- Email: [email protected]
Psychiatric Aspects of Sterility
Psychiatric Aspects of Sterility M. STRAKER, M.D.
• Medical research is the search for the understanding and the solution to problems through the study of normal or disturbed biological processes in living organisms. Deficiencies inherent in single techniques, whether basic, experimental, statistical or clinical, encourages the development of composite programs in varying proportions. The clinical appraisal of some. complex medical problems must also of necessity involve composite programs whereby multiple observers of varied backgrounds contribute observations. This interdisciplinary approach is a useful technique in the progression of understanding of psychosomatic problems. Psychosomatic research has not fulfilled its original promise, when personality profiles were in vogue. The hope of clarification of difficult medical problems through classification of typical personality types has not been sustained. In many syndromes, the basic issue of cause and effect still remains unclear. For many psychosomatic disorders, it is still unknown whether psychological disturbances cause the somatic dysfunction, or result from the somatic dysfunction, or whether both psychological and somatic disorders are evidence of a deeper disturbance common to both. Kubie ' has summarized our present knowledge on organ choice or specificity. He honestly states that it is still unclear how a psychologic conflict becomes precisely translated into a specific goal directed negative neurophysiologic pattern. The consideration of the psychological and psychiatric aspects of infertility can contribute some measure of understanding about this problem, and points up the particular promise of long-term interdisciplinary studies. Doctor Straker is Assistant Psychiatrist, Montreal General Hospital, and Assistant Professor, McGill University Psychiatric Department. 150
ENDOCRINE AND NEUROPHYSIOLOGICAL INFLUENCES
The mechanisms involved in psychogenic infertility occur as a result of the dysfunctions in the endocrine and the autonomic nervous systems. As Bos and Cleghorn 2 describe it, hypothalamic activity, via vascular mechanisms, activates the anterior pituitary lobe for the production and release of luteinizing hormone (LH), which stimulates the production of estrogens by the ovary and results in ovulation. The autonomic nervous system is closely bound to areas of the brain concerned with emotional expression, especially the cortex, hypothalamus, thalamus and mid-brain structures, including the reticular activating system and the limbic system (rhinencephalon). The efferent fibres of the autonomic can mediate a variety of motor and secretory genital disturbances, when there exists an altered emotional state concerned with sexual function. It is presumed that autonomic influences are operative in producing tubal spasm (fallopian tube dysfunction) and vaginismus, and via influences on the vascular bed, can also produce endometrial changes incompatible with implantation, or vaginal Ph changes which inactivate sperm. Such changes can be considered to be similar to those found in the congested bowel of the irritable colon syndrome, or the nasal congestion of certain neurotic individuals. The brief reference to the above mechanisms serves as a bridge behveen the diagnostic establishment of the psychologic disorder and the presence of the somatic disorder. In critical thinking about the psychosomatic concept, the correlation behveen the hvo observed sets of facts must be established either on a psychological conversion basis (suppression or distortion of normal organ function), or on the basis of physiological inter-relationVolume IV
---~.
__
.
--PSYCHIATRIC ASPECTS OF STERILITY-STRAKER
ships which are a reflection of the particular homeostatic disturbance. The hypothalamus is regarded as the key structure for emotional activities. It regulates the anterior pituitary and through it, the endocrine system; directs the autonomic vegetative functions, coordinating breathing rate, heart rate, blood flow, mobilization of blood sugar, et cetera, to meet the fight or flight situation. Hunger and sexual activities are also under hypothalamic regulation. Those clinical states which relate immediately to the problem of sterility include tubal spasm and "hypothalamic amennorhea" ( anovulation). It is well known that hypothalamic ammenorhea may result from a feared exposure to pregnancy, or accompany a marked stress reaction accompanied by or expressed in the form of fear, grief or depression. The most common emotional disturbance associated with menses arrest is depression, whether overtly expressed or masked. Other factors also decrease hypothalamic activity and can result in amennorhea. These include electroshock treatment, phenothiazine medication ( tranquilizers), hypothyroidism, and certain adrenal disorders. The patterns of thyroid, gonadal and adrenal hormone secretions related to psychological stress in the monkey 3 were reported in a recent study. During the stress, urinary corticosteroid levels increased threefold, epineph~ rine urinary levels doubled, thyroid hormone levels increased slowly to twofold, whereas urinary andosterone and estrone dropped to below half the baseline levels. The values reversed and readjusted dUring the recovery phase over a period of one week. The authors stated that "every hormone underwent marked changes either during or after psychological stress." These changes were oriented towards mobilization of energy during the stress period, followed by anabolic restoration. The differences noted in the pattern of the endocrine responses suggested the basis for the development of endocrine imbalance during chronic or repetitive stress. Selye 4 has pointed out that during stress, the sex glands shrink and become less active. The pituitary has to produce more ACTH to maintain life, and it must cut down production of other hormones less urgently needed. Menses become irregular, or stop, and during lactation, milk secretion may become inMay-June, 1963
sufficient. In men the sexual urge and spermcell formation are diminished. The premenstrual tension syndrome is evidenced by fluid retention, predisposition to allergic and hypersensitivity reactions, and a tendency toward seizures and vascular disturbances. A decrease of gonadotrophic excretion is a characteristIC response in the general adaptation snydrome. Thus, from clinical observation and from experimental data, it is clear that states of stress result in a decreased sexual activity. INCIDENCE OF INFERTILITY
The frequency of this problem is difficult to estimate with accuracy, depending on the adequacy of the statistical sampling as well as on the special group sampled. Rutherford et ala estimate that 12 per cent of all American couples are infertile. Weir and Weir also estimate a 12 per cent incidence on the basis of large scale population studies. The author has reviewed the incidence of absolute and relative infertility in his office psychiatric population. During the last 12month period, there were examined, evaluated and treated a total of 104 persons who were married a minimum of five years. In this group, 20 presented childless marriages, and of this number five had proceeded to the adoption of children. An additional 16 had only one child, and were avoiding further pregnancies. In this latter group of 16, seven women had suffered a postpartum psychosis, while in five cases, the husband had reacted to the arrival of a child by an exacerbation of his neurotic problems so that additional pregnancies were precluded. The absolute sterility incidence of the five-year married psychiatric group is over 19 per cent. In this particular group (referred for problems unrelated to sterility), four women had pelvic pathology; two men had aspermia. The etiology of the other 14 cases was undetermined, although all had undergone investigation at various times. While no firm conclusions can be drawn about the functional aspects of this infertile group at this time, the overall infertility incidence noted in this psycholowcalIy ill group is certainly much higher than noted in large population studies. It is also difficult to evaluate the incidence 151
PSYCHOSOMATICS
