear."

"Do all women get physical symptoms?"

"I think most women have konenki shokogun [menopausal syndrome], but they don't usually come to the doctor. When the estrogen levels drop, the hypothalamus becomes very active and this is near the center of the autonomic nervous system. So this center is stimulated, which results in many nonspecific symptoms of various kinds."

"Can symptoms like shoulder stiffness [katakori ] be part of this syndrome?"

"Yes, this could certainly be one of the symptoms, but of course, this is not the only reason for shoulder stiffness."

"What about emotional states? Would they also be involved?"

"Certainly. A woman could quite easily become psychologically unstable at this time."

"Is it a more difficult age emotionally than say twenty or thirty?"

"Yes, I think so. There's a lot of individual variation, but generally speaking it's quite a difficult time."

The majority of physicians who were interviewed incorporated the concept of the autonomic nervous system into their explanations in order to account for menopausal symptoms. An Osaka gynecologist put it this way:

"Headaches, ringing in the ears, shoulder stiffness, and sudden heat are all related to the autonomic nervous system."

"These are all symptoms of konenki ?"

"Yes, they're all related. You see, the mechanism is that when estrogen and progesterone are not secreted normally by the ovaries this has an effect on the vasomotor nerves and the general circulation is impaired. I believe that troubles with the autonomic nervous system, including all the konenki symptoms, are related to poor circulation. When I prescribe medication to improve the hormone cycle, my understanding is that it also indirectly helps blood circulation. I often give peripheral circulation boosters at the same time, and sometimes minor tranquilizers, depending on the woman's condition."

Not all doctors would agree with this statement entirely, but its gist resembles the type of explanation that dominated discourse in Japanese medical journals until recently. For example, a gynecologist's talk at a meeting of the Japanese Medical Association started out: "It is common knowledge that an imbalance of the autonomic nervous system often occurs in connection with the changes in ovarian function that happen at konenki " (Ikeda 1979, 1405).

When asked about the symptoms of konenki , the majority of physicians produce a long list that includes shoulder stiffness, headaches, a heavy head, palpitations, feelings of heat combined with feelings of cold (hienobose ), lack of concentration, ringing in the ears, tiredness, dizziness, insomnia, irritability, and depression (Mori 1978, 249). In scientific articles these lists are subdivided and grouped in various ways in order to assist in the selection of appropriate treatments. It is striking how dose the descriptions given by women and physicians are, despite the technical language that, naturally, pervades the medical literature.

Over the past fifteen years or so, general discussions about konenki have appeared regularly in the mass media. Described here as in the professional medical literature, konenki is said to last for about ten years from the midforties to the midfifties, and a large number of symptoms are associated with this stage of the life cycle. Books designed for the intelligent layperson usually have a scientific air about them and resort to a very liberal sprinkling of medical jargon:

Functional disturbances of the autonomic nervous system are the principal symptoms of konenki but added to these are metabolic and psychological/nervous disturbances [seishin shinkeisho ] that lead to a variety of symptoms. . . .

The psychological/nervous symptoms include headaches, heavy head, dizziness, ringing in the ears, insomnia, lethargy, irritability . . . farsightedness, memory problems and melancholy. Circulatory disturbances include sudden feelings of heat, palpitations, feelings of cold, sweating and changes in the pulse. Disturbances of the kinetic system include shoulder stiffness, lumbago, back pains, joint pains, and tiredness.
(Okamura 1977, 40-41)

A few physicians, especially in recent years, give more significance to the hot flash than did earlier writers in professional and in popular literature. When asked by a newspaper reporter in 1987 about the symptoms of konenki , Dr. Honda, a Tokyo-based gynecologist, responded:

The most frequent symptom is nobose [a rush of blood to the head], even when there is no reason to blush, the face suddenly gets hot and there is sweating. . . . It cools down after a very little while but then starts all over again. This has nothing to do with the outside temperature, or whether one is in or out of doors. It happens many times a day. . . .

Is this caused by lack of harmony in the autonomic nervous system?

