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dia and Mastoiditis, Chronic Suppurative Otitis
iNIedia and Its Complications, Examination of the
Kose and Throat, Injuries of the Nose and Throat,
The Nose and the Nasal Sinuses, The Pharynx and
the Larynx, Index.

While the subject of ear, nose and throat dis-
eases is treated of with a special view to prevalence
and importance in the armed services, this little
book has no superior in its field as a text for the
practitioner of general medicine and surgery.



PROFESSIONAL CARDS



November, 1943



NEUROLOGY and PSYCHIATRY



(Now in the Country's Srri'ice)

J. FRED MERRITT. M. D.

NERVOUS and MILD MENTAL

DISEASES

ALCOHOL and DRUG ADDICTIONS

Glenwood Park Sanitarium Greensboro



TOM A. WILLIAMS, M.D.



(Neurologist of Washington, D. C.)
Consultation by appointment at

Phone 3994-W
77 Kenilworth Ave. Asheville, N. C.



EYE, EAR. NOSE AND THROAT



H. C. NEBLETT, M.D.

OCULIST

Pbone 3-5852

Professional Bldg. Charlotte



AMZI J. ELLINGTON, M.D.

DISEASES of the
EYE, EAR, NOSE and THROAT

Phones: Office 992— Residence 761

Burlington North Carolina



THOMAS H. HALSTED, M.D., F.A.C.S.
Otologist
Practice limited to the Selection and Fitting
of Hearings Aids. Hours 9:30-4:30 daily.
Saturday 9:30-1:00. By appointment. 475
Fifth Avenue (cor. 41st St.), New York City.
Phone LE. 2-3427.



UROLOGY, DERMATOLOGY and PROCTOLOGY

THE CROWELL Cl5:IC of UROLOGY and UROLOGICAL SURGERV"

Hours— Nine to Five Telephones— 3-7101— 3-7 lOJ

STAFF

.Andrew J. Crowell, M. D.

(lQIl-1938)

Angus M. McDonald, M. D. Claude B. Soutres, M. D.

Suite 700-711 Professional Building Charlotte



Raymond Thompson. M. D., F. A. C. S. Walter E. D.^niel. A. B., M. D

THE THOMPSON - D.AXIEL CLINIC

of

UROLOGY & UROLOGICAL SURGERY

Fifth Floor Professional Bldg.



Charlotte



C. C. MASSEY, M. D.

PRACTICE LIMITED

TO

DISEASES OF THE RECTUM

Professional Bldg. Chai



WYETT F. SIMPSON, M. D.

CENITO-URINARY DISEASES

Phone 1234

Hot Springs National Park Arkansas



ORTHOPEDICS



HERBERT F. MUNT, M.D.
ACCIDENT SURGERY & ORTHOPEDICS

FRACTURES
Nissen Building Winston-Salem



November, 1943



PROFESSIONAL CARDS



S25



GENERAL



Nilla Clinic Bulldina



412 North Church Street, Charlotte



THE NALLE CLINIC

Telephone— 3-214i (I) no answer, call 3-2621)
General Surgery General Medicine



BROD 1 \-\LI.E, M.D.

OvVEi > Obstethics..

EDWAklj K HIPP, M.D.

Traum.*t:c Surgery

PRESTON NOWLIN, M D.

Urology



Consulting Staff

DRS. LAFFERTY & BAXTER

RADIOIOdY

W. M. SUMMERVILLE, M. D.
Patholocy



LUCIUS G. GAGE, M.D.
Diagnosis



LUTHER W. KELLY, M.D.
Cardio-Respiratory Diseases



J. R. ADAMS, M.D.
Diseases of Infants & Children



W. B. MAYER, M. D.
Dermatology & Stphilology



C— H— M MEDICAL OFFICES

DIAGNOSIS— SURGERY

X-RA Y— RADIUM

Dr. G Carlyi.e Cooke — Abdominal Surgery

dr Gynecology
Dr. Geo. W. Holmes— Orthapedia
Dr. C. H. McCants — General Surgery
222-226 Nissen Bid. Winston-Saletn



WADE CLINIC

Wade Building
Hoi Springs National Park, Arkansas

H. King Wade, M.D. Urology

Ernest M. McKenzie, M.D. Medicine

*Frank M. Adams, M.D. Medicine

*Jack Ellis, M.D. Medicine

Bessey H. Shebesta, M.D. Medicine

*Wm. C. Hays, M.D. Medicine

N. B. BuRCH, M.D.

Eye, Ear, Nose and Throat

A. W. Scheer X-ray Technician

Etta Wade Clinical Laboratory

Merna Spring Clinical Pathology

(*In Military Service)



INTERNAL MEDICINE



ARCHIE A. BARRON, M. D., F. A. C. P.
INTERNAL MEDICINE— NEUROLOGY
Professional Bldg. Charlotte



JOHN DONNELLY, M. D.