of the functional etiology and outcome of infertility. Southam' noted that in a series of 312 couples who were "normal yet infertile," 51.3 per cent had a pregnancy during the observation period of one or more years. Fiftynine per cent of 1,568 couples showed abnormalities that could explain the infertility. Twenty-two per cent of the total women showed abnormalities, with the man normal. Twenty-seven per cent of the men showed decreased fertility. Ten per cent presented abnormal findings in both partners. Although the rates of pregnancy differed in each group studied, the overall pregnancy rate was 30 per cent where a definite abnormality was present. Age of the couple and duration of infertility were important considerations in determining the reasonable deferral of adoption proposals. Prueter8 described a series of 97 infertile couples. Seven husbands had aspermia and 32 women had organic problems, while 58 per cent had "functional infertility". In a~di tion to investigative contacts, he prescnbed Stelazine or Parstelin b.i.d., and 56 per cent became pregnant. This rationale came from his conviction that primary infertility is due to deep underlying fears and tension. The latter develop out of a previous traumatic pregnancy, abortion or stillbirth, or reBect a poor emotional preparation for adulthood. He felt that pharmacological control of the tension aided the task of realizing the wish for a pregnancy. SandlerD analyzed 268 consecutive childless marriages and diagnosed 25 per cent to be stress-related. In his opinion, stress produces varied symptoms and reflects· the unreadiness for parenthood. PSYCHOLOGICAL FACTORS PERTAINING TO FEMALE STERILITY
Fenichel'° has stated that a psychogenic resistance to pregnancy can affect the course of pregnancy and childbirth through inBuencing muscular functions and to some extent, the circulatory and metabolic ones. However, he is not certain that there is a psychogenic inhibition of procreation, i.e., whether a truly psychogenic sterility exists. A number of authors have described personality profiles of women likely to develop functional reproductive disorders. Mandy et al" described two main types. The first is the physically and emotionally immature 152
woman, overly dependent, functioning in a childlike role in marriage and fearing motherhood as too threatening. She is easily fatigued and prone to functional disorders. The second type is described as the aggressive masculine competitive woman, often overambitious and career-minded. There is often an open rejection of the feminine role and of motherhood. Their conflicts about roles in life "often prevent conception or cause miscarriages". The rejection of motherhood is expressed by the use of criminal abortions or failure to cooperate with sterility programs. They show a high incidence of menses irregularity, anovulation, tubal spasm, spontaneous abortion due to uterine irritability and vascular accidents. Rutherford et al 5 ,12 emphasized the importance of psychogenic anovulation in sterility, and described the use of a full battery of psychological tests in every patient. These include Thematic Apperception, the Rorshach, and the Minnesota Multiphasic Personality Inventory. He felt that anovulation was not the main problem, but only a symptom of a more serious emotional disturbance, and on this basis, recommended psychotherapy as the treatment of choice for such cases. "The evaluation of the infertile couple's adjustment is as important as it is to scrutinize the abnormal physiology". Pommerenkel:l also states that conception failures may well have causes not necessarily organic and that the physician involved must fill many therapeutic roles, psychotherapeutic as much as others. Benedek H points out that psychogenic infertility can be considered as a defense against the dangers inherent in procreative functions. Thus it may be temporary and disappear with maturational processes. Infertility may be a conjugal phenomenon caused by sexual maladjustment or by deep dissatisfaction with the marital partner. Relative infertility may be expressed by the inhibition of heterosexual drive or by the suppression of intercourse during the fertile period. Conflicts lead to suppression of gonadal function and anovulation. Reflex action may produce tubal spasm as an expression of acute fear of pregnancy. Benedek points out that sterility symptoms are really an expression of much wider psychosexual disturbance, otherwise evidenced by spontaneous abortions, psychological difficulVolume IV
PSYCHIATRIC ASPECTS OF STERILITY-STRAKER
ties regarding menstruation and pregnancy, the deepest unconscious sources of psychic life. and also by postpartum difficulties. The writer's interest has already been diBos and Cleghorn 2 also emphasize that disturbed personality traits are the broad base rected to a study of the special psychological from which infertility conflicts arise. When factors which operate during pregnancy ami I psychologic conflicts surrounding impregna- childbirth. ' Mention is made of this, since tion occur, these are manifestations of an any consideration of psychogenic sterility must emotionally disordered personality. The na- include the special fears and anxieties which ture of the personality disturbance varies, and are expressed in relationship to one or more may be described as emotional immaturity, an of four areas of experience. These are (1) aggressive masculine woman, a hostile mother fear of intercourse, (2) fear of menses, imidenti6cation, or an obsessive compulsive neu- pregnation and the state of pregnancy, (3) rosis. They pointed out that the sterility may fear of childbirth, (4) fears of the state of represent the defense of the disturbed person motherhood. There is certainly overlapping from one against the stresses of pregnancy and motherarea to another, and I would agree with hood, stresses with which they cannot cope. many writers, already quoted, that the fears l5 Blau and others recently reported a psyand conflicts which express as psychogenic chiatric and psychological study of women sterility are simply an expression of a larger who are mothers of prematures. "The data, on clinical and statistical grounds, showed a personality disorder. Yet some comment distinctive difference in that the premature should be made about the constellation of mothers seem to have negative attitudes to the commoner fears. The fear of intercourse involves the lack of the pregnancy, greater emotional immaturity, emotional growth adequate to permit funcmore narcissistic trends, and inadequate resolution of familial problems". The findings in tioning at the adult level. The woman may the "premature" group, when contrasted to be immature, infantile, fixated at levels of the "full term" group, are similar to those pregenital sexual activity. She may be inrecorded in the functional infertile group. terested in the goals of the little girl, to be Blau and roo-workers are devising a self-report petted, admired, comforted and protected. A multiple choice questionnaire to predict and variety of masturbatory needs dominate. Whether expressed in passive or aggressive possibly prevent prematurity. 16 forms, the personality is narcissistic, incapable Helene Deutsch has pointed out from detailed case studies and analytic investigation of giving or of loving in an adult sense. Such and therapy, that unconscious feelings of guilt a woman often marries with the illusion that frequently cause psychogenic sterility. She de- she is to remain the omnipotent child, and scribed a number of personality types, which she feels traumatized, degraded, inadequate include: (1) the immature infantile dependent and extremely anxious in the adult sexual rechild woman. (2) the maternal giving wom- lationship. To a minor degree, the lack of an, whose husband absorbs all her maternal psychosexual development may be a reflecdrives and feels threatened by a child. (3) tion of faulty education and the exposure to the active masculine aggressive woman who unhealthy family attitudes in the home. In rejects her femininity. (4) the woman whose actuality, she avoids intercourse whenever dedication is to interests which exclude moth- possible, and when involved, she reacts with erhood. (5) the emotionally ill woman who anxiety, hostility or the appearance of psychoperceives the poverty of her emotional life somatic complaints. The fear of the menses, impregnation and and cannot meet the demands of motherhood. She also drew attention to the para- the state of pregnancy itself is also of comdoxical counterphobic state, where compul- mon occurrence. The predominant endocrinsive impregnation is the alternative solution ological setting for the premenses and extendto the same fears and conflicts which in the ing into the period of pregnancy is described more usual case results in sterility. The fears by the dominance of the progesterone phase. which dictate the sterility response she de- This is closely correlated with increased feelscribes as a fear of death, or stemming from ings of passivity, dependency and regressive May-June, 1963
