The sexual life of woman in its physiological, pathological and hygienic aspects

by E. Heinrich Kisch

The Menopause.

That time in a woman’s life at which her sexual activities come to their natural termination, marked by the cessation of menstruation, is known as the menopause, climax, or climacteric period.

This “change of life,” from a condition of sexual maturity to a condition of quiescence of sexual functions, is not a sudden one, the symptoms of sexual retrogression making their appearance gradually, until the cessation of the monthly recurring menstrual flow indicates that the termination of sexual activity has arrived, and that sexual death is taking place.

The influence of this period of life is not manifested by the sexual organs alone—in these latter indeed various changes may be detected already before the cessation of menstruation, whilst after that cessation, the atrophic changes characteristic of old age proceed in these organs with a slow but continuous advance,—but the disturbances evoked by the climacteric involve the entire organism and affect the functions of numerous organs, giving rise to a true storm of irritant phenomena, and to manifestations of decay of manifold nature.

The stormy manifestations, the occurrence of which led the ancients to denote this period as the “critical age” of a woman’s life, are in the first place due to changes in the ovaries; the tissue changes in these organs give rise to a powerful ovarian stimulus, which, by irradiation and reflex action, leads to the occurrence of a number of nervous disturbances, vasomotor manifestations, and circulatory disorders; whilst owing to the cessation of the internal secretions of the ovaries, numerous and intense pathological disorders of metabolism arise. These various symptoms become apparent at the very outset of the menopause, when the oncoming entire cessation of menstruation is already foreshadowed by irregularity in the periods, gradual diminution in the quantity of the flow, and variations in the number of days during which the flow on each occasion persists.

The manifestations of the menopause are in fact so striking, that from ancient times down to the present day a widespread belief has prevailed that especial danger to a woman’s life is threatened by the climacteric age. The statistics available on this subject are, however, of dubious significance. Although it cannot be denied that the changes in the entire organism which attend the extinction of sexual activity, bring numerous dangerous influences into play, yet I feel bound to maintain that these dangers are by no means so great as those which are involved by the sexual life in its ripest period of development—the dangers of pregnancy, parturition, and the puerperium.

It is often asserted that in this “critical period” of the menopause, the mortality of the female sex is notably increased. The data available are somewhat conflicting, but a careful examination leads us to believe that, if due allowance is made for the natural increase in mortality with advancing years, no important increase in the mortality of women can be traced as due to the troubles and disturbances of the climacteric period.

The age at which a woman’s last sexual epoch begins is a very variable one. The duration of the “change of life,” the length of time during which the occurrence of the “change” is manifested by local and general disturbances, also varies greatly. Not less variable are the intensity and the general distribution of the symptoms which mark the climacteric.

The external configuration of woman at the climacteric age is usually characterized by signs of over-ripeness, and these changes appear to exercise upon certain men—more especially very young men—a peculiar kind of erotic stimulus. Many women remain long at this period quite fresh looking, with a vivid, youthful colouring; others, however, early manifest alterations in their finer feminine characteristics, hairs, for instance sprouting on the chin, and the voice becoming deeper in tone.

The outward characters of senescence, with withering of the tissues, are not commonly manifested at this time, but first make their appearance in later years, after the completion of the menopause.

A tendency to the excessive accumulation of fatty tissue is one of the most distinctive characteristics of the menopause, varying, however, greatly in degree according to race, family predisposition, and nutritive conditions. The dominant tone is thus given to the physical configuration by the deposit of fat. The face comes to have a rounded, spherical appearance, the eyes looking smaller in proportion, whilst the furrows and folds which form the natural boundaries between the features become indistinct. The formation of the “double chin,” and the abundant deposit of fatty tissue in the supraclavicular region, gives to these extremely obese women an appearance of such a shortening of the neck, that head and thorax seem to be connected as it were by a great mass of fat, marked by furrows in the thyroid and sub-hyoid regions. The breasts sometimes attain an enormous size, hanging down to the gastric and even to the umbilical region. The abdomen is greatly enlarged, the fat in the anterior abdominal wall projecting more especially in the hypogastric region, hanging down in two or three horizontal rolls over the tops of the thighs, and pushing the mons veneris downwards, so that this latter itself projects over the genital fissure. The posterior projection of the buttocks is also greatly increased, until they form a huge elastic cushion, of which the sensual orientals, who regard obesity in women as a beauty, poetically write: “Her face is like the full moon, and her buttocks are like two pillows.” Occasionally, so huge a mass of fat forms beneath the tuberosity of the ischium, that the configuration of the nates reminds us of the well-known steatopyga or fat-rump of the Hottentot and Bosjesman women. In the genital organs, as already mentioned, the genital fissure is hidden by the projection of the mons veneris. The labia majora are also greatly enlarged by the deposit of fat, so that they look like two great cylinders lying side by side. Another way in which the characteristic sexual beauty is often lost in extremely obese women, is by the falling out of the pubic hair.