Yes, and then many things go wrong with the functioning of various organs. The next most usual symptoms . . . include dizziness, nausea, ringing in the ears, palpitations, and a choking or stifling feeling.
(Asahi shinbun 1987a)

Since almost all Japanese doctors read English-language publications with great regularity, in addition to numerous Japanese journals, the disparity between their explanations and dominant Western medical thinking is striking, a disparity that is now beginning to be aired among interested physicians. In one recent popular magazine article, for example, where medical professionals took a thorough look at konenki and compared it with menopause, an edition of two hundred thousand copies sold out in the space of a few days (Shufu no tomo 1991). A brief historical excursion is necessary in order to unravel some of the reasons for the discrepancies that exist between Japanese and North American medical thinking about female midlife.

The Invention of Konenki

Although a sensitivity to the human life cycle has long been a part of Japanese consciousness, middle age, the prime of life (sonen ), was until well into this century a relatively undifferentiated time span that commenced with marriage and lasted until ritual entry, at sixty, into old age. An age-grade system and associated rituals traditionally marked the passage of groups of people through successive stages of the life cycle (Segawa 1947; Norbeck 1953) but, as in many other societies, most of these rituals occurred during the first twenty years of life. Individual biological aging, although recognized, was in general subordinated to a communally based concern with social maturation, and the timing of events in the two cycles, the biological and the social, did not necessarily correspond very closely.

Although physical aging was not marked by the community at large, family celebrations were in order when a young woman reached menarche. At the other end of reproductive life, however, the end of menstruation was not socially recognized in Japan (as it appears was probably the case

in virtually all other societies), leaving the event essentially unmarked. We noted in the prologue that when the average life span is less than fifty—as was the case in Japan until the middle of this century—it is often assumed very few women lived beyond the end of their reproductive years, and for this reason no attention was paid to the end of menstruation. However, a study done in the village of Yokouchi, in what used to be the province of Shinano in central Japan, examined the population registers all village headmen were required to keep and showed that the fifty-six women born between 1751 and 1775 who reached sixty years of age could expect to live sixteen years beyond that age (Cornell 1991). Having survived infancy, and later the dangers associated with childbirth, a woman might live well past konenki into old age; a lack of ritual concern about this part of the life cycle cannot simply be accounted for by an absence of older women.7 Nevertheless, the end of menstruation was probably unnoticed except by each individual, who no doubt wondered what distress chi no michi might bring to her.

In addition to ritual celebrations of social maturation, the Japanese also paid attention to yakudoshi (years of calamity or dangerous years), when people were thought to be at great risk for illness or misfortune. The idea of yakudoshi is still widely acknowledged in Japan today (Lewis 1986), and while only a very few of the women in the present study observe the required precautions against misfortune, all were well aware of the "calamitous years" and just about everyone pointed out that the most dangerous age for men is forty-two and for women thirty-three.

At the Meiji Restoration of 1868, with the official opening of Japan to the outside world after two hundred fifty long years of self-imposed isolation, the Japanese deliberately set about creating a modern nation state. When they sent emissaries to Europe and America to observe the process of modernization elsewhere, they discovered much that was reasonably compatible with their own ideas about the life cycle. In Europe, although the word climacteric is now more or less confined to medical usage in connection with female midlife, it was originally used in daily conversation to describe the dangers associated with the many critical transitions conceptualized throughout the life cycle, regardless of age or gender—thus climacteric originally corresponded quite closely with yakudoshi . Despite this compatibility, contact with Europe appears to have stimulated the need to create a new term, konenki , which made its first appearance in the late nineteenth century when medical scholars translating texts from German into Japanese apparently were not satisfied with the folk term the "dangerous years" as the medical version for the climacteric. Nishiyama be-

lieves that konenki , when it was first invented, was originally used, like climacteric, for male or female transitions throughout the life cycle and not simply those of middle age (1981).