153
PSYCHOSOMATICS
phenomena at the psychological level to anal and oral orientations. Such regressive reactions provide a setting in many women for the activation of anxiety and depression. Henrietta Klein et a)t8 concluded that previously existing personality difficulties were often accentuated during a pregnancy. Many superstitions are deeply rooted in the unconscious regarding both menstruation and pregnancy. The loss of control is greatly feared by some. The growth in oneself of a monstrous or defective child, is an expression of primitive masturbation guilt or expresses the unconscious equation of the pregnancy with an internalized phallus, which is soon to be lost again (at delivery). The whole pregnancy is also a period of psychological preparation for delivery and motherhood, and grave fears may develop in relationship to both anticipated experiences. The central fear in childbirth is the fear of death in the childbirth process. The anticipation of pain, of loss of control, of loss of consciousness are focal anxieties. Women instinctively feel that childbirth is a testing experience in which all their emotional and physical reserves will be drawn upon. The self image in relationship to femininity is most important, as is the strength of the identification with her own mother. Fodor'" suggests that the mother is also identified with the child in her womb. The birth process becomes also "the giving birth to oneself", or being born again, thus setting in motion the most primitive springs of anxiety which relate to the archaic anxieties of the birth of the mother as a child. Greenacre 2 has described such anxieties in considerable detail, also noting that this very birth anxiety serves to mobilize, stimulate and direct the maturational energies of the newborn infant. Delltschtr. has also noted the importance of the reawakening of early traumatic experiences connected with loss of control in childbirth, which relate especially to early bladder and bowel training. The separation from the fetus is also reacted to by some women as though this were an organ or body loss. Such concepts simplify the understanding of postpartum depressive reactions or other psychopathology appearing at this time. Fears related to the status of motherhood itself relate to the adequacy of the individual 154
to function in a maternal glvmg protective role. It involves a narcissistic blow, and calls upon the capacity to change one's self image as normally occurs during maturation processes. The failure to succeed in this task is nakedly exposed to the new mother who be: comes acutely aware of her inadequacy, of her emotional depletion, of her lack of anticipated love for the child. If this should happen, there is marked anxiety, a rejection or hatred of the newborn child, and the appearance of psychopathological flight and denial of reality when she reaches the postpartum state. This short summary of commonly experienced fears and anxieties describes an overlapping of feeling which become active in susceptible women in relationship to physiological events which are closely associated. These events form an inseparable series in the psychosexual experience of the woman, and special problems in anyone area may become important in the determination of psychogenic sterility. STERILITY FACTORS PERTAINING TO MEN
Although the man can exert a decisive role in the determination of a childless marriage, the psychological problems pertaining thereto will be only briefly reviewed. Impotence in men is, with rare exception, always psychological in origin. This may be evidenced by failure of erection, premature ejaculation precluding penetration, or ejaculo retarda. The basis of the impotence is a conflict between instinctual forces, or between morality issues and unacceptable sexual impulses. In simplified form, the dilemma is stated, "I want, I mustn't, I can't." Impotence is the expression of resistance against the sexual act due to guilt, anxiety or hositility to the object. Fear of injury to self or others (sado-masochistic components), fears of inadequacy (fear of women, homosexual latencies, castration anxieties) or predominance of pregenital impulses are important factors. The therapist's role is to discover the nature of the inhibition and help the patient work through his conflict. Another important cause of male infertility is represented not by impotence, but by the voluntary avoidance of parenthood. This expresses the male's unreadiness for parenthood, Volume IV
PSYCHIATRIC ASPECTS OF STERILITY-STRAKER
either out of fear, narcissism, a sense of inadequacy, or the desire to remain the only child in the relationship to the wife. An example of such difficulties is evidenced by a male patient in therapy. The preliminary investigation of infertility in his marriage had established his wife's ovulation time, but he found himself repeatedly impotent during this phase of the wife's cycle. This was one expression of his infantile relationship to his wife otherwise expressed in jealousy and fears of being displaced in his wife's affection. Elin et al 21 have emphasized an importan£ issue. They point out that the infertility study should have a definite predictable end. The survey should include certain standard tests which can be concluded in five or six visits spaced approximately one month apart. If pregnancy has not ensued within one year of the study's completion, it is encumbent to guide the infertile couple to a reliable adoption source. The writer can confirm from clinical experience that serious emotional illness can result from unending sterility programs which are carried on for a number of years when the attention of the physician is not directed to the whole patient but remains focused only on the reproductive apparatus. Clinical practice rarely presents the uncomplicated medical situation. The common complexity is the mixture of the organic and the functional. A short case sample will illustrate. Mrs. L. G., now age 47, was referred for psychiatric treabnent. Presenting complaints consisted of severe recurring depressions occurring in the setting of a rigid obsessional phobic state. She was an intelligent, but cold, undemonstrative, emotionally restricted person, chiefly interested in business life. She always thought she would never marry, and had no interest in sexual experience. She married at age 27, mainly to escape a difficult home where she was dominated by her mother. The onset of her menses was at 13. Severe dysmenorrhea, premenstrual irritability, depression and compulsive activity were present. She was always sexually frigid. Her first gynecological investigation, undertaken at her husband's insistence, at age 31, occurred four years after marriage. This revealed no abnormalities. The second gynecological enquiry came at age 32, and her ovulation cycle was then clarified. Her first pregnancy ended in a miscarriage at six weeks at age 33. A second miscarriage occured at 12 weeks, at age 34. She adopted a newborn child at age 35. She then had a full-term pregnancy at 36, but remained in bed approximately seven months with severe nausea, but no bleeding. The labor was prolonged, lasting five days, and delivery was difficult, with forceps assistance. Hysterectomy May-June, 1963
was carried out at age 39, because of patient's insistent complaints about dysmenorrhea. A small fibroid was removed. She was depressed after the adoption, after the conception, during the pregnancy and afterward, and reacted with depression to the hysterectomy. A large number of psychosomatic complaints remained unchanged after the surgery. The older child was referred for psychiatric care at age eight because of emotional difficulties. This was regarded as developing out of a cold overcontrolling hostile mother-child relationship. She was advised to have therapy herself at this time but did not take the advice. The second child (her own) had also developed an emotional illness, manifesting near psychotic behavior which necessitated a lengthy treabnent program. In the course of this psychiatric management the mother sought help for herself.