DISEASES OF THE LUNGS

324^ N. Tryon St. Charlotte



CLYDE M. GILMORE, A. B., M. D.
CARDIOLOGY-INTERNAL MEDICINE
Dixie Building Greensboro



\■t•^*■^■^, :.■'.



JAMES M. NORTHINGTON, M.D.

INTERNAL MEDICINE— GERIATRICS

Medical Building Charlotte



PROFESSIONAL CARDS



November, 1943



SURGERY


R. S. ANDERSON. M. D.

GENERAL SURGERY

144 Coast Line Street Rocky Mount




R. B. DAVIS, M. D., M. M. S., F. A. C. P.
GENERAL SURGERY

AND
RADIUM THERAPY

Hours by Appointment

Fiedmont-Memorial Hosp. Greensboro


{Now in the Country's Service)

WILLIAM FRANCIS MARTIN. M.D

GENERAL SURGERY

Professional Bldg. Charlotte


OBSTETRICS & GYNECOLOGY




IVAN M. PROCTER, M.D.
OBSTETRICS & GYNECOLOGY

Hi Fayetteville Street Raleigh


SPECIAL NOTICES




TO THE BUSY DOCTOR WHO WANTS TO PASS HIS
EXPERIENCE ON TO OTHERS

Vou have probably been postponing writing that original
co.itribution. You can do it, and save your time and effort
by employing an expert literary assistant to prepare the
address, article or book, under your direction or relieve you
of tlie details of looking up references, translating, index-
u.R. typin;;. and the complete preparation of your manu-
script.

Address: WRITING AIDE, care Southern Medicine &

Surgery.



THE JOURNAL OF
SOUTHERN MEDICINE AND SURGERY

306 North Tryon Street, Charlotte, N. C.

The Journal assumes no responsibility for the authenticity of opinion or statements made by authors or in communica-
tions submitted to this Journal for publication.




JAMES M. NORTHINGTON, M. D., Editor



VOL. CV



DECEMBER, 1943



No. 12



Psychological Study of Sterility in Women*

Joseph Bear, M.D., Richmond, Virginia



rPHE DISCUSSION of the subject to which this
•'■ paper is devoted will be arranged along the line
of general considerations and no attempt made to
discuss any of the specific details. The scope herein
described does not include the problem of sterility
in the male, but this, like its feminine counterpart,
offers an almost new opportunity for psychological
study. The association of the relations of psychia-
try to other medical and surgical specialties, and
especially obstetrics and gynecology, is compara-
tively new. These relations embracing the complex
etiological, concomitant and resultant roles which
psychological or emotional factors play in all types
of human illness, comprise the most recent empha-
sis in medicine, sometimes being referred to as
psychosomatic medicine. In the consideration of
this classification of medicine it may be regarded
that the individual is a psychological-chemical-
physical unit, a personality possessing and operat-
ing what we know as a person and everything that
happens to this individual-as-a-unit has psycholog-
ical, chemical, physical and social aspects.

In the field of obstetrics and gynecology there
already exists an appreciation of the importance of
the correlation with psychological factors, since the
sexual-reproductive processes are obviou.sly physi-
ological, chemical and psychological. Therefore,
proper understanding of illness and proper treating
of sick persons includes something more than a
knowledge of disease.



Marital unfruitfulness has always been consid-
ered by the great majority as a great misfortune
and in ancient times even as a curse. Upon the
unhappy woman was usually placed the blame
("the woman thou gavest me") ; but, in our present-
day knowledge the jaiilt lies in the male in thirty
to forty per cent of the cases! It is estimated that
ten per cent of all marriages are sterile. Nature in
her infinite wisdom has provided woman from the
time of birth with a maternal sense and desire for
children. This maternal instinct is the dominant
trait and central point of her being. Nature con-
ceives of woman chiefly as a mother, even more
than as a mate, and has endowed her with mental
and moral characteristics which are conducive to
her role as mother, and which find their true ex-
planation and unity in the maternal instinct — real-
ism, judgment, patience with details, love of the
small and helpless, desire to take care of someone,
strong animal love, tender sympathies, great per-
sonal and emotional slant and a personal outlook
on things generally.