Beyond the bounds of the medical world, konenki first appeared in print in 1909 in a novel by Oguri Fuyo entitled The Spring of Youth (Seishun ); its protagonist laments the loss of his sexual vigor after three years in prison and likens his state to the "agony of women who, entering konenki in their forties or fifties, lose their femininity" (Oguri 1971, 3:505). The Chinese ideogram selected for the ko of konenki means renewal and regeneration, while nen means year or years, and ki means a season—a period or stage. As with so many other Chinese ideograms, the meaning is condensed and various possible interpretations exist. For example, in addition to renewal, ko refers to the time from sunset to sunrise and can also convey the idea of "deep into the night." Hence, as Rosenberger points out (Rosenberger 1987, 167), konenki could be translated as the "darkening years"—and this appears to be the meaning Oguri wished to convey, since he likened konenki to autumn nights, to corpselike weakness, to bleakness, and to loneliness. In contrast, the image of the sun has long been associated with menstruation in Japan, and sekihan , the red bean rice cakes traditionally used to celebrate the onset of menstruation, are likened to the sun.

At the end of the last century Germany became the model for the new Japanese medical system, in part because government representatives stated explicitly that Germany and Japan shared institutional and political interests (Powell and Anesaki 1990, 27). The conceptual approaches of the two medical systems also had much in common. Japanese medical knowledge (originally adapted from China) placed emphasis on the interaction among the various parts of the body. The meridians and points used for acupuncture, and the concept of ki (which translates very loosely as energy),8 along with other fundamental ideas, provide the framework for an integrated approach to the body. Restoration of a homeostatic balance is the basis for all therapeutic interventions in this system.

Japanese doctors of the late nineteenth century found their thinking compatible with the newly formulated European medical concept, eagerly touted in Germany, of the "autonomic nervous system," that visualized various body systems as intimately related. The concept had been in the air for at least one hundred years but caused a stir throughout the Western medical world when it acquired this name in 1898 (Sheehan 1936); contemporary Japanese physicians, a good number of whom lived and studied in Germany, incorporated it with ease into their professional discourse

(Suzuki 1982). When the idea of the endocrine system was formulated and explicated in the 1920s, close links were postulated between the autonomic nervous system and the endocrine system (Sheehan 1936, 1110); the effects of these links are still apparent in contemporary Japanese descriptions of konenki .

A compatible approach to the human body was not all that made Japanese physicians feel at home in Europe. Until the end of the nineteenth century European doctors used a concept of "plethora" or "stale blood" to explain symptoms such as headaches, dizziness, palpitations, and the so-called hot blooms (later renamed hot flushes or flashes) associated with the climacteric (Tilt 1870; Barnes 1873; see also chapter 11). Japanese beliefs about the path of blood and stale blood must have allowed Japanese doctors to understand nineteenth-century European accounts of menopausal problems and also encouraged the belief that their knowledge, since it was so similar to that of European doctors, was an accurate scientific representation of female physiology. Indeed, it seems as if Japanese physicians had little, if anything, to learn from nineteenth-century Europe about the end of menstruation, with the notable exception perhaps of the emphasis given to hot blooms, which no doubt incited some curiosity.

In Europe, although the word climacteric has its roots in antiquity, the term menopause was not created until the middle of the nineteenth century by a doctor in France, Gardanne. Its origin was closely associated with the emergence of the gynecological profession, and it was specifically designated as the end of menstruation. During the latter part of the nineteenth century the meaning of climacteric was gradually pared down and refined within medical circles to represent only the female midlife transition, believed to last several years and to be accompanied by a variety of characteristic symptoms. Menopause was understood as just one part of this larger process.

A Japanese medical dictionary published in 1909, no doubt reflecting these changes, translated the German term Klimacterium as gekkei heishi ki (meaning the time during which menstruation stops) and the word menopause simply as gekkei heishi (the end of menstruation, a term related to the now current shorter heikei ). Early medical discussions of gekkei heishi were limited to obvious pathologies, and konenki appears to have been understood as a natural event, of medical interest but largely outside the purview of the new field of gynecology. Not until the discovery of the endocrine system in the 1920s and, in the 1930s the development of a simple hormone replacement therapy, did a few Japanese gynecologists start to take an interest in the "normal" transition of konenki , but even

these developments did not interest many. Nevertheless, from the 1920s onward the narrowly conceived, pathologically oriented terms fell out of use, and gynecologists adopted in their place the concepts of konenki shogai (disorders) and konenki shokogun (syndrome), terms they could comfortably apply to nearly all types of discomfort experienced by middle-aged women, and ones they could use freely in conversations with patients.