This brief case summary illustrates familiar clinical findings. The patient presented the clinical picture of a long-standing phobic obsessional personality disturbance. Some reflections of this disorder were her emotional coldness, her delay in marriage, the period of infertility, the lifelong dysmenorrhea, the spontaneous miscarriages and finally the adoption and the difficult pregnancy. The latter was culminated by a difficult labor, a postpartum depression and finally a hysterectomy. The relationship of the psychological disorder and the small fibroid which was only a late diagnosis must remain speculative. THE PSYCIllATRIST'S ROLE
A psychiatric evaluation may be indicated whenever the gynecologist becomes aware of serious psychological problems in his infertile patient. Accurate personality assessment will provide a working diagnosis and therapy if indicated. In the event that the infertility study is completed, and a pregnancy does not ensue after one year, a psychiatric assessment is also indicated. The role of psychological forces in perpetuating the infertility, the consideration of adoption procedures or the decision to terminate endless gynecological investigations can then be clarified to a fuller extent. Continuing psychiatric studies are needed to advance our understanding of this complex problem. The fact that a considerable proportion of women conceive within one year of the infertility investigation poses a number of interesting questions for clarification. What is the role played by the physician's scientific skill alone, and what is the importance of the interpersonal patient-physi155
PSYCHOSOMATICS
cian relationship? What meaning is given to the interventions into sexual body areas, as distorted in the transference phantasies of the patient? What are the precise maturational processes which translate the functionally barren female into a woman capable of childbearing and motherhood? SUMMARY
Women who present as functional infertility problems manifest findings of psychological and emotional disorders. The psychiatric examination reveals personality disturbances which inBuence the psychosexual course of the patient. It is well to remember that the sterility can be nature's way of shielding the emotionally ill-prepared woman from motherhood tasks which are beyond her resources. Detailed long-term interdisciplinary studies can enlarge our basic understandings of the multiple aspects of the problem of infertilify and improve our clinical skills in patient car~. REFERENCES
1. Kubie, L. S.: The Problem of Specificity in the Psychosomatic Process: Recent Developments in Psychosomatic Medicine. Page 29. Philadelphia: Lippincott, 1954. 2. 80s, C. and Cleghorn, R. A.: Psychogenic steriIity.}. Fertility Sterility, 19:No. 2 (March-April) 1958. 3. Mason, J. W., Brady, J. V., et al: Patterns of thyroid, gonadal, adrenal hormone secretion related to psychological stress in the monkey. Psychosom. Med., 23:446, 1961. 4. Selye, Hans: The Stress of Life, pp. 176-178. New York: McGraw-Hili Book Co., Inc., 1956. 5. Rutherford, R., Banks, A. L., et al: Treatment of psychologic factors in ovulation. }. Amer. Soc. Study Infertility, 12: No.1, 1961.
6. Weir, Wm. and Weir, D.: Natural history of infertility. ]. FertUity Sterility, 12:443 (Sept.Oct.) 1961. 7. Southam, A. L.: What to do with the "normal" infertile couple. }. Fertility Sterility, 11: 16, 1960. 8. Prueter, G. W.: Combined tranylcyprominetrilluoperazine therapy in obstetrics and gynecology. Presented at Canadian Conference on Anxiety and Depression, June 3, 1961. 9. Sandler, B.: Infertility of emotional origin. }. Obstet. Gynec. Brit. Common., 68:809 (Oct.) 1961. 10. Fenichel, 0.: The Psychoanalytic Theory of Neurosis. New York: W. W. Norton & Co., Inc., 1945. II. Mandy, T., Scher, E., et al: Psychic aspects of sterility and abortion. South. M.H., 144: 1054 (Nov.) 1951. 12. Rutherford, R., Banks, A. L., et al: Infertility: Current evaluation and treatment: Medical arts and sciences. }. CoU. Med. Evangelists, 14:No. 2, 1960. 13. Pommerenke, W. T.: The normal infertile woman is not normal. }. Fertility Sterility, 11: 1960. 14. Benedek, T. F.: Sexual functions in women. American Handbook of Psychiatry, Chap. 37. New York: Basic Books, Inc., 1959. 15. Blau, A., Slaff, B., et al: The psychogenic etiology of premature births. Presented at 118th Annual Meeting American Psychiatric Association, Toronto, Canada, May 10, 1962. 16. Deutsch, H.: The Psychology of Women. Vol. 11, Chap. V. New York: Grune and Stratton, 1945. 17. Straker, M.: ~sX<:hological factors during pregnancy and childbirth. Canad. Med. Ass. }., 70: 510, 1954. 18. Klein, H., Potter, H. and Dyk, R.: Anxiety in pregnancy and childbirth. Psychosom. Med. Monograph. New York: Paul Hoeber, Inc., 1960. 19. Fodor, N.: Psychiat. Quart., 23:59, 1949. 20. Greenacre, P.: Biological Economy of Birth. Psychoanalytic Study of the Child. Vol. 1. New York: International University Press, Inc., 1945. 21. Elin, T. W., Danforth, I. W., et al: A study of infertility in the private practice of obstetrics and gynecology. }. Fertility Sterility, 11 :No. 2 (Mar.Apr.) 1960.