Moreau, in his work on The Natural History of Woman, describes the changes occurring in a woman at the climacteric in similar terms, and concludes: “The only elements of a woman’s beauty that may sometimes be saved from the wreck, to persist for a shorter or longer time after the climacteric, are, the abundance of her hair, the vivacity of her glance, and sometimes also the amiable expression of her countenance; gradually, however, even these last remnants of beauty disappear, and old age takes possession with its irresistible force.”

None the less, some women may preserve substantial elements of beauty for a long time after the menopause. A classical example of this fact is furnished by Ninon de l’Enclos. When she died, at the age of 90, she was still beautiful. At the age of 65 she aroused the passionate love of a young man, who, unfortunately, was her own son. When informed of this, he committed suicide. A young abbé fell in love with her when she was 75 years old.

The psychical life of woman is profoundly affected by the stormy physical changes of the climacteric. Not merely does a woman entertain the disturbing thought that the critical age has begun, bringing in its train certain dreaded dangers to her health and even her life, but she is further depressed by the consciousness that she is about to lose her feminine attractions, and to decline in sexual esteem, and that her reproductive capacity is now to be extinguished. She realizes vividly that the beautiful past, the loving and beloved womanhood, is now to be left behind for ever, and by this an intelligent and sensitive woman cannot fail to be profoundly affected. Her feelings at this time were never more characteristically expressed than by the Frenchwoman who said “Autrefois quand j’étais femme.” If, indeed, a woman has been so fortunate as to have made a happy marriage, to have borne healthy children, and to be living a satisfactory family life, she will be enabled to bear with comparative equanimity the disappearance of her sexual life; but it is different with the childless wife and with the unmarried woman, who, at the onset of the climacteric, must bury all their sexual aspirations, and who see the remainder of their lives stretch before them without hopes for the future. The psychical predisposition and the intellectual education of the woman concerned, will now determine whether she will bear the onset of the menopause with composure and resignation, or whether she will become a prey to melancholia. Women of the former kind will seek to find employment for the powers set free by their sexual non-activity, in services of neighbourly affection, in works of benevolence, and in the performance of social duties; women less happily endowed will display their hostility to the world in ill-nature, scandal-mongering, and intrigue, thus giving vent to their inward bitterness; whilst those, finally, with hereditary predisposition to nervous degeneration, will become the prey of veritable psychoses.

A by no means rare result of the excited fantasy and of the eager desire not to grow old, is displayed at the climacteric in the form of self-deception. The women thus affected cannot understand, and cannot be made to believe, that the cessation of menstruation is the natural sign of their sexual decadence, they trick themselves into believing that in their case it is a sign that they have become pregnant. We must not indeed forget that the enlargement of the abdomen, so common at the commencement of the climacteric, in association with the unexpected failure of the menstrual flow to appear, the frequent dyspeptic troubles, and the enlargement of the breasts in consequence of the deposit of fat in these organs, often enough lead to appearance which have a deceptive resemblance to the clinical picture of early pregnancy. The mistake is the more readily made because the breasts sometimes secrete a serous fluid, whilst sacrache is not infrequent, and peristaltic movements of the intestines are mistaken for the movements of the foetus. Cases of this kind, in which all the objective signs of pregnancy appear to be present, and in which it is impossible to convince the woman that she has been deceiving herself, and that all the signs and symptoms are due to the menopause, are mentioned already by very early writers, and have been frequently reported by modern gynecologists. (An example of spurious pregnancy especially familiar to English readers is that of Mary I, Queen of England. Transl.)