In Nature's scheme, the paternal instinct is not
as great or as profound and none is provided for;
for man, like the drake or gander, has little concern
over his offspring other than contributing his essen-
tial part. Woman, therefore, suffers most psycho-
logically when this central motive power of their
being is not expressed and does not function. Man,
we know, is the most amorous animal in the zoo-



•Read before the Caduceua Club, Sept. 13th, 1943; Grace Hospital Stail Meeting, Nov. 4th, 1943.



PSYCHOLOGY OF STERILITY IN WOMEN— Bear



December, 1943



logical kingdom.

No study of fertility or sterility can be in an}'
degree satisfactory unless it be conducted in the
light of a competent knowledge of the normal phy-
siology of impregnation. Most of the recent ad-
vances in our knowledge of the failures in fertility
which constitute sterility are, in fact, the result of
work done on laboratory animals; but it should be
borne in mind that the anatomy and physiology of
one animal often varies greatly from those of an-
other species. This vista furnished by knowledge
gained from other animals thus presents a problem
which can be solved satisfactorily only in the light
of biologic principles.

In the specific study of any subject in human
physiology we invariably meet with many obstacles
which do not exist in the conduct of laboratory ex-
periments on other animals. We cannot submit
individuals of the human race to experimental con-
ditions. We cannot study the various processes in
minute detail by killing several individuals at dif-
ferent periods in an investigation. Rarely can we
have the benefit of the follow-up observations which
are readily to be made in the experiments on con-
trol animals. But, on the other hand, there is a
distinct advantage that in the study of the human,
fairly accurate details of the past history and of
the symptoms and sensations can be elicited.
Also, decided advantages are derived from the
much more perfect methods of examination which
have been outlined in detail for the human. The
study of human fertility and sterility, therefore,
requires a full knowledge of general biologic prin-
ciples, of the physiology of impregnation, and of
clinical experience, during which the essentials of
both sciences have been applied to the complexities
of our human race.

Sexual F.actoes

It is often stated that there has been a funda-
mental change in the nature of woman especially
during the post-war period. According to Charles
Duff, there has been no fundamental change in the
nature of woman since the dawn of history: there
is a peculiar sameness about woman's nature ever>r-
where and at all times. The specific reason for this
is that she has a function which dominates all oth-
ers and far exceeds in their impelling force all those
of man — the function of procreation and the early
care of children. After self -nourishment, it is the
supreme function of the human being, and very
well woman knows it. Her physical and psychol-
ocfical texture is patterned toward this great end.
Her whole behavior revolves around it and is held
in a more or less fixed manner. The .superficial
fashions and manners of woman mav change; but
not woman herself. As a biological being, woman
tends to follow the trend of man's development,
but always there looms in the background the great



function of sex and the reproductive instinct.

Woman may be a different creature from what
we have believed. She may be just like a man in
every respect except that she produces ova instead
of spermatozoa. The psychical influences which
proceed from the female genital organs in the dif-
ferent periods of sexual life have also great signifi-
cance for the organism as a whole. IMany impulses,
both stimulating and depressing, arising in the re-
productive organs may affect the mental status.
The maiden at puberty is affected by the knowledge
of sexuality; the sexually mature woman by the
desire for sexual satisfaction and by the yearning
for motherhood — the processes of pregnancy, par-
turition and lactation. Psychical manifestations
and the nervous states associated with these are
rather frequently, and even actual psychoses occa-
sionally, encountered in the various phases of the
sexual life of woman.

Psychological Factors

The psychiatrists' opinion that the emotional
state of a woman influences conception makes this
subject still more interesting as an important factor
in the widespread problem of sterility. In this new
field of psychosomatic investigation it is believed
that psychic and somatic phenomena are different
aspects of the same thing. Due to the vital inter-
relationship between psyche and soma, not only is
the psychic life influenced by changes in the som-
atic being, but psychic influences may also change
the somatic state. Emotional conflicts can result in
somatic dysfunctions and psychological therapy is
often able to bring about improvement in such dis-
orders. This is equally as true of the generative
functions as of other physiological processes. In-
vestigations into the problems relating to pregnancy
include the well-known phenomenon of conception
occurring in a previously sterile woman after she
has adopted a child. ]\Iany women do not conceive
although no organic obstacle can be found. There
may be some hidden biologic phenomenon. Due to
some change in the mode of life situation of some
of these women (for example after adoption of a
child), but without discernible changes in their
structure or physiology, conception takes place.
This has become common knowledge, to the extent
that married couples, about to adopt a child, often
hear predictions to the effect that they will now
have a child of their own. Unfortunately, accurate
statistics of the frequency of such blessed events
are not available: but, inasmuch as almost every-
one knows of one or two such cases, they must be
of rather frequent occurrence. Common experience
pnd observation seem to agree here with the
psychosomatic vievA^point that psychological factors
mav play an important role in the ability of a
woman to conceive. Recently, the scant literature
on this interesting topic has been reviewed by D.