1 respect faith, but doubt is what gets you an education. WILSON MIZNER (1876-1933)
156
Volume IV
• Medical research is the search for the understanding and the solution to problems through the study of normal or disturbed biological processes in living organisms. Deficiencies inherent in single techniques, whether basic, experimental, statistical or clinical, encourages the development of composite programs in varying proportions. The clinical appraisal of some. complex medical problems must also of necessity involve composite programs whereby multiple observers of varied backgrounds contribute observations. This interdisciplinary approach is a useful technique in the progression of understanding of psychosomatic problems. Psychosomatic research has not fulfilled its original promise, when personality profiles were in vogue. The hope of clarification of difficult medical problems through classification of typical personality types has not been sustained. In many syndromes, the basic issue of cause and effect still remains unclear. For many psychosomatic disorders, it is still unknown whether psychological disturbances cause the somatic dysfunction, or result from the somatic dysfunction, or whether both psychological and somatic disorders are evidence of a deeper disturbance common to both. Kubie ' has summarized our present knowledge on organ choice or specificity. He honestly states that it is still unclear how a psychologic conflict becomes precisely translated into a specific goal directed negative neurophysiologic pattern. The consideration of the psychological and psychiatric aspects of infertility can contribute some measure of understanding about this problem, and points up the particular promise of long-term interdisciplinary studies. Doctor Straker is Assistant Psychiatrist, Montreal General Hospital, and Assistant Professor, McGill University Psychiatric Department. 150
ENDOCRINE AND NEUROPHYSIOLOGICAL INFLUENCES
The mechanisms involved in psychogenic infertility occur as a result of the dysfunctions in the endocrine and the autonomic nervous systems. As Bos and Cleghorn 2 describe it, hypothalamic activity, via vascular mechanisms, activates the anterior pituitary lobe for the production and release of luteinizing hormone (LH), which stimulates the production of estrogens by the ovary and results in ovulation. The autonomic nervous system is closely bound to areas of the brain concerned with emotional expression, especially the cortex, hypothalamus, thalamus and mid-brain structures, including the reticular activating system and the limbic system (rhinencephalon). The efferent fibres of the autonomic can mediate a variety of motor and secretory genital disturbances, when there exists an altered emotional state concerned with sexual function. It is presumed that autonomic influences are operative in producing tubal spasm (fallopian tube dysfunction) and vaginismus, and via influences on the vascular bed, can also produce endometrial changes incompatible with implantation, or vaginal Ph changes which inactivate sperm. Such changes can be considered to be similar to those found in the congested bowel of the irritable colon syndrome, or the nasal congestion of certain neurotic individuals. The brief reference to the above mechanisms serves as a bridge behveen the diagnostic establishment of the psychologic disorder and the presence of the somatic disorder. In critical thinking about the psychosomatic concept, the correlation behveen the hvo observed sets of facts must be established either on a psychological conversion basis (suppression or distortion of normal organ function), or on the basis of physiological inter-relationVolume IV
---~.
__
.
--PSYCHIATRIC ASPECTS OF STERILITY-STRAKER
ships which are a reflection of the particular homeostatic disturbance. The hypothalamus is regarded as the key structure for emotional activities. It regulates the anterior pituitary and through it, the endocrine system; directs the autonomic vegetative functions, coordinating breathing rate, heart rate, blood flow, mobilization of blood sugar, et cetera, to meet the fight or flight situation. Hunger and sexual activities are also under hypothalamic regulation. Those clinical states which relate immediately to the problem of sterility include tubal spasm and "hypothalamic amennorhea" ( anovulation). It is well known that hypothalamic ammenorhea may result from a feared exposure to pregnancy, or accompany a marked stress reaction accompanied by or expressed in the form of fear, grief or depression. The most common emotional disturbance associated with menses arrest is depression, whether overtly expressed or masked. Other factors also decrease hypothalamic activity and can result in amennorhea. These include electroshock treatment, phenothiazine medication ( tranquilizers), hypothyroidism, and certain adrenal disorders. The patterns of thyroid, gonadal and adrenal hormone secretions related to psychological stress in the monkey 3 were reported in a recent study. During the stress, urinary corticosteroid levels increased threefold, epineph~ rine urinary levels doubled, thyroid hormone levels increased slowly to twofold, whereas urinary andosterone and estrone dropped to below half the baseline levels. The values reversed and readjusted dUring the recovery phase over a period of one week. The authors stated that "every hormone underwent marked changes either during or after psychological stress." These changes were oriented towards mobilization of energy during the stress period, followed by anabolic restoration. The differences noted in the pattern of the endocrine responses suggested the basis for the development of endocrine imbalance during chronic or repetitive stress. Selye 4 has pointed out that during stress, the sex glands shrink and become less active. The pituitary has to produce more ACTH to maintain life, and it must cut down production of other hormones less urgently needed. Menses become irregular, or stop, and during lactation, milk secretion may become inMay-June, 1963
sufficient. In men the sexual urge and spermcell formation are diminished. The premenstrual tension syndrome is evidenced by fluid retention, predisposition to allergic and hypersensitivity reactions, and a tendency toward seizures and vascular disturbances. A decrease of gonadotrophic excretion is a characteristIC response in the general adaptation snydrome. Thus, from clinical observation and from experimental data, it is clear that states of stress result in a decreased sexual activity. INCIDENCE OF INFERTILITY
The frequency of this problem is difficult to estimate with accuracy, depending on the adequacy of the statistical sampling as well as on the special group sampled. Rutherford et ala estimate that 12 per cent of all American couples are infertile. Weir and Weir also estimate a 12 per cent incidence on the basis of large scale population studies. The author has reviewed the incidence of absolute and relative infertility in his office psychiatric population. During the last 12month period, there were examined, evaluated and treated a total of 104 persons who were married a minimum of five years. In this group, 20 presented childless marriages, and of this number five had proceeded to the adoption of children. An additional 16 had only one child, and were avoiding further pregnancies. In this latter group of 16, seven women had suffered a postpartum psychosis, while in five cases, the husband had reacted to the arrival of a child by an exacerbation of his neurotic problems so that additional pregnancies were precluded. The absolute sterility incidence of the five-year married psychiatric group is over 19 per cent. In this particular group (referred for problems unrelated to sterility), four women had pelvic pathology; two men had aspermia. The etiology of the other 14 cases was undetermined, although all had undergone investigation at various times. While no firm conclusions can be drawn about the functional aspects of this infertile group at this time, the overall infertility incidence noted in this psycholowcalIy ill group is certainly much higher than noted in large population studies. It is also difficult to evaluate the incidence 151
PSYCHOSOMATICS