Sexual desire in woman by no means reaches its physiological term with the climacteric and the cessation of menstruation. On the contrary, we have observed it to be the rule that shortly before and at the commencement of the climacteric, there is a considerable increase in the libido sexualis, and at the same time an increase in sexual sensibility during coitus. This sexual erethism makes its appearance in a manner often extremely surprising to the husband—and especially surprising in the case of women who have previously been characterized by a certain frigidity in sexual matters, and who have, perhaps, always needed strong persuasion before they would consent to perform their marital duties. It is by no means rare for the increased sexual impulse to manifest itself in some pathological form. Even some time after the menopause, when senile changes in the genital organs are far advanced, the sexual impulse may still be remarkably active. There is an interesting analogy in the fact that Glaevecke observed that the sexual impulse was persistent in women in whom an artificial menopause had been induced by oophorectomy; and that Lawson Tait and L. Smith have reported cases in which dyspareunia, which had existed prior to the operation, passed away after the removal of the ovaries, so that after the artificial menopause, voluptas coeundi for the first time made its appearance. Other authors, Goodell, for instance, report that libido sexualis is retained only for a short time after oophorectomy, but subsequently disappears, as in the course of the physiological menopause, and that at the same time the voluptas coeundi is entirely extinguished.

When the menopause is fully established, and the processes of involution in the reproductive organs have taken place in a normal manner, the woman has had time to acquiesce in the inevitableness of the changes that have occurred, and she often attains a state of emotional repose which was quite unknown to her in the earlier phases of her sexual life. More particularly, those women who hitherto during menstruation, and for some days before and after the flow, have been the prey of numerous nervous symptoms and troubles, rejoice, after the menopause, at their new-won freedom from these pains and disquiets, at their delivery from the excitements of the reproductive system, at their now uninterrupted state of well-being.

I once saw a group of statuary by Pietro Balestra, entitled “Time carries off Beauty.” A beautiful woman was striving in vain to resist the overwhelming might of Chronos, whilst Cupid, about to be abandoned, was standing sorrowfully by. Here we have a symbolic representation of the sexual epoch of the menopause.

In a recently published romance, “Les Demi-Vieilles,” Yvette Guilbert has described in a manner most true to nature the feelings of the “Half-Old,” the mental condition of women at the climacteric, “They endeavour to remain young, to hide their defects, they seek once again the intoxication of love. But that which aforetime in hours of depression they have foreseen, now becomes a dreadful reality. When the lemon has been squeezed dry, the skin is thrown away.”

Sooner or later after the completion of the menopause, the signs of senile marasmus become apparent. The soft, feminine configuration of the face disappears, the features become coarser, approaching the masculine type, hairs appear on the upper lip and on the chin. The voice becomes deeper and harsher. As decrepitude begins, the breasts wither, a change that occurs sooner in proportion to the degree in which their functions have been in previous years exercised by suckling; but also sometimes after a life of complete sexual inactivity. Even in cases in which the loss of substance of the breasts is apparently small, the glandular tissue of the organs has really disappeared, and has been replaced by fat. In advanced age, the breasts become quite small, wrinkled, flaccid, and dependent, and sometimes atrophied to become mere cutaneous folds. The nipples project more prominently, they are darker in colour, and their surface is wrinkled. In the genital organs, the fat disappears from the mons veneris, which becomes flattened, whilst the pubic hair ceases to be curly, and much or all of it is ultimately shed. The labia majora become thin and flaccid, until they are mere empty folds of skin; they are widely separated, so that the vaginal orifice is closed only by the withered nymphæ, until these latter are themselves ultimately indicated by mere traces.

Where the menopause has been artificially induced, the signs of senescence do not appear immediately after the removal of the ovaries; their development is a very gradual one. The sexually mature woman, from whom these tokens of femininity have been removed, experiences at first little change in external configuration, beyond a somewhat exaggerated tendency to the deposit of fat; the other changes described do not usually set in until the physiological climacteric age is attained. A few cases only have been observed in which after oophorectomy a rapid change to the masculine configuration has been observed.

Seldom if ever does it happen that menstruation suddenly ceases without any notable constitutional disturbance, so that in a moment, as it were, the menopause is effected, without any period of transition. Rarely, even, do we meet with cases in which the peculiar manifestations foreshadowing or accompanying the cessation of menstruation last for no more than a few weeks. Most commonly the irregularities of the menstrual function (of which the most noteworthy characteristic has hitherto been its extreme regularity), and the associated symptoms of the climacteric period, endure for months, and occasionally for years. According to my own observations, the mean duration of the climacteric manifestations is from two to three years, the limits of variation in individual cases being, however, exceedingly wide.