December, 1943



PSYCHOLOGY OF STERILITY IN WOMEN— Bear



S27



W. Orr, whc has contributed probably the first
careful ps\-chological surve\^ of a childless married
couple who had a child of their own shortly after
the decision to adopt. The literature consists
chiefly of discussions of the possibility that sterility
may be psychogenic. The views of several observ-
ers are outlined by Dunbar as follows:

''Psychic influences, associated with a vivid but
unsatisfied desire for a child, may stimulate the
ovaries to pathological growth. It is possible that
this may result in premature maturation of the fol-
licles and discharge of ova which are not ready for
fertilization, and consequent sterility. The peculiar
cases of first conception after fifteen or twenty
years of married life may be explained by the fact
that as a woman becomes gradually reconciled to
her sterility this injurious influence on the follicu-
lar apparatus disappears. The influence of psychic
factors on the endocrines is sufficiently proven to
give additional justification for the belief that
psychically influenced hormonal proceses may play
a role in conception." Orr summarizes Benedek's
views as follows: "There is a definite interrelation
between the psychosexual development of the indi-
vidual and the hormonal cycles, so that psycho-
sexual fixations or inhibitions may lead to irregu-
larities of the gonadal cycles producing a psycho-
somatic vicious circle."

Effects of Childless Marriage

A^'ith ten per cent of marriages barren, there
must be in this country today at least 2,000,000
childless couples who are still at an age of potential
child-bearing. Xo doubt, modern civilization and
the high-geared age play some part in the rapid
dechne of production of children. Voluntary limi-
tation is, perhaps, the chief point in the develop-
ment of such a state of affairs; but involuntary
sterility is a factor of considerable magnitude.

Failure to conceive is frequently responsible for
much unhappiness and when the natural maternal
longing is not gratified, the woman's very nature
will frequenth' become changed and her mind take
various abnormal slants that are not conducive to
her happiness, or the happiness of those around
her. The psychic changes which occur are many
and at times marked. There may be lassitude, shy-
ness, tendency to introspection, changes in the
mental and emotional outlook, alteration in tem-
perament, irritability, psychological reactions, de-
pressions — minglefl bitterness, regret, anger and
despair. In tho.se women with a psychasthenic
tendency these changes may become very serious.
It may be reasonably assumed this long-continued
psychologic change produces an altered metabolism
which i*; certainly not conducive to pregnancy.
When a childless patient sees a child with a friend
or even with a stranger there tends to be imme-
diately set up in her being, a complex emotional



tension — a feeling of anxiety, disappointment, dis-
tressing consciousness of sterility, a sense of de-
pression with its associated reactions.

These patients migrate from one physician to
another, sometimes receiving only a meager sur-
vey. As a rule the husband sends his wife for ex-
amination because he takes it for granted that she
must be the cause, or the wife comes of her own
accord under the same impression and in the de-
sire to remove any obstruction to marital happi-
ness. The physician is thus easily tempted to direct
his attention chiefly to the wife and to neglect the
husband, a practice which is quite wrong, as our
views on this subject have undergone great change
in recent years. These facts have caused a complete
revolution in the therapeutic approach. Unfortu-
nately, it has been the custom of some members of
the profession to go lightly into the case and dis-
miss the patient with the statement, "I see no
reason why you can't get pregnant." Then they
may or may not seek other advice. Still another
angle in this connection may be briefly mentioned.
Even in the case where the specialist makes the ex-
amination and finds, for example, a minor pelvic
lesion, one is prone to make a hasty decision as to
the outcome and the patient is told promptly,
"You cannot become pregnant." This is bad psych-
ology, and the lesson it teaches is to be tolerant,
more reserved, and that the case in question should
be studied more in detail. For even in the presence
of various pathological findings, for example, con-
genital anomalies, glandular dyscrasias and pelvic
tumors, in due time many cases can be rectified.
When these women do not attain their supreme
objective and the child-bearing cycle remains in-
complete, as the years pass by they become hyper-
sensitive and depressed as their visions of mother-
hood still remain unrealized. There is, indeed, a
tragic incompleteness in the home lives; they felt
that in the most important of all earthly functions
they have failed.

Prevention of Sterility

In this connection the period to begin is in early
childhood and the approach to puberty demands
special care. One may venture to say that the time
is not far distant when preconceptional care and
even care at puberty will play the most important
role in the field of conservative obstetrics. This
plan will tend to bring about the proper develop-
ment of these young women, that they may reach
the reproductive stage in best physiological po-
tency.