of the functional etiology and outcome of infertility. Southam' noted that in a series of 312 couples who were "normal yet infertile," 51.3 per cent had a pregnancy during the observation period of one or more years. Fiftynine per cent of 1,568 couples showed abnormalities that could explain the infertility. Twenty-two per cent of the total women showed abnormalities, with the man normal. Twenty-seven per cent of the men showed decreased fertility. Ten per cent presented abnormal findings in both partners. Although the rates of pregnancy differed in each group studied, the overall pregnancy rate was 30 per cent where a definite abnormality was present. Age of the couple and duration of infertility were important considerations in determining the reasonable deferral of adoption proposals. Prueter8 described a series of 97 infertile couples. Seven husbands had aspermia and 32 women had organic problems, while 58 per cent had "functional infertility". In a~di tion to investigative contacts, he prescnbed Stelazine or Parstelin b.i.d., and 56 per cent became pregnant. This rationale came from his conviction that primary infertility is due to deep underlying fears and tension. The latter develop out of a previous traumatic pregnancy, abortion or stillbirth, or reBect a poor emotional preparation for adulthood. He felt that pharmacological control of the tension aided the task of realizing the wish for a pregnancy. SandlerD analyzed 268 consecutive childless marriages and diagnosed 25 per cent to be stress-related. In his opinion, stress produces varied symptoms and reflects· the unreadiness for parenthood. PSYCHOLOGICAL FACTORS PERTAINING TO FEMALE STERILITY
Fenichel'° has stated that a psychogenic resistance to pregnancy can affect the course of pregnancy and childbirth through inBuencing muscular functions and to some extent, the circulatory and metabolic ones. However, he is not certain that there is a psychogenic inhibition of procreation, i.e., whether a truly psychogenic sterility exists. A number of authors have described personality profiles of women likely to develop functional reproductive disorders. Mandy et al" described two main types. The first is the physically and emotionally immature 152
woman, overly dependent, functioning in a childlike role in marriage and fearing motherhood as too threatening. She is easily fatigued and prone to functional disorders. The second type is described as the aggressive masculine competitive woman, often overambitious and career-minded. There is often an open rejection of the feminine role and of motherhood. Their conflicts about roles in life "often prevent conception or cause miscarriages". The rejection of motherhood is expressed by the use of criminal abortions or failure to cooperate with sterility programs. They show a high incidence of menses irregularity, anovulation, tubal spasm, spontaneous abortion due to uterine irritability and vascular accidents. Rutherford et al 5 ,12 emphasized the importance of psychogenic anovulation in sterility, and described the use of a full battery of psychological tests in every patient. These include Thematic Apperception, the Rorshach, and the Minnesota Multiphasic Personality Inventory. He felt that anovulation was not the main problem, but only a symptom of a more serious emotional disturbance, and on this basis, recommended psychotherapy as the treatment of choice for such cases. "The evaluation of the infertile couple's adjustment is as important as it is to scrutinize the abnormal physiology". Pommerenkel:l also states that conception failures may well have causes not necessarily organic and that the physician involved must fill many therapeutic roles, psychotherapeutic as much as others. Benedek H points out that psychogenic infertility can be considered as a defense against the dangers inherent in procreative functions. Thus it may be temporary and disappear with maturational processes. Infertility may be a conjugal phenomenon caused by sexual maladjustment or by deep dissatisfaction with the marital partner. Relative infertility may be expressed by the inhibition of heterosexual drive or by the suppression of intercourse during the fertile period. Conflicts lead to suppression of gonadal function and anovulation. Reflex action may produce tubal spasm as an expression of acute fear of pregnancy. Benedek points out that sterility symptoms are really an expression of much wider psychosexual disturbance, otherwise evidenced by spontaneous abortions, psychological difficulVolume IV
PSYCHIATRIC ASPECTS OF STERILITY-STRAKER
ties regarding menstruation and pregnancy, the deepest unconscious sources of psychic life. and also by postpartum difficulties. The writer's interest has already been diBos and Cleghorn 2 also emphasize that disturbed personality traits are the broad base rected to a study of the special psychological from which infertility conflicts arise. When factors which operate during pregnancy ami I psychologic conflicts surrounding impregna- childbirth. ' Mention is made of this, since tion occur, these are manifestations of an any consideration of psychogenic sterility must emotionally disordered personality. The na- include the special fears and anxieties which ture of the personality disturbance varies, and are expressed in relationship to one or more may be described as emotional immaturity, an of four areas of experience. These are (1) aggressive masculine woman, a hostile mother fear of intercourse, (2) fear of menses, imidenti6cation, or an obsessive compulsive neu- pregnation and the state of pregnancy, (3) rosis. They pointed out that the sterility may fear of childbirth, (4) fears of the state of represent the defense of the disturbed person motherhood. There is certainly overlapping from one against the stresses of pregnancy and motherarea to another, and I would agree with hood, stresses with which they cannot cope. many writers, already quoted, that the fears l5 Blau and others recently reported a psyand conflicts which express as psychogenic chiatric and psychological study of women sterility are simply an expression of a larger who are mothers of prematures. "The data, on clinical and statistical grounds, showed a personality disorder. Yet some comment distinctive difference in that the premature should be made about the constellation of mothers seem to have negative attitudes to the commoner fears. The fear of intercourse involves the lack of the pregnancy, greater emotional immaturity, emotional growth adequate to permit funcmore narcissistic trends, and inadequate resolution of familial problems". The findings in tioning at the adult level. The woman may the "premature" group, when contrasted to be immature, infantile, fixated at levels of the "full term" group, are similar to those pregenital sexual activity. She may be inrecorded in the functional infertile group. terested in the goals of the little girl, to be Blau and roo-workers are devising a self-report petted, admired, comforted and protected. A multiple choice questionnaire to predict and variety of masturbatory needs dominate. Whether expressed in passive or aggressive possibly prevent prematurity. 16 forms, the personality is narcissistic, incapable Helene Deutsch has pointed out from detailed case studies and analytic investigation of giving or of loving in an adult sense. Such and therapy, that unconscious feelings of guilt a woman often marries with the illusion that frequently cause psychogenic sterility. She de- she is to remain the omnipotent child, and scribed a number of personality types, which she feels traumatized, degraded, inadequate include: (1) the immature infantile dependent and extremely anxious in the adult sexual rechild woman. (2) the maternal giving wom- lationship. To a minor degree, the lack of an, whose husband absorbs all her maternal psychosexual development may be a reflecdrives and feels threatened by a child. (3) tion of faulty education and the exposure to the active masculine aggressive woman who unhealthy family attitudes in the home. In rejects her femininity. (4) the woman whose actuality, she avoids intercourse whenever dedication is to interests which exclude moth- possible, and when involved, she reacts with erhood. (5) the emotionally ill woman who anxiety, hostility or the appearance of psychoperceives the poverty of her emotional life somatic complaints. The fear of the menses, impregnation and and cannot meet the demands of motherhood. She also drew attention to the para- the state of pregnancy itself is also of comdoxical counterphobic state, where compul- mon occurrence. The predominant endocrinsive impregnation is the alternative solution ological setting for the premenses and extendto the same fears and conflicts which in the ing into the period of pregnancy is described more usual case results in sterility. The fears by the dominance of the progesterone phase. which dictate the sterility response she de- This is closely correlated with increased feelscribes as a fear of death, or stemming from ings of passivity, dependency and regressive May-June, 1963