The manifestations which accompany the cessation of menstruation are as a rule the following: The woman is for some months in an irritable condition, complains of digestive disturbances, constipation, meteorism, epistaxis, haemorrhoidal flux, congestions of the head, increasing fugitive sensations of heat (Ger. fliegende Hitze), and a tendency to profuse perspiration.

The length of the intermenstrual interval commonly increases, to as much as six or eight weeks; the flow itself becomes scantier. In other cases, however, the flow becomes much more abundant, and the intermenstrual intervals much shorter than normal. In some cases, the regularity of the flow is altogether lost, it appears now soon, now late, and is now scanty, now profuse. Sometimes the intervals are several months, it may be 6, 8, and even 10 months, then again the flow will occur every two or three weeks; in exceptional cases, a scanty flow persists right through what should be the interval, so that menstruation becomes continuous, with periodic increases in the flow. Not infrequently, after a sudden cessation of the flow lasting for many months, menstruation recurs, and continues at regular intervals for a long time, until the final cessation of menstrual activity.

The mode of cessation which is most favourable to a woman’s general health, is for the duration of the intermenstrual interval gradually to increase, whilst pari passu with this increase, the amount of the flow progressively decreases, until it ceases altogether. In such cases, the general constitutional disturbance is reduced to a minimum. On the other hand, the sudden cessation of menstruation gives rise to profound disturbance of the domestic economy of the feminine organism, and causes violent changes therein. But even the gradual cessation of menstruation causes notable disturbance of the woman’s mental and physical equilibrium, if the irregularities in the menstrual process are very great and spread over a very long period—more especially when the loss of blood is extensive.

Even after the menopause, after the final termination of the flow, there persists a more or less regular recurrence of certain symptoms referable to the continuance of ovulation. Sacrache, a sense of abdominal tension, a feeling of heat and fullness in the pelvis, dragging pain in the hypogastrium, and general irritability, occur at intervals, so that the woman thus affected sometimes describes herself as suffering from the continuance of a “bloodless menstruation.”

Tilt made observations in 637 women, in order to ascertain the various modes in which the menopause occurs, and obtained the following results. The menopause occurred:

By gradual diminution of the amount of the flow	in	171	women, or	26.84	per cent.
By sudden interruption of the flow	in	94	women, or	14.76	per cent.
By sudden interruption and a terminal attack of metrorrhagia	in	43	women, or	6.75	per cent.
By a terminal attack of metrorrhagia	in	82	women, or	12.87	per cent.
By a series of attacks of metrorrhagia	in	56	women, or	8.79	per cent.
By alternations of very profuse and very scanty menstruation	in	36	women, or	5.65	per cent.
By irregular recurrence of menstruation, at intervals exceeding 21 days	in	99	women, or	15.54	per cent.
By irregular recurrence of menstruation, at intervals of less than 21 days	in	33	women, or	5.18	per cent.
By irregular recurrence of menstruation, the intervals being sometimes longer and sometimes shorter than 21 days	in	23	women, or	3.61	per cent.
Totals		637		99.99

The two principal dangers of the climacteric period in women are, first, the great tendency to profuse uterine haemorrhages, and, secondly, the liability to the occurrence of malignant tumours, more especially to carcinomatous disease of the ovaries, the uterus, and the mammae.

With regard to the question whether, in any particular individual, the course of the menopause is likely to be favourable or unfavourable, there are, in my experience, four considerations of principal prognostic significance: the condition of the woman during the menarche, the state of the general health at the time of commencement of the menopause, the degree to which the sexual functions have been and are being exercised, and the manner in which the cessation of menstruation takes place.

As a rule, the disturbances and pathological states of the climacteric period will be especially frequent and severe in women whose sexual development at the time of the menarche was accompanied by severe disturbances of the general condition. In every individual, there appears to be a certain connexion between the manifestations attending the menarche and those attending the menopause, of such a nature that according as puberty has been passed through with little or with much disturbance of the general condition, a similar favourable or unfavourable course of the menopause may be prognosticated. If, at the time of the menarche, there were severe nervous manifestations, or heart troubles of a serious kind, the passage of the menopause may be expected to give rise to neuropathic affections and to cardiac disturbances in a similar manner.