Disregard of abnormal symptoms in girls is
much to be criticized. It results partly from lack
of appreciation on the part of the parents of the
importance of preventive care and partly from the
idea that vaginal e.xaminations of unmarried girls
is contraindicated. Allen believes that physicians,



PSYCHOLOGY OF STERILITY IN WOMEN— Bear



December, 1943



too, are inclined to stress too little the importance
of various abnormal symptoms such as pain or ex-
cessive bleeding. The efforts of the profession
should be directed toward the education of women
concerning the value of preventive rather than cur-
ative medicine, especially at the beginning of the
maturation process; and the necessity for careful,
routine, physical examinations, even of young girls.
Universal sex enlightenment is also of great impor-
tance. Routine rectoabdominal examination (espe-
cially in girls) is advocated and if it becomes nec-
essary, a vaginal examination. By intelligent fore-
sight and careful examination many of the dis-
orders of the growing girl and adult woman, such
as functional dysmenorrhea, amenorrhea, congeni-
tal erosion, genital irritations, infections, frigidity
and sterility, as well as psychological disturbances,
may be modified or prevented. This preventive
aspect of the management of hximan sterility not
only involves the work of the physician, but also
extends into the fields of economics, of sociology,
and of education. Thus the psychological approach
leads to measures having a more far-reaching effect.
A practical scheme of prevention is applicable to
several of the underlying causes of infertility. Im-
portant among these are: genital hypoplasia, faulty
sex hygiene, venereal disease, improper therapeutic
measures and a long delay in treatment.

Many sterile couples strongly desirous of chil-
dren are prone to live in hopes for many years be-
fore they seek help in the solution of their prob-
lems. Many a sterility which might be relieved with
comparative ease at the age of twenty-five becomes
more resistant to all efforts, even irremediable, ten
years later, when the maximum degree of fertility
of both partners has diminished according to the
normal physiologic principle.
Conclusions

In concluding this presentation on such a vital
human topic, I have, with full realization of its
many shortcomings, given an exposition of the
problems with the endeavor to aid in the psychol-
ogical and therapeutic approach to this social blight
so vitally concerned with the welfare and perpetua-
tion of the race. The search for the cause of ster-
ility is of paramount importance. Before study of
the female partner is begun, the fertility of the
male must be evaluated and his responsibility de-
termined. Although the sperm cells come from the
male they play their most important role within
the female, hence both partners should cooperate
and a thorough investigation be made as to the
combined fertility levels. It is a problem of the seed
and the soil. The causative factors are many. They
may be local, systemic, functional or organic and
are frequently associated with endocrine dysfunc-
tion. Besides a detailed history of the life and hab-
its of both partners and a complete physical survey.



psychologic observations should be regularly made.
Incomplete studies usually prove fruitless. The
medico-social field of human reproduction demands
more. Sex maladjustment and various incompat-
abilities can be safely minimized by early investi-
gation and prompt treatment. Many of these pa-
tients feel they are wellnigh helpless. It becomes
the important duty of the physician to display a
feeling of understanding sympathy and helpfulness,
encouragement and inspiration, with a deeper ap-
preciation of the fact that there is an instinctive
urge to gain a complete insight into the pattern of
their living and a willingness to bring forth off-
spring.

As has been truly stated, a fruitless marriage is
one of Nature's saddest tragedies and, from what-
ever angle it may be viewed, the result is detrimen-
tal to the best interests of society.

With the advance of years, science has substi-
tuted knowledge for platitudes. Improved scientific
techniques and special tests have now advanced to
the point where the psychological aspects of ster-
ility can be observed. With careful and faithful
study of these problems, the relationships between
fertility and emotional states can often be explored
with happy results. This may serve as a new sign-
post for proper direction toward further develop-
ment. Thus, all this leads to one desired goal, the
expulsion of the fully developed end-product of
conception, namely, babies, which may be rightly
defined as: "The rivets of the bonds of matri-
mony."

— 609 Professional Building

Bibliography

Ballantine, J. W.: Expectant Motherhood. Funk and
Wagnalls Co., New York, 1914.

Bear, Joseph: Discussion of Rubin Test and Hystero-
salpingography in Sterility. Virginia Medical Monthly,
May, 1935; Further Comments on Human Sterility, Medi-



Online LibraryNorth Carolina. Comptroller's DeptSouthern medicine and surgery [serial] (Volume 105 (1943)) → online text (page 101 of 109)