153
PSYCHOSOMATICS
phenomena at the psychological level to anal and oral orientations. Such regressive reactions provide a setting in many women for the activation of anxiety and depression. Henrietta Klein et a)t8 concluded that previously existing personality difficulties were often accentuated during a pregnancy. Many superstitions are deeply rooted in the unconscious regarding both menstruation and pregnancy. The loss of control is greatly feared by some. The growth in oneself of a monstrous or defective child, is an expression of primitive masturbation guilt or expresses the unconscious equation of the pregnancy with an internalized phallus, which is soon to be lost again (at delivery). The whole pregnancy is also a period of psychological preparation for delivery and motherhood, and grave fears may develop in relationship to both anticipated experiences. The central fear in childbirth is the fear of death in the childbirth process. The anticipation of pain, of loss of control, of loss of consciousness are focal anxieties. Women instinctively feel that childbirth is a testing experience in which all their emotional and physical reserves will be drawn upon. The self image in relationship to femininity is most important, as is the strength of the identification with her own mother. Fodor'" suggests that the mother is also identified with the child in her womb. The birth process becomes also "the giving birth to oneself", or being born again, thus setting in motion the most primitive springs of anxiety which relate to the archaic anxieties of the birth of the mother as a child. Greenacre 2 has described such anxieties in considerable detail, also noting that this very birth anxiety serves to mobilize, stimulate and direct the maturational energies of the newborn infant. Delltschtr. has also noted the importance of the reawakening of early traumatic experiences connected with loss of control in childbirth, which relate especially to early bladder and bowel training. The separation from the fetus is also reacted to by some women as though this were an organ or body loss. Such concepts simplify the understanding of postpartum depressive reactions or other psychopathology appearing at this time. Fears related to the status of motherhood itself relate to the adequacy of the individual 154
to function in a maternal glvmg protective role. It involves a narcissistic blow, and calls upon the capacity to change one's self image as normally occurs during maturation processes. The failure to succeed in this task is nakedly exposed to the new mother who be: comes acutely aware of her inadequacy, of her emotional depletion, of her lack of anticipated love for the child. If this should happen, there is marked anxiety, a rejection or hatred of the newborn child, and the appearance of psychopathological flight and denial of reality when she reaches the postpartum state. This short summary of commonly experienced fears and anxieties describes an overlapping of feeling which become active in susceptible women in relationship to physiological events which are closely associated. These events form an inseparable series in the psychosexual experience of the woman, and special problems in anyone area may become important in the determination of psychogenic sterility. STERILITY FACTORS PERTAINING TO MEN
Although the man can exert a decisive role in the determination of a childless marriage, the psychological problems pertaining thereto will be only briefly reviewed. Impotence in men is, with rare exception, always psychological in origin. This may be evidenced by failure of erection, premature ejaculation precluding penetration, or ejaculo retarda. The basis of the impotence is a conflict between instinctual forces, or between morality issues and unacceptable sexual impulses. In simplified form, the dilemma is stated, "I want, I mustn't, I can't." Impotence is the expression of resistance against the sexual act due to guilt, anxiety or hositility to the object. Fear of injury to self or others (sado-masochistic components), fears of inadequacy (fear of women, homosexual latencies, castration anxieties) or predominance of pregenital impulses are important factors. The therapist's role is to discover the nature of the inhibition and help the patient work through his conflict. Another important cause of male infertility is represented not by impotence, but by the voluntary avoidance of parenthood. This expresses the male's unreadiness for parenthood, Volume IV
PSYCHIATRIC ASPECTS OF STERILITY-STRAKER
either out of fear, narcissism, a sense of inadequacy, or the desire to remain the only child in the relationship to the wife. An example of such difficulties is evidenced by a male patient in therapy. The preliminary investigation of infertility in his marriage had established his wife's ovulation time, but he found himself repeatedly impotent during this phase of the wife's cycle. This was one expression of his infantile relationship to his wife otherwise expressed in jealousy and fears of being displaced in his wife's affection. Elin et al 21 have emphasized an importan£ issue. They point out that the infertility study should have a definite predictable end. The survey should include certain standard tests which can be concluded in five or six visits spaced approximately one month apart. If pregnancy has not ensued within one year of the study's completion, it is encumbent to guide the infertile couple to a reliable adoption source. The writer can confirm from clinical experience that serious emotional illness can result from unending sterility programs which are carried on for a number of years when the attention of the physician is not directed to the whole patient but remains focused only on the reproductive apparatus. Clinical practice rarely presents the uncomplicated medical situation. The common complexity is the mixture of the organic and the functional. A short case sample will illustrate. Mrs. L. G., now age 47, was referred for psychiatric treabnent. Presenting complaints consisted of severe recurring depressions occurring in the setting of a rigid obsessional phobic state. She was an intelligent, but cold, undemonstrative, emotionally restricted person, chiefly interested in business life. She always thought she would never marry, and had no interest in sexual experience. She married at age 27, mainly to escape a difficult home where she was dominated by her mother. The onset of her menses was at 13. Severe dysmenorrhea, premenstrual irritability, depression and compulsive activity were present. She was always sexually frigid. Her first gynecological investigation, undertaken at her husband's insistence, at age 31, occurred four years after marriage. This revealed no abnormalities. The second gynecological enquiry came at age 32, and her ovulation cycle was then clarified. Her first pregnancy ended in a miscarriage at six weeks at age 33. A second miscarriage occured at 12 weeks, at age 34. She adopted a newborn child at age 35. She then had a full-term pregnancy at 36, but remained in bed approximately seven months with severe nausea, but no bleeding. The labor was prolonged, lasting five days, and delivery was difficult, with forceps assistance. Hysterectomy May-June, 1963
was carried out at age 39, because of patient's insistent complaints about dysmenorrhea. A small fibroid was removed. She was depressed after the adoption, after the conception, during the pregnancy and afterward, and reacted with depression to the hysterectomy. A large number of psychosomatic complaints remained unchanged after the surgery. The older child was referred for psychiatric care at age eight because of emotional difficulties. This was regarded as developing out of a cold overcontrolling hostile mother-child relationship. She was advised to have therapy herself at this time but did not take the advice. The second child (her own) had also developed an emotional illness, manifesting near psychotic behavior which necessitated a lengthy treabnent program. In the course of this psychiatric management the mother sought help for herself.