The woman’s state of general health is likewise of importance in determining whether the course of the menopause will be favourable or unfavourable. Perfectly healthy women, with a quiescent temperament, and in favourable circumstances of life, will pass most easily through the climacteric period without disturbance of their general condition. Every departure from normal health has an unfavourable influence upon the course of the climacteric. In women of a plethoric habit of body, there is an especial tendency at this time to the occurrence of symptoms of stasis and hyperaemia. Chlorotic and anæmic women are more prone than others to suffer at the time of the menopause from uterine haemorrhages. Women of a sanguino-erethistic constitutional disposition often manifest at this epoch a tendency to neuroses and psychoses. Those women have the best prospect of a smooth and undisturbed passage through the climacteric age, who enter upon it in a state of perfect health. Less favourable is the prognosis in the case of those women who already some time before the climax, at the outset of the fourth decade of their lives, have begun to complain of severe haemorrhages and various other pathological states.

Regarding the influence which the sexual activity of a woman during the menacme exercises upon the course of the climacteric, it may be said, generally speaking, that a previous free exercise of the sexual functions in normal conditions has a favourable influence upon the state of health during the menopause. Women who have been married for many years, who have had many children, and who have suckled these children, pass through the changes of the climacteric much more easily than old maids, than women who have lived for many years in continent widowhood, or than women who have had very few children or none at all. The practice of prohibitive coitus, i. e., the use during intercourse of methods of preventing the occurrence of conception, a form of sexual immorality which has become extraordinarily common during the last few decades, has an unfavourable influence upon the course of the climacteric. Unfavourable, also, is the effect of great sexual activity during the four or five years immediately preceding the menopause. Women who marry shortly before the commencement of the climacteric, and those who have given birth to a child shortly before this time, commonly experience very severe disturbances during the menopause. Prostitutes who continue the active pursuit of their profession until the climacteric age, have at this time much to suffer. Women who have had difficult deliveries, or several miscarriages, or severe puerperal illnesses—and indeed, speaking generally, those women who have been subject to any kind of disease of the reproductive organs—are apt to suffer from serious disturbances of the general health during the climacteric period.

The mode in which the cessation of menstruation takes place, is also causally connected with the easy or difficult course of the menopause. Premature cessation of menstruation, or very sudden interruption of this function, has a deleterious effect, manifesting itself both by local disorders of the reproductive organs, and by general disturbances in the nervous system and in the circulatory organs. On the other hand, a late menopause and a gradual cessation of menstruation, are both usually accompanied by a favourable course of the climacteric phenomena.

The influence of sexual activity upon the course of the climacteric is described by Busch in the following terms: “Women who have led an exhausting mode of life, who have had intercourse too frequently, those who have been given to onanism or to some other sexual irregularity, and who therefore enter upon the menopause with flaccid and deteriorated reproductive organs, are liable to haemorrhagic and mucous fluxes, to prolapse, carcinoma, dropsies, enlargements, and suppurative processes. Women, on the other hand, who have lived a life of strict isolation, and who have forcibly repressed all sexual inclinations, frequently suffer from ossifications, indurations, and atrophic conditions of the reproductive organs, and also from neoplasmata.”

After an artificial menopause, induced by the operative removal of the ovaries, similar manifestations occur to those witnessed during the natural menopause. Similar disturbances and troubles occur in both cases, but in the artificial menopause they are commonly more severe than in the natural; they last also for a longer time, varying usually from three to six years; moreover, in the artificial menopause, as in the natural, the disturbance of health is more severe and lasts longer in proportion to the youth of the individual. Further, in the artificial menopause also, the intensity and the duration of the climacteric manifestations are influenced by the constitutional state and by the condition of the genital organs at the time when the operation is performed. We note, moreover, that, just as in the physiological menopause, the attendant troubles are most violent in the initial period, and then gradually subside, so also after the induction of an artificial menopause by the removal of the ovaries, the resultant disturbances rapidly increase in severity, to attain their maximum in from three to six months, and then, after lasting for a year or so, they gradually become less severe, until they are ultimately extinguished.

The extensive process of transformation which goes on in a woman’s system during this period of the sexual life, from the very first diminution in ovarian activity to the complete extinction of the reproductive functions, manifests itself throughout the organism by means of a series of changes which can for the most part be referred either to states of blood-stasis and their consequences—congestion of various organs, haemorrhages, and disorders of secretion—or else to perversions of nervous function.