Japanese gynecologists remained heavily under the influence of German medicine until the end of World War II. Yamada, for example, writing about menopause in 1927, cited only German references. At the top of his list of general symptoms of konenki shogai appeared mood changes, memory loss, and becoming easily anxious or upset, to which he added the most common symptom, loss of temper, which happens to "90 percent of all women" (1927, 1097). He also pointed out that women are at high risk for cancer between the ages of forty and forty-five and linked this to age-related changes in "physical constitution." Other symptoms that he listed include dizziness, perspiration, ringing in the ears, headaches, and hot flashes, for which he invented a cumbersome word to gloss the German term—sokoekishakunekkan (this particular neologism apparently never caught on with other physicians). He also included increased blood pressure, nausea, diarrhea, severe constipation, shortness of breath, spasmodic palpitations, frequent urination and pain on urination, perceptual disorders, and backache. All these symptoms he associated with changes in "ovarian function" and also with the autonomic nervous system.9

For women having a major problem with uterine bleeding Yamada recommended surgery or radiation therapy of the ovaries or the spleen. He also ascribed to the German literature's suggestion that irradiation of the thyroid gland was sometimes necessary since reduced ovarian function was believed to cause an increase in thyroid activity. He recommended hormone therapy and therapeutic baths but concluded that the selection of treatment depended on each individual case. This theme of a close association between changes in ovarian function, the autonomic nervous system, and a bevy of nonspecific symptoms remains central to gynecological literature in Japan right up to the present time and is also, as we have seen, the thrust of professional writing for the general public.

Dr. Mori Ichiro, who works in Kyushu, has spent the greater part of his career doing research on konenki . He thinks that neither its definition nor its symptoms coincide with the current Western concept of menopause. He distributed questionnaires among his patients several times over the past ten years and consistently found that shoulder stiffness, backache, headaches, fatigue, forgetfulness, a "heavy" head, constipation, eye prob-

lems, dizziness, and low blood pressure are the most frequently reported symptoms. Dr. Mori notes that perspiration and hoteri (hot flashes) occur to some extent in the two years immediately after the end of menstruation, but he emphasizes that they are apparently less frequent than in the "West" and cause few problems for most Japanese women (Mori 1978). He also points out that his observations and those of other Japanese doctors are compatible with what is common knowledge in Japan. He believes that "environmental differences" account for variation in symptom reporting and that Japanese patients can be taught to overcome most of their symptoms without resort to medication. In common with other gynecologists he recommends the use of jiritsu kunren (discipline or training of the autonomic nervous system, through meditative exercises).

Why are there discrepancies between Japanese descriptions of konenki and those that predominate in contemporary North America and Europe? Perhaps Japanese women and their doctors misread or misrepresent their bodies or simply lack the precision that has slowly emerged in North America over the past decade about the menopausal transition. Or, alternatively, are we perhaps misreading our bodies? I have been asked by more than one Japanese doctor, for example, why Western women make such a "fuss" about hot flashes. These remarks have a jingoistic ring to them because they have their source in the common belief, held mostly by people over fifty, that Western women cannot endure pain and suffering as can Japanese women. But, aside from lurking discrimination, confusion may nevertheless exist in the minds of Japanese physicians about the Menopausal Woman. What they read in international medical journals, observe in their own clinical experience, and find in their culturally constructed understanding of konenki do not mesh very well at all. Could it be that the menopausal body, and perhaps the Menopausal Woman as well, is not after all universal? Survey research proves to be a useful device for exploring this possibility.

Continues...

Excerpted from Encounters with Aging: Mythologies of Menopause in Japan and North Americaby Margaret Lock Copyright © 1994 by Margaret Lock. Excerpted by permission.
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Edition details

• Publisher: University of California Press
• Publication date: 1994
• Language: English
• ISBN 10: 0520082214
• ISBN 13: 9780520082212
• Binding: Hardcover
• Number of pages: 439