This brief case summary illustrates familiar clinical findings. The patient presented the clinical picture of a long-standing phobic obsessional personality disturbance. Some reflections of this disorder were her emotional coldness, her delay in marriage, the period of infertility, the lifelong dysmenorrhea, the spontaneous miscarriages and finally the adoption and the difficult pregnancy. The latter was culminated by a difficult labor, a postpartum depression and finally a hysterectomy. The relationship of the psychological disorder and the small fibroid which was only a late diagnosis must remain speculative. THE PSYCIllATRIST'S ROLE
A psychiatric evaluation may be indicated whenever the gynecologist becomes aware of serious psychological problems in his infertile patient. Accurate personality assessment will provide a working diagnosis and therapy if indicated. In the event that the infertility study is completed, and a pregnancy does not ensue after one year, a psychiatric assessment is also indicated. The role of psychological forces in perpetuating the infertility, the consideration of adoption procedures or the decision to terminate endless gynecological investigations can then be clarified to a fuller extent. Continuing psychiatric studies are needed to advance our understanding of this complex problem. The fact that a considerable proportion of women conceive within one year of the infertility investigation poses a number of interesting questions for clarification. What is the role played by the physician's scientific skill alone, and what is the importance of the interpersonal patient-physi155
PSYCHOSOMATICS
cian relationship? What meaning is given to the interventions into sexual body areas, as distorted in the transference phantasies of the patient? What are the precise maturational processes which translate the functionally barren female into a woman capable of childbearing and motherhood? SUMMARY
Women who present as functional infertility problems manifest findings of psychological and emotional disorders. The psychiatric examination reveals personality disturbances which inBuence the psychosexual course of the patient. It is well to remember that the sterility can be nature's way of shielding the emotionally ill-prepared woman from motherhood tasks which are beyond her resources. Detailed long-term interdisciplinary studies can enlarge our basic understandings of the multiple aspects of the problem of infertilify and improve our clinical skills in patient car~. REFERENCES
1. Kubie, L. S.: The Problem of Specificity in the Psychosomatic Process: Recent Developments in Psychosomatic Medicine. Page 29. Philadelphia: Lippincott, 1954. 2. 80s, C. and Cleghorn, R. A.: Psychogenic steriIity.}. Fertility Sterility, 19:No. 2 (March-April) 1958. 3. Mason, J. W., Brady, J. V., et al: Patterns of thyroid, gonadal, adrenal hormone secretion related to psychological stress in the monkey. Psychosom. Med., 23:446, 1961. 4. Selye, Hans: The Stress of Life, pp. 176-178. New York: McGraw-Hili Book Co., Inc., 1956. 5. Rutherford, R., Banks, A. L., et al: Treatment of psychologic factors in ovulation. }. Amer. Soc. Study Infertility, 12: No.1, 1961.
6. Weir, Wm. and Weir, D.: Natural history of infertility. ]. FertUity Sterility, 12:443 (Sept.Oct.) 1961. 7. Southam, A. L.: What to do with the "normal" infertile couple. }. Fertility Sterility, 11: 16, 1960. 8. Prueter, G. W.: Combined tranylcyprominetrilluoperazine therapy in obstetrics and gynecology. Presented at Canadian Conference on Anxiety and Depression, June 3, 1961. 9. Sandler, B.: Infertility of emotional origin. }. Obstet. Gynec. Brit. Common., 68:809 (Oct.) 1961. 10. Fenichel, 0.: The Psychoanalytic Theory of Neurosis. New York: W. W. Norton & Co., Inc., 1945. II. Mandy, T., Scher, E., et al: Psychic aspects of sterility and abortion. South. M.H., 144: 1054 (Nov.) 1951. 12. Rutherford, R., Banks, A. L., et al: Infertility: Current evaluation and treatment: Medical arts and sciences. }. CoU. Med. Evangelists, 14:No. 2, 1960. 13. Pommerenke, W. T.: The normal infertile woman is not normal. }. Fertility Sterility, 11: 1960. 14. Benedek, T. F.: Sexual functions in women. American Handbook of Psychiatry, Chap. 37. New York: Basic Books, Inc., 1959. 15. Blau, A., Slaff, B., et al: The psychogenic etiology of premature births. Presented at 118th Annual Meeting American Psychiatric Association, Toronto, Canada, May 10, 1962. 16. Deutsch, H.: The Psychology of Women. Vol. 11, Chap. V. New York: Grune and Stratton, 1945. 17. Straker, M.: ~sX<:hological factors during pregnancy and childbirth. Canad. Med. Ass. }., 70: 510, 1954. 18. Klein, H., Potter, H. and Dyk, R.: Anxiety in pregnancy and childbirth. Psychosom. Med. Monograph. New York: Paul Hoeber, Inc., 1960. 19. Fodor, N.: Psychiat. Quart., 23:59, 1949. 20. Greenacre, P.: Biological Economy of Birth. Psychoanalytic Study of the Child. Vol. 1. New York: International University Press, Inc., 1945. 21. Elin, T. W., Danforth, I. W., et al: A study of infertility in the private practice of obstetrics and gynecology. }. Fertility Sterility, 11 :No. 2 (Mar.Apr.) 1960.
1 respect faith, but doubt is what gets you an education. WILSON MIZNER (1876-1933)
156
Volume IV