The most manifold symptoms of disordered circulation may occur: hyperaemic states of the central nervous system, flushings of the face, the so-called fugitive heats (Ger. fliegende Hitze), a tendency to epistaxis, to haemorrhoidal flux, and to profuse perspiration. The changes which take place in the reproductive organs at the time of the menopause give rise to venous engorgement and to collateral congestions. Such a condition of venous hyperaemia may occur in the gastric and the intestinal mucous membrane, giving rise to various dyspeptic manifestations, and at times, when severe, even to actual gastric and intestinal catarrh. Hyperaemia of the liver may also arise. In this case, the pressure of the distended bloodvessels on the biliary ducts may interfere with the outflow of the bile, and thus give rise to a slight icterus. Further, the intra-abdominal venous congestion leads to overfilling of the haemorrhoidal veins, and hence to bleeding piles.

When the congestion is long-lasting, various further morbid changes may arise, pulmonary hyperaemia may eventuate in bronchitis, hyperaemia of the cerebral meninges may cause very severe headache, there may be syncopal attacks, tinnitus aurium, choroidal congestion, impaired vision, etc.

Congestion of a more active nature arises from an increased and usually accelerated flow of blood through the vessels of a part in which the resistance to the blood stream has been lowered proportionately to its propulsive force. In this way arises that characteristic symptom of the menopause known as ardor fugax—fugitive heat—one link in the long chain of vasomotor manifestations occurring at this period of life. Fugitive heats are commonly most clearly marked in the face, head, and neck, in which region there suddenly occurs a reddening of the skin, with diffuse and increasing subjective sensation of heat. At the same time there is often a sense of tension, as if the part were about to burst. Actual slight swelling may be noticed, the eyes sparkle and are somewhat prominent, the head feels heavy, stupid, and dizzy. Sometimes these symptoms last for a considerable time; at other times they terminate speedily and suddenly with a local perspiration or with an attack of epistaxis. Not infrequently, after lasting a short time in one region, they pass away as rapidly as they came, but are immediately succeeded by a similar attack in some other part of the body, or by vasomotor phenomena of a slightly different kind. Thus, such a flushing and heat of the face may be replaced by a sudden sense of heat in the small of the back or in the sacral region, by pruritus of the extremities, by palpitation of heart, or by an attack of pseud-angina.

A further consequence of active hyperaemia is the onset of those confused states, so common in the climacteric age, of mental and bodily disquiet, which find expression, now in states of excitement, and now in states of depression. So we often observe change of disposition, associated with incapacity for regular work, whilst sleep is restless, and much disturbed by dreams; and again states of dizziness, a sense of mental uneasiness and confusion, and even actual delirium.

In the skin, in addition to the fugitive heats, we often have a peculiar pricking, itching, or stabbing sensation, and various kinds of hyperaesthesia, frequently associated with disturbances of tactile sensation. We observe also muscular twitchings, and general weakness of the organs of locomotion.

In association with the passive and active hyperaemias of the menopause, we frequently see increase or some qualitative change in the various secretions. Above all, these changes affect the various secretions of the different reproductive organs, but we have also increased intestinal secretion, leading to diarrhoea, increased excretion of urinary deposits, and increased secretion by the skin. Symptoms which are common at the menarche, and frequently recurs at the menopause, are: headache, migraine, a state of pseudo-narcotism, slight hysterical attacks, indications of moral insanity, lumbo-abdominal neuralgias, neuralgia of the breasts, leucorrhoea, and various skin eruptions.

According to Tilt, the changes occurring in the organism at the climacteric period may be summarized under the following heads:

1. Increased elimination of carbonic acid by the lungs, 2. Increased elimination of uric acid in the urine, 3. Increased perspiration, 4. Increased mucous flux, 5. Haemorrhages from various organs.

As regards the first point, the extensive researches of Andral and Gavaret have shown that in the female sex the quantity of carbonic acid eliminated by the lungs diminishes when menstruation first appears at puberty, but increases again at the climacteric age, when menstruation ceases—whereas in the male a gradual diminution in the elimination of carbonic acid begins already in the 36th year of life; in old age the quantity eliminated is greatly reduced in both sexes